October 1, 2016

Arkansas Blue Cross and Blue Shield Metallic Formulary 2016 List of Covered Drugs

PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Members must use network pharmacies to fill their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change.

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 1

October 1, 2016

What is the Arkansas Blue Cross and Blue Shield Metallic Plans Drug List? A drug list is a list of covered drugs. Arkansas Blue Cross and Blue Shield Metallic Plans works with a team of health care providers to choose drugs that provide quality treatment. Arkansas Blue Cross and Blue Shield Metallic Plans cover drugs on our drug list, as long as:   

The drug is medically necessary The prescription is filled at a Arkansas Blue Cross and Blue Shield Metallic Plans network pharmacy Other plan rules are followed

For more information on how to fill your prescriptions, please review your plan document or other plan materials.

Can the Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed drug list is the most current drug list covered by Arkansas Blue Cross and Blue Shield Metallic Plans. To get updated information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans, please www.arkansasbluecross.com, or call Member Services at 1-800-863-5561.

How do I use the Drug List? There are two ways to find your drug on the drug list: 1. Medical Condition The drug list starts on page 5. The drugs on this drug list are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under “anticoagulants.”  

If you know what your drug is used for, look for the category name in the list that starts on the next page. Then look under the category name for your drug

2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 60. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.   

Look in the Index and find your drug Next to your drug, see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list

For more information about your Arkansas Blue Cross and Blue Shield Metallic Plans prescription drug coverage, please look at your plan document and other plan materials. If you have questions

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 2

October 1, 2016 about Arkansas Blue Cross and Blue Shield Metallic Plans, or this drug list please call Member Services at 1-800-863-5561or visit www.arkansasbluecross.com.

Arkansas Blue Cross and Blue Shield Metallic Plans’ Drug List The drug list set forth below gives information about the drugs covered by Arkansas Blue Cross and Blue Shield Metallic Plans. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Arkansas Blue Cross and Blue Shield Metallic Plans have any special requirements for coverage of your drug. These requirements and limits may include: 

Prior Authorization: Arkansas Blue Cross and Blue Shield needs you (or your doctor) to get prior approval or authorization for certain drugs. This means that you need to get approval from Arkansas Blue Cross and Blue Shield before you fill your prescriptions. If you don’t get approval, Arkansas Blue Cross and Blue Shield may not cover the drug



Quantity Limits: For certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that it will cover. For example, Arkansas Blue Cross and Blue Shield provides 28 caplets per 90 day prescription for Tamiflu. This may be in addition to a standard one-month or three-month supply



Step Therapy: Arkansas Blue Cross and Blue Shield needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Arkansas Blue Cross and Blue Shield may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Arkansas Blue Cross and Blue Shield will then cover Drug B



Specialty Medications: Arkansas Blue Cross and Blue Shield requires that specialty medications be filled at a network specialty pharmacy.

What if my drug is not on the Drug List? If your drug is not on this drug list, call Member Services and make sure that your drug is not covered. If you learn that Arkansas Blue Cross and Blue Shield does not cover your drug, you have two choices:



Ask Member Services for a list of similar drugs that are covered by Arkansas Blue Cross and Blue Shield Metallic Plans. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Arkansas Blue Cross and Blue Shield Metallic Plans. Similar drugs that are preferred and covered by your plan’s formulary may be easier to obtain and lower cost to you than non-preferred drugs.

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 3

October 1, 2016 

Ask Arkansas Blue Cross and Blue Shield to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Arkansas Blue Cross and Blue Shield limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more.

Generally, Arkansas Blue Cross and Blue Shield will only approve your request for an exception if the preferred drugs included on the plan’s drug list are not as effective in treating your condition or cause you to have adverse medical effects. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug’s cost that you will pay) for drugs in each tier. Drug Tier column instructions: Plans that provide different levels of cost sharing for drugs depending on their tier must include a column indicating the drug’s tier placement. Plans may choose from several methods to indicate the tier placement, including tier numbers from your plan benefit package (e.g., 0/1/2/3), standard tier names from your plan benefit package (e.g., ACA preventive/generic/preferred brand/other brand), copayment amounts (e.g.,$0/$10/$20/$35), or coinsurance percentages (e.g., 0%/10%/25%). The latter two methods are preferred because they are generally easier for members to understand. If one of the two former methods is used, plans must provide an explanation before the table explaining the copayment amount or coinsurance percentage associated with each tier number or tier name. Plans that have different copayment amounts or coinsurance percentages for retail and mail-service prescriptions may include both retail and mail service amounts within the same column or include separate columns for retail and mail service prescriptions.

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 4

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines§ amphetamine-dextroamphetamine cap sr 2 24hr 5 mg amphetamine-dextroamphetamine cap sr 2 24hr 10 mg amphetamine-dextroamphetamine cap sr 2 24hr 15 mg amphetamine-dextroamphetamine cap sr 2 24hr 20 mg amphetamine-dextroamphetamine cap sr 2 24hr 25 mg amphetamine-dextroamphetamine cap sr 2 24hr 30 mg amphetamine-dextroamphetamine tab 5 2 mg amphetamine-dextroamphetamine tab 7.5 2 mg amphetamine-dextroamphetamine tab 10 2 mg amphetamine-dextroamphetamine tab 12.52 mg amphetamine-dextroamphetamine tab 15 2 mg amphetamine-dextroamphetamine tab 20 2 mg amphetamine-dextroamphetamine tab 30 2 mg dextroamphetamine sulfate cap sr 24hr 5 2 mg dextroamphetamine sulfate cap sr 24hr 10 2 mg dextroamphetamine sulfate cap sr 24hr 15 2 mg dextroamphetamine sulfate oral solution 5 2 mg/5ml dextroamphetamine sulfate tab 5 mg 2 dextroamphetamine sulfate tab 10 mg 2 methamphetamine hcl tab 5 mg 2 VYVANSE CAP 10MG 3 VYVANSE CAP 20MG 3 VYVANSE CAP 30MG 3 VYVANSE CAP 40MG 3 VYVANSE CAP 50MG 3

QL (90 caps / 25 days) QL (90 caps / 25 days) QL (30 caps / 25 days) QL (30 caps / 25 days) QL (30 caps / 25 days) QL (30 caps / 25 days) QL (90 tabs / 25 days) QL (90 tabs / 25 days) QL (90 tabs / 25 days) QL (90 tabs / 25 days) QL (60 tabs / 25 days) QL (60 tabs / 25 days) QL (30 tabs / 25 days) QL (120 caps / 25 days) QL (120 caps / 25 days) QL (60 caps / 25 days) QL (1,200 mL / 25 days) QL (120 tabs / 25 days) QL (120 tabs / 25 days) QL (150 tabs / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 5

October 1, 2016 Drug Tier Requirements/Limits 3 3 2 QL (120 tabs / 25 days) 2 QL (120 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (30 tabs / 25 days)

Drug Name VYVANSE CAP 60MG VYVANSE CAP 70MG zenzedi tab 2.5mg zenzedi tab 7.5mg zenzedi tab 15mg zenzedi tab 20mg zenzedi tab 30mg

Attention-Deficit/Hyperactivity Disorder (ADHD) Agents guanfacine hcl tab sr 24hr equiv) guanfacine hcl tab sr 24hr equiv) guanfacine hcl tab sr 24hr equiv) guanfacine hcl tab sr 24hr equiv) STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG STRATTERA CAP 100MG

1 mg (base

2

ST; PA**

2 mg (base

2

ST; PA**

3 mg (base

2

ST; PA**

4 mg (base

2

ST; PA**

3 3 3 3 3 3 3

Stimulants - Misc.§ armodafinil tab 50 mg 2 armodafinil tab 150 mg 2 armodafinil tab 200 mg 2 armodafinil tab 250 mg 2 dexmethylphenidate hcl cap sr 24 hr 5 mg 2 dexmethylphenidate hcl cap sr 24 hr 10 mg2 dexmethylphenidate hcl cap sr 24 hr 15 mg2 dexmethylphenidate hcl cap sr 24 hr 20 mg2 dexmethylphenidate hcl cap sr 24 hr 30 mg2 dexmethylphenidate hcl cap sr 24 hr 40 mg2 dexmethylphenidate hcl tab 2.5 mg 2 dexmethylphenidate hcl tab 5 mg 2 dexmethylphenidate hcl tab 10 mg 2 methylphenidate hcl cap cr 10 mg (cd) 2 methylphenidate hcl cap cr 20 mg (cd) 2 methylphenidate hcl cap cr 30 mg (cd) 2 methylphenidate hcl cap cr 40 mg (cd) 2 methylphenidate hcl cap cr 50 mg (cd) 2

PA PA PA PA QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(60 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (30 caps / 25 days) (30 caps / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (60 tabs / 25 days) (60 caps / 25 days) (60 caps / 25 days) (60 caps / 25 days) (30 caps / 25 days) (30 caps / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 6

Drug Name methylphenidate methylphenidate methylphenidate methylphenidate methylphenidate

hcl hcl hcl hcl hcl

cap cr 60 mg (cd) cap sr 24hr 20 mg cap sr 24hr 30 mg cap sr 24hr 40 mg chew tab 2.5 mg

methylphenidate hcl chew tab 5 mg methylphenidate hcl chew tab 10 mg methylphenidate hcl soln 5 mg/5ml methylphenidate hcl soln 10 mg/5ml methylphenidate hcl tab 5 mg methylphenidate hcl tab 10 mg methylphenidate hcl tab 20 mg methylphenidate hcl tab cr 10 mg methylphenidate hcl tab cr 20 mg methylphenidate hcl tab sa osm 18 mg methylphenidate hcl tab sa osm 27 mg methylphenidate hcl tab sa osm 36 mg methylphenidate hcl tab sa osm 54 mg methylphenidate hcl tab sr 24hr 18 mg methylphenidate hcl tab sr 24hr 27 mg methylphenidate hcl tab sr 24hr 36 mg methylphenidate hcl tab sr 24hr 54 mg modafinil tab 100 mg modafinil tab 200 mg

October 1, 2016 Drug Tier Requirements/Limits 2 QL (30 caps / 25 days) (la)2 QL (60 caps / 25 days) (la)2 QL (60 caps / 25 days) (la)2 QL (30 caps / 25 days) 2 QL (180 chew tabs / 25 days) 2 QL (180 chew tabs / 25 days) 2 QL (180 chew tabs / 25 days) 2 QL (1800 mL / 25 days) 2 QL (900 mL / 25 days) 2 QL (180 tabs / 25 days) 2 QL (180 tabs / 25 days) 2 QL (90 tabs / 25 days) 2 QL (90 tabs / 25 days) 2 QL (90 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (30 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (30 tabs / 25 days) 2 PA 2 PA

AMINOGLYCOSIDES Aminoglycosides amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2 amikacin sulfate inj 500 mg/2ml (250 2 mg/ml) GENTAM/NACL INJ 0.9MG/ML 4 GENTAM/NACL INJ 1.4MG/ML 4 gentamicin in saline inj 0.8 mg/ml 2 gentamicin in saline inj 1 mg/ml 2 gentamicin in saline inj 1.2 mg/ml 2 gentamicin in saline inj 1.6 mg/ml 2 gentamicin in saline inj 2 mg/ml 2 gentamicin sulfate inj 10 mg/ml 2 gentamicin sulfate inj 40 mg/ml 2 gentamicin sulfate iv soln 10 mg/ml 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 7

Drug Name kanamycin sulfate inj 333 mg/ml NEO-FRADIN SOL 125/5ML neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg streptomycin sulfate for inj 1 gm TOBRA/NACL INJ 80/0.9 tobramycin nebu soln 300 mg/5ml tobramycin sulfate for inj 1.2 gm tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base equivalent) tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)

October 1, 2016 Drug Tier Requirements/Limits 2 4 2 2 2 4 2 PA 2 2 2 2 2

ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonal Antibodies HUMIRA INJ 10MG/0.2 HUMIRA KIT 20MG/0.4 HUMIRA KIT 40MG/0.8 HUMIRA PEN INJ CROHNS SIMPONI ARIA SOL 50MG/4ML SIMPONI INJ 50/0.5ML SIMPONI INJ 100MG/ML

5 5 5 5 6 6 6

PA PA PA PA PA, ST PA, ST PA, ST

6

PA, ST

Antirheumatic - Enzyme Inhibitors XELJANZ TAB 5MG

Antirheumatic Antimetabolites RHEUMATREX TAB 2.5MG

4

Interleukin-1 Blockers ARCALYST INJ 220MG

5

PA

Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ

6

PA, ST

6 6 6 6

PA, PA, PA, PA,

Interleukin-6 Receptor Inhibitors ACTEMRA ACTEMRA ACTEMRA ACTEMRA

INJ INJ INJ INJ

80MG/4ML 162/0.9 200/10ML 400/20ML

ST ST ST ST

Nonsteroidal Anti-inflammatory Agents (NSAIDs)§ celecoxib cap 50 mg celecoxib cap 100 mg

2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 8

Drug Name celecoxib cap 200 mg celecoxib cap 400 mg diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg diclofenac w/ misoprostol tab delayed release 50-0.2 mg diclofenac w/ misoprostol tab delayed release 75-0.2 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg fenoprofen calcium cap 400 mg fenoprofen calcium tab 600 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg INDOCIN SUS 25MG/5ML indomethacin cap 25 mg indomethacin cap 50 mg indomethacin cap cr 75 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap sr 24hr 200 mg ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) ketorolac tromethamine inj 15 mg/ml ketorolac tromethamine inj 30 mg/ml ketorolac tromethamine inj 60 mg/2ml (30 mg/ml)

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 9

Drug Name ketorolac tromethamine inj 300 mg/10ml (30 mg/ml) ketorolac tromethamine tab 10 mg meclofenamate sodium cap 50 mg meclofenamate sodium cap 100 mg mefenamic acid cap 250 mg meloxicam susp 7.5 mg/5ml meloxicam tab 7.5 mg meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg sulindac tab 200 mg tolmetin sodium cap 400 mg tolmetin sodium tab 200 mg tolmetin sodium tab 600 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

QL (20 tabs / 25 days)

Pyrimidine Synthesis Inhibitors leflunomide tab 10 mg leflunomide tab 20 mg

2 2

Selective Costimulation Modulators ORENCIA CLCK INJ 125MG/ML ORENCIA INJ 125MG/ML ORENCIA INJ 250MG

6 6 6

PA, ST PA, ST PA, ST

Soluble Tumor Necrosis Factor Receptor Agents ENBREL ENBREL ENBREL ENBREL

INJ 25/0.5ML INJ 25MG INJ 50MG/ML SRCLK INJ 50MG/ML

5 5 5 5

PA PA PA PA

2

QL (720 mL / 25 days)

ANALGESICS - NonNarcotic Analgesic Combinations§ alagesic lq sol

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 10

Drug Name butalbital-acetaminophen-caffeine cap 50-300-40 mg butalbital-acetaminophen-caffeine cap 50-325-40 mg butalbital-acetaminophen-caffeine tab 50-325-40 mg butalbital-aspirin-caffeine cap 50-325-40 mg butalbital-aspirin-caffeine tab 50-325-40 mg

October 1, 2016 Drug Tier Requirements/Limits 2 QL (48 caps / 25 days) 2

QL (48 caps / 25 days)

2

QL (48 tabs / 25 days)

2

QL (48 caps / 25 days)

2

QL (48 tabs / 25 days)

aspirin chew tab 81 mg

1

aspirin low tab 81mg ec

1

aspirin tab 81 mg

1

aspirin tab 325 mg

1

aspirin tab delayed release 325 mg

1

QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies

diflunisal tab 500 mg

2

Salicylates

ANALGESICS - OPIOID Opioid Agonists§ ABSTRAL SUB 100MCG

3

ABSTRAL SUB 200MCG

3

ABSTRAL SUB 300MCG

3

ABSTRAL SUB 400MCG

3

ABSTRAL SUB 600MCG

3

ABSTRAL SUB 800MCG

3

astramorph inj 1mg/2ml astramorph inj 2mg/2ml CODEINE SULF SOL 30MG/5ML

2 2 3

QL (120 Units days), PA QL (120 Units days), PA QL (120 Units days), PA QL (120 Units days), PA QL (120 Units days), PA QL (120 Units days), PA

per 25 per 25 per 25 per 25 per 25 per 25

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 11

Drug Name codeine sulfate tab 15 mg codeine sulfate tab 30 mg codeine sulfate tab 60 mg EMBEDA CAP 20-0.8MG EMBEDA CAP 30-1.2MG EMBEDA CAP 50-2MG EMBEDA CAP 60-2.4MG EMBEDA CAP 80-3.2MG EMBEDA CAP 100-4MG fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl citrate lozenge on a handle mcg fentanyl td patch 72hr 12 mcg/hr fentanyl td patch 72hr 25 mcg/hr fentanyl td patch 72hr 50 mcg/hr fentanyl td patch 72hr 75 mcg/hr fentanyl td patch 72hr 100 mcg/hr

200 400 600 800 1200 1600

October 1, 2016 Drug Tier Requirements/Limits 2 QL (42 tabs / 25 days) 2 QL (42 tabs / 25 days) 2 QL (42 tabs / 25 days) 4 QL (60 caps / 25 days) 4 QL (60 caps / 25 days) 4 QL (60 caps / 25 days) 4 QL (30 caps / 25 days) 4 QL (30 caps / 25 days) 4 QL (30 caps / 25 days) 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (10 patches / 25 days) 2 QL (10 patches / 25 days) 2 QL (10 patches / 25 days) 2 QL (10 patches / 25 days) 2 QL (10 patches / 25 days) 4 QL (120 units / 25 days) 2 2 2 2 QL (600 mL / 25 days) 2

HYDROMORPHON SUP 3MG hydromorphone hcl inj 1 mg/ml hydromorphone hcl inj 2 mg/ml hydromorphone hcl inj 4 mg/ml hydromorphone hcl liqd 1 mg/ml hydromorphone hcl preservative free (pf) inj 10 mg/ml hydromorphone hcl tab 2 mg 2 hydromorphone hcl tab 4 mg 2 hydromorphone hcl tab 8 mg 2 hydromorphone hcl tab er 24hr deter 8 mg 2

QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (180 tabs / 25 days) QL (30 tablets per 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 12

October 1, 2016 Drug Name Drug Tier Requirements/Limits hydromorphone hcl tab er 24hr deter 12 mg2 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 16 mg2 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 32 mg2 QL (30 tablets per 25 days) levorphanol tartrate tab 2 mg 2 QL (120 tabs / 25 days) meperidine hcl inj 10 mg/ml 2 meperidine hcl inj 25 mg/ml 2 meperidine hcl inj 50 mg/ml 2 meperidine hcl inj 100 mg/ml 2 meperidine hcl oral soln 50 mg/5ml 2 QL (90 mL / 25 days) meperidine hcl tab 50 mg 2 QL (18 tabs / 25 days) meperidine hcl tab 100 mg 2 QL (18 tabs / 25 days) methadone hcl conc 10 mg/ml 2 QL (30mL / 25 days) methadone hcl soln 5 mg/5ml 2 QL (600 mL / 25 days) methadone hcl soln 10 mg/5ml 2 QL (300 mL / 25 days) methadone hcl tab 5 mg 2 QL (120 tabs / 25 days) methadone hcl tab 10 mg 2 QL (60 tabs / 25 days) methadone hcl tab for oral susp 40 mg 2 QL (9 tabs / 25 days) METHADONE INJ 10MG/ML 4 methadose tab 40mg 2 QL (9 tabs / 25 days) MORPHINE SUL INJ 2MG/ML 4 MORPHINE SUL INJ 4MG/ML 4 MORPHINE SUL INJ 5MG/ML 4 MORPHINE SUL INJ 150/30ML 4 MORPHINE SUL SUP 30MG 3 QL (180 supp / 25 days) morphine sulfate beads cap sr 24hr 30 mg 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 45 mg 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 60 mg 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 75 mg 2 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 90 mg 2 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 120 mg2 QL (30 caps / 25 days) morphine sulfate cap sr 24hr 10 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 20 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 30 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 50 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 60 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 80 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 100 mg 2 QL (30 caps / 25 days) morphine sulfate inj 8 mg/ml 2 morphine sulfate inj 10 mg/ml 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 13

October 1, 2016 Drug Name Drug Tier Requirements/Limits morphine sulfate inj 15 mg/ml 2 morphine sulfate inj pf 1 mg/ml 2 morphine sulfate iv soln 1 mg/ml 2 morphine sulfate iv soln 25 mg/ml 2 morphine sulfate iv soln 50 mg/ml 2 morphine sulfate iv soln pf 4 mg/ml 2 morphine sulfate iv soln pf 8 mg/ml 2 morphine sulfate iv soln pf 10 mg/ml 2 morphine sulfate iv soln pf 15 mg/ml 2 morphine sulfate oral soln 10 mg/5ml 2 QL (900 mL / 25 days) morphine sulfate oral soln 20 mg/5ml 2 QL (900 mL / 25 days) morphine sulfate oral soln 100 mg/5ml (20 2 QL (180 mL / 25 days) mg/ml) morphine sulfate suppos 5 mg 2 QL (180 supp / 25 days) morphine sulfate suppos 10 mg 2 QL (180 supp / 25 days) morphine sulfate suppos 20 mg 2 QL (180 supp / 25 days) morphine sulfate tab 15 mg 2 QL (180 tabs / 25 days) morphine sulfate tab 30 mg 2 QL (180 tabs / 25 days) morphine sulfate tab cr 15 mg 2 QL (120 tabs / 25 days) morphine sulfate tab cr 30 mg 2 QL (120 tabs / 25 days) morphine sulfate tab cr 60 mg 2 QL (120 tabs / 25 days) morphine sulfate tab cr 100 mg 2 QL (60 tabs / 25 days) morphine sulfate tab cr 200 mg 2 QL (60 tabs / 25 days) NUCYNTA ER TAB 50MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 100MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 150MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 200MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 250MG 3 QL (60 tabs / 25 days) NUCYNTA TAB 50MG 3 QL (360 tabs / 25 days) NUCYNTA TAB 75MG 3 QL (240 tabs / 25 days) NUCYNTA TAB 100MG 3 QL (180 tabs / 25 days) oxycodone hcl cap 5 mg 2 QL (180 caps / 25 days) oxycodone hcl conc 100 mg/5ml (20 mg/ml)2 QL (180 mL / 25 days) oxycodone hcl soln 5 mg/5ml 2 QL (900 mL / 25 days) oxycodone hcl tab 5 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 10 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 15 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 20 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 30 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab er 12hr deter 10 mg 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 20 mg 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 40 mg 2 QL (120 tabs / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 14

Drug Name oxycodone hcl tab er 12hr deter 80 mg OXYCONTIN TAB 10MG CR OXYCONTIN TAB 15MG CR OXYCONTIN TAB 20MG CR OXYCONTIN TAB 30MG CR OXYCONTIN TAB 40MG CR OXYCONTIN TAB 60MG CR OXYCONTIN TAB 80MG CR oxymorphone hcl tab 5 mg oxymorphone hcl tab 10 mg oxymorphone hcl tab sr 12hr 5 mg oxymorphone hcl tab sr 12hr 7.5 mg oxymorphone hcl tab sr 12hr 10 mg oxymorphone hcl tab sr 12hr 15 mg oxymorphone hcl tab sr 12hr 20 mg oxymorphone hcl tab sr 12hr 30 mg oxymorphone hcl tab sr 12hr 40 mg tramadol hcl tab 50 mg tramadol hcl tab sr 24hr 100 mg tramadol hcl tab sr 24hr 200 mg tramadol hcl tab sr 24hr 300 mg

October 1, 2016 Drug Tier Requirements/Limits 2 QL (60 tabs / 25 days) 3 QL (120 tabs / 25 days) 3 QL (120 tabs / 25 days) 3 QL (120 tabs / 25 days) 3 QL (120 tabs / 25 days) 3 QL (120 tabs / 25 days) 3 QL (60 tabs / 25 days) 3 QL (60 tabs / 25 days) 2 QL (180 tabs / 25 days) 2 QL (180 tabs / 25 days) 2 QL (120 tabs / 25 days) 2 QL (120 tabs / 25 days) 2 QL (120 tabs / 25 days) 2 QL (120 tabs / 25 days) 2 QL (120 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (60 tabs / 25 days) 2 QL (240 tabs / 25 days) 2 QL (90 tabs / 25 days) 2 QL (30 tabs / 25 days) 2 QL (30 tabs / 25 days)

Opioid Combinations§ acetaminophen w/ codeine soln 120-12 2 mg/5ml acetaminophen w/ codeine tab 300-15 mg 2 acetaminophen w/ codeine tab 300-30 mg 2 acetaminophen w/ codeine tab 300-60 mg 2 CAPITAL/COD SUS 120-12/5 4 endocet tab 5-325mg 2 endocet tab 7.5-325 2 endocet tab 10-325mg 2 hydrocodone-acetaminophen soln 7.5-325 2 mg/15ml hydrocodone-acetaminophen soln 10-325 2 mg/15ml hydrocodone-acetaminophen tab 2.5-325 2 mg hydrocodone-acetaminophen tab 5-300 mg 2 hydrocodone-acetaminophen tab 5-325 mg 2 hydrocodone-acetaminophen tab 7.5-300 2 mg hydrocodone-acetaminophen tab 7.5-325 2 mg

QL (5000 mL / 25 days) QL QL QL QL QL QL QL QL

(400 tabs (400 tabs (400 tabs (5000 mL (375 tabs (375 tabs (375 tabs (5540 mL

/ / / / / / / /

25 25 25 25 25 25 25 25

days) days) days) days) days) days) days) days)

QL (5540 mL / 25 days) QL (375 tabs / 25 days) QL (400 tabs / 25 days) QL (375 tabs / 25 days) QL (400 tabs / 25 days) QL (375 tabs / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 15

October 1, 2016 Drug Name Drug Tier Requirements/Limits hydrocodone-acetaminophen tab 10-300 2 QL (400 tabs / 25 days) mg hydrocodone-acetaminophen tab 10-325 2 QL (375 tabs / 25 days) mg oxycodone w/ acetaminophen soln 5-325 2 QL (1850 mL / 25 days) mg/5ml oxycodone w/ acetaminophen tab 2.5-325 2 QL (375 tabs / 25 days) mg oxycodone w/ acetaminophen tab 5-325 mg2 QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab 7.5-325 2 QL (375 tabs / 25 days) mg oxycodone w/ acetaminophen tab 10-325 2 QL (375 tabs / 25 days) mg oxycodone-aspirin tab 4.8355-325 mg 2 QL (375 tabs / 25 days) oxycodone-ibuprofen tab 5-400 mg 2 QL (28 tabs / 25 days) PRIMLEV TAB 5-300MG 4 QL (400 tabs / 25 days) PRIMLEV TAB 7.5-300 4 QL (400 tabs / 25 days) PRIMLEV TAB 10-300MG 4 QL (400 tabs / 25 days) roxicet tab 5-325mg 2 QL (375 tabs / 25 days) vicodin es tab 7.5-300 2 QL (400 tabs / 25 days) vicodin hp tab 10-300mg 2 QL (400 tabs / 25 days) vicodin tab 5-300mg 2 QL (400 tabs / 25 days)

Opioid Partial Agonists§ buprenorphine hcl inj 0.3 mg/ml (base 2 equiv) buprenorphine hcl sl tab 2 mg (base equiv) 2 buprenorphine hcl sl tab 8 mg (base equiv) 2 buprenorphine hcl-naloxone hcl sl tab 2-0.52 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 2 mg (base equiv) butorphanol tartrate inj 1 mg/ml 2 butorphanol tartrate inj 2 mg/ml 2 butorphanol tartrate nasal soln 10 mg/ml 2 BUTRANS DIS 5MCG/HR

4

BUTRANS DIS 7.5/HR

4

BUTRANS DIS 10MCG/HR

4

QL (90 tablets per 25 days), PA QL (90 tablets per 25 days), PA QL (90 tabs per 25 days), PA QL (90 tabs per 25 days), PA

QL (2 days) QL (8 PA QL (8 PA QL (8 PA

bottles per 25 patches/25 days), patches/25 days), patches/25 days),

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 16

Drug Name BUTRANS DIS 15MCG/HR BUTRANS DIS 20MCG/HR nalbuphine hcl inj 10 mg/ml nalbuphine hcl inj 20 mg/ml SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG SUBOXONE MIS 12-3MG

October 1, 2016 Drug Tier Requirements/Limits 4 QL (4 patches/25 days), PA 4 QL (4 patches/25 days), PA 2 2 3 QL (90 units per 25 days), PA 3 QL (90 units per 25 days), PA 3 QL (90 units per 25 days), PA 3 QL (60 films per 25 days), PA

ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG oxandrolone tab 2.5 mg oxandrolone tab 10 mg

4 2 2

PA PA PA

4 2 2 2 2 2

PA

2

PA

2

PA

2 2

PA PA

Androgens ANDROXY TAB 10MG danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg methyltestosterone cap 10 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml testosterone td gel 10mg/act (2%) testosterone td gel 25 mg/2.5gm (1%)

PA PA

ANORECTAL AGENTS Intrarectal Steroids colocort ene 100mg

2

Rectal Steroids procto-pak cre 1% proctosol hc cre 2.5% proctozone cre -hc 2.5%

2 2 2

Vasodilating Agents RECTIV OIN 0.4%

4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 17

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG BILTRICIDE TAB 600MG ivermectin tab 3 mg

3 4 2

ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM aztreonam for inj 1 gm aztreonam for inj 2 gm CAYSTON INH 75MG FLAGYL ER TAB 750MG metronidazole cap 375 mg metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 250 mg metronidazole tab 500 mg NEBUPENT INH 300MG PENTAM 300 INJ 300MG PRIMSOL SOL 50MG/5ML tinidazole tab 250 mg tinidazole tab 500 mg trimethoprim tab 100 mg vancomycin hcl cap 125 mg vancomycin hcl cap 250 mg vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 mg vancomycin hcl for inj 1000 mg vancomycin hcl for inj 5000 mg VIBATIV INJ 250MG VIBATIV INJ 750MG XIFAXAN TAB 200MG XIFAXAN TAB 550MG

4 4 2 2 5 4 2 2 2 2 4 4 3 2 2 2 2 2 2 2 2 2 4 4 3 3

PA

ST; PA** ST; PA**

PA

Anti-infective Misc. - Combinations e.s.p. sus 200-600 2 sulfamethoxazole-trimethoprim iv soln 2 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 2 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 2 mg

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 18

Drug Name sulfamethoxazole-trimethoprim tab 800-160 mg

October 1, 2016 Drug Tier Requirements/Limits 2

Antiprotozoal Agents ALINIA SUS 100/5ML ALINIA TAB 500MG atovaquone susp 750 mg/5ml

3 3 2

Carbapenems DORIBAX INJ 250MG DORIBAX INJ 500MG imipenem-cilastatin intravenous for soln 250 mg imipenem-cilastatin intravenous for soln 500 mg INVANZ INJ 1GM meropenem iv for soln 1 gm meropenem iv for soln 500 mg

4 4 2 2 4 2 2

Chloramphenicols chloramphenicol sodium succinate for iv inj 2 1 gm

Cyclic Lipopeptides CUBICIN SOL 500MG

4

Glycylcyclines TYGACIL INJ 50MG

4

Ketolides KETEK TAB 300MG KETEK TAB 400MG

4 4

Leprostatics dapsone tab 25 mg dapsone tab 100 mg

2 2

Lincosamides clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml clindamycin phosphate inj 300 mg/2ml clindamycin phosphate inj 600 mg/4ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate iv soln 300 mg/2ml clindamycin phosphate iv soln 600 mg/4ml

2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 19

October 1, 2016 Drug Name Drug Tier Requirements/Limits clindamycin phosphate iv soln 900 mg/6ml 2 lincomycin hcl inj 300 mg/ml 2

Oxazolidinones linezolid for susp 100 mg/5ml linezolid in sodium chloride iv soln 600 mg/300ml-0.9% linezolid iv soln 600 mg/300ml (2 mg/ml) linezolid tab 600 mg

2 2 2 2

Polymyxins polymyxin b sulfate for inj 500000 unit

2

ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG RANEXA TAB 1000MG

3 3

ST; PA** ST; PA**

Nitrates DILATRATE SR CAP 40MG 4 isoditrate tab 40mg er 2 ISORDIL TAB 40MG 3 isosorbide dinitrate sl tab 2.5 mg 2 isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab cr 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab sr 24hr 30 mg 2 isosorbide mononitrate tab sr 24hr 60 mg 2 isosorbide mononitrate tab sr 24hr 120 mg 2 minitran dis 0.1mg/hr 2 minitran dis 0.2mg/hr 2 minitran dis 0.4mg/hr 2 minitran dis 0.6mg/hr 2 NITRO-BID OIN 2% 4 NITRO-DUR DIS 0.3MG/HR 3 NITRO-DUR DIS 0.8MG/HR 3 NITROGLYCER INJ 5MG/ML 4 nitroglycerin cap cr 2.5 mg 2 nitroglycerin cap cr 6.5 mg 2 nitroglycerin cap cr 9 mg 2 nitroglycerin iv soln 100 mcg/ml in d5w 2 nitroglycerin iv soln 200 mcg/ml in d5w 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 20

October 1, 2016 Drug Name Drug Tier Requirements/Limits nitroglycerin iv soln 400 mcg/ml in d5w 2 nitroglycerin lingual aerosol 400 mcg/spray 2 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) NITROSTAT SUB 0.3MG 3 NITROSTAT SUB 0.4MG 3 NITROSTAT SUB 0.6MG 3

ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg hydroxyzine hcl im soln 25 mg/ml

2 2 2 2 2 2

hydroxyzine hcl im soln 50 mg/ml

2

hydroxyzine hcl syrup 10 mg/5ml

2

hydroxyzine hcl tab 10 mg

2

hydroxyzine hcl tab 25 mg

2

hydroxyzine hcl tab 50 mg

2

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 21

Drug Name hydroxyzine pamoate cap 25 mg

hydroxyzine pamoate cap 50 mg

hydroxyzine pamoate cap 100 mg

meprobamate tab 200 mg meprobamate tab 400 mg

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 2

Benzodiazepines§ ALPRAZOLAM CON 1 MG/ML 3 alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 0.25 mg2 alprazolam orally disintegrating tab 1 mg 2 alprazolam orally disintegrating tab 2 mg 2 alprazolam tab 0.5 mg 2 alprazolam tab 0.25 mg 2 alprazolam tab 1 mg 2 alprazolam tab 2 mg 2 clorazepate dipotassium tab 3.75 mg 2 clorazepate dipotassium tab 7.5 mg 2 clorazepate dipotassium tab 15 mg 2 diazepam con 5mg/ml 2 diazepam oral soln 1 mg/ml 2 diazepam tab 2 mg 2 diazepam tab 5 mg 2 diazepam tab 10 mg 2 lorazepam conc 2 mg/ml 2 lorazepam tab 0.5 mg 2 lorazepam tab 1 mg 2 lorazepam tab 2 mg 2 oxazepam cap 10 mg 2 oxazepam cap 15 mg 2 oxazepam cap 30 mg 2

QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(120 mL / 25 days) (90 tabs / 25 days) (90 tabs / 25 days) (90 tabs / 25 days) (60 tabs / 25 days) (90 tabs / 25 days) (90 tabs / 25 days) (90 tabs / 25 days) (60 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (240 mL / 25 days) (1200 mL / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (120 tabs / 25 days) (150 mL / 25 days) (150 tabs / 25 days) (150 tabs / 25 days) (150 tabs / 25 days) (120 caps / 25 days) (120 caps / 25 days) (120 caps / 25 days)

ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide phosphate cap 100 mg disopyramide phosphate cap 150 mg

2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 22

Drug Name NORPACE CAP 100MG CR NORPACE CAP 150MG CR procainamide hcl inj 100 mg/ml PROCAINAMIDE INJ 500MG/ML

October 1, 2016 Drug Tier Requirements/Limits 3 3 2 4

Antiarrhythmics Type I-B lidocaine hcl iv inj 10 mg/ml lidocaine hcl iv inj 20 mg/ml lidocaine iv infusion in d5w inj 4 mg/ml lidocaine iv infusion in d5w inj 8 mg/ml mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg

2 2 2 2 2 2 2

Antiarrhythmics Type I-C flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg propafenone hcl cap sr 12hr 225 mg propafenone hcl cap sr 12hr 325 mg propafenone hcl cap sr 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg

2 2 2 2 2 2 2 2 2

Antiarrhythmics Type III amiodarone hcl inj 150 mg/3ml (50 mg/ml)2 amiodarone hcl inj 450 mg/9ml (50 mg/ml)2 amiodarone hcl inj 900 mg/18ml (50 2 mg/ml) amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 dofetilide cap 125 mcg (0.125 mg) 5 dofetilide cap 250 mcg (0.25 mg) 5 dofetilide cap 500 mcg (0.5 mg) 5 MULTAQ TAB 400MG 4 NEXTERONE INJ 4 pacerone tab 100mg 2 pacerone tab 200mg 2

PA PA PA PA

ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents§ cromolyn sodium soln nebu 20 mg/2ml

2

QL (2 boxes / 25 days)

2

QL (5 boxes / 25 days)

Bronchodilators - Anticholinergics§ ipratropium bromide inhal soln 0.02%

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 23

Drug Name SPIRIVA AER 1.25MCG SPIRIVA CAP HANDIHLR SPIRIVA SPR RESPIMAT

October 1, 2016 Drug Tier Requirements/Limits 3 3 3

Leukotriene Modulators montelukast sodium chew tab 4 mg (base 2 equiv) montelukast sodium chew tab 5 mg (base 2 equiv) montelukast sodium oral granules packet 4 2 mg (base equiv) montelukast sodium tab 10 mg (base equiv)2 zafirlukast tab 10 mg 2 zafirlukast tab 20 mg 2 ZYFLO CR TAB 600MG 4

Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG

4

PA

ASMANEX 30 AER 110MCG ASMANEX 60 AER 220MCG

3 3

ASMANEX 120 AER 220MCG

3

ASMANEX HFA AER 100 MCG

3

ASMANEX HFA AER 200 MCG

3

budesonide inhalation susp 0.5 mg/2ml budesonide inhalation susp 0.25 mg/2ml budesonide inhalation susp 1 mg/2ml QVAR AER 40MCG QVAR AER 80MCG

2 2 2 3 3

QL (2 QL (2 days) QL (1 days) QL (1 days) QL (1 days) QL (2 QL (3 QL (1

Steroid Inhalants§ inhalers / 25 days) inhalers per 25 inhaler per 25 inhaler per 25 inhaler per 25 boxes / 25 days) boxes / 25 days) box / 25 days)

Sympathomimetics§ ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 albuterol sulfate soln nebu 0.5% (5 mg/ml)2 albuterol sulfate soln nebu 0.5% (5 mg/ml)2 albuterol sulfate soln nebu 0.63 mg/3ml 2 (base equiv)

QL (3 boxes / 25 days) QL (4 boxes / 25 days) QL (5 boxes / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 24

Drug Name albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab sr 12hr 4 mg albuterol sulfate tab sr 12hr 8 mg ARCAPTA CAP 75MCG BREO ELLIPTA INH 100-25

October 1, 2016 Drug Tier Requirements/Limits 2 QL (5 boxes / 25 days) 2 2 2 2 2 2 4 4

QL (5 boxes / 25 days)

BREO ELLIPTA INH 200-25

4

BROVANA NEB 15MCG COMBIVENT AER 20-100 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg PERFOROMIST NEB 20MCG PROAIR HFA AER PROVENTIL AER HFA SEREVENT DIS AER 50MCG terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg VENTOLIN HFA AER XOPENEX HFA AER

4 3 2

QL (30 caps / 25 days) QL (1 package / 25 days), PA QL (1 package / 25 days), PA QL (2 boxes / 25 days) QL (2 inhalers / 25 days) QL (6 boxes / 25 days)

2

QL (300 mL / 25 days)

2

QL (300 mL / 25 days)

2

QL (300 mL / 25 days)

2

QL (90 mL / 25 days)

2 2 2 3 3 3 4 2 2 2 3 4

QL QL QL QL

(2 (2 (2 (1

boxes / 25 days) inhalers / 25 days) inhalers / 25 days) inhaler / 25 days)

QL (2 inhalers / 25 days) QL (2 inhalers per 25 days), ST; PA**

Xanthines aminophylline inj 25 mg/ml ELIXOPHYLLIN ELX 80/15ML LUFYLLIN TAB 200MG

2 4 4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 25

Drug Name LUFYLLIN TAB 400MG THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR THEO-24 CAP 400MG ER theochron tab 100mg cr theochron tab 200mg cr theochron tab 300mg cr theophylline soln 80 mg/15ml theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg

October 1, 2016 Drug Tier Requirements/Limits 4 4 4 4 4 2 2 2 2 2 2 2

ANTICOAGULANTS Coumarin Anticoagulants COUMADIN INJ 5 MG jantoven tab 1mg jantoven tab 2.5mg jantoven tab 2mg jantoven tab 3mg jantoven tab 4mg jantoven tab 5mg jantoven tab 6mg jantoven tab 7.5mg jantoven tab 10mg warfarin sodium tab 1 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg warfarin sodium tab 10 mg

4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Direct Factor Xa Inhibitors ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG

3 3 3 3 3 3

Heparins And Heparinoid-Like Agents enoxaparin sodium inj 30 mg/0.3ml

2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 26

October 1, 2016 Drug Name Drug Tier Requirements/Limits enoxaparin sodium inj 40 mg/0.4ml 2 enoxaparin sodium inj 60 mg/0.6ml 2 enoxaparin sodium inj 80 mg/0.8ml 2 enoxaparin sodium inj 100 mg/ml 2 enoxaparin sodium inj 120 mg/0.8ml 2 enoxaparin sodium inj 150 mg/ml 2 enoxaparin sodium inj 300 mg/3ml 2 fondaparinux sodium subcutaneous inj 2.5 2 mg/0.5ml fondaparinux sodium subcutaneous inj 5 2 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 2 mg/0.6ml fondaparinux sodium subcutaneous inj 10 2 mg/0.8ml FRAGMIN INJ 2500/0.2 4 FRAGMIN INJ 5000/0.2 4 FRAGMIN INJ 7500/0.3 4 FRAGMIN INJ 10000/ML 4 FRAGMIN INJ 12500UNT 4 FRAGMIN INJ 15000UNT 4 FRAGMIN INJ 18000UNT 4 FRAGMIN INJ 25000/ML 4 FRAGMIN INJ 95000UNT 4 heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj 10000 unit/ml 2 heparin sodium (porcine) inj 20000 unit/ml 2 heparin sodium (porcine) pf inj 5000 2 unit/0.5ml

Thrombin Inhibitors ARGATROBAN INJ 125/125 4 argatroban inj 250 mg/2.5ml (concentrate 2 for iv infusion) ARGATROBAN INJ 250/250 4

ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg ONFI SUS 2.5MG/ML ONFI TAB 5MG

2 2 2 4 4

PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 27

Drug Name ONFI TAB 10MG ONFI TAB 20MG

October 1, 2016 Drug Tier Requirements/Limits 4 PA 4 PA

Anticonvulsants - Misc. BANZEL SUS 40MG/ML 4 BANZEL TAB 200MG 4 BANZEL TAB 400MG 4 carbamazepine cap sr 12hr 100 mg 2 carbamazepine cap sr 12hr 200 mg 2 carbamazepine cap sr 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 2 carbamazepine tab sr 12hr 100 mg 2 carbamazepine tab sr 12hr 200 mg 2 carbamazepine tab sr 12hr 400 mg 2 epitol tab 200mg 2 gabapentin cap 100 mg 2 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin oral soln 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 LAMICTAL CHW 2MG 3 LAMICTAL KIT START 35 4 LAMICTAL KIT START 49 4 LAMICTAL KIT START 98 4 LAMICTAL XR KIT 4 lamotrigine orally disintegrating tab 25 mg 2 lamotrigine orally disintegrating tab 50 mg 2 lamotrigine orally disintegrating tab 100 mg2 lamotrigine orally disintegrating tab 200 mg2 lamotrigine tab 25 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab chewable dispersible 25 mg 2 lamotrigine tab disp 25 (14) & 50 mg (14) &2 100 mg (7) kit lamotrigine tab disp 25 mg (21) & 50 mg (7)2 titration kit

PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 28

October 1, 2016 Drug Name Drug Tier Requirements/Limits lamotrigine tab disp 50 mg (42) & 100 mg 2 (14) titration kit lamotrigine tab sr 24hr 25 mg 2 lamotrigine tab sr 24hr 50 mg 2 lamotrigine tab sr 24hr 100 mg 2 lamotrigine tab sr 24hr 200 mg 2 lamotrigine tab sr 24hr 250 mg 2 lamotrigine tab sr 24hr 300 mg 2 LEVETIRACETA INJ 5MG/ML 4 LEVETIRACETA INJ 10MG/ML 4 LEVETIRACETA INJ 15MG/ML 4 levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab sr 24hr 500 mg 2 levetiracetam tab sr 24hr 750 mg 2 LYRICA CAP 25MG 4 ST; PA** LYRICA CAP 50MG 4 ST; PA** LYRICA CAP 75MG 4 ST; PA** LYRICA CAP 100MG 4 ST; PA** LYRICA CAP 150MG 4 ST; PA** LYRICA CAP 200MG 4 ST; PA** LYRICA CAP 225MG 4 ST; PA** LYRICA CAP 300MG 4 ST; PA** LYRICA SOL 20MG/ML 4 ST; PA** oxcarbazepine susp 300 mg/5ml (60 2 mg/ml) oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 POTIGA TAB 50MG 4 PA POTIGA TAB 200MG 4 PA POTIGA TAB 300MG 4 PA POTIGA TAB 400MG 4 PA primidone tab 50 mg 2 primidone tab 250 mg 2 topiramate sprinkle cap 15 mg 2 topiramate sprinkle cap 25 mg 2 topiramate tab 25 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 29

Drug Name topiramate tab 50 mg topiramate tab 100 mg topiramate tab 200 mg VIMPAT INJ 200MG/20 VIMPAT SOL 10MG/ML VIMPAT TAB 50MG VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG zonisamide cap 25 mg zonisamide cap 50 mg zonisamide cap 100 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 4 PA 4 PA 4 PA 4 PA 4 PA 4 PA 2 2 2

Carbamates felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg

2 2 2

GABA Modulators GABITRIL TAB 12MG GABITRIL TAB 16MG SABRIL POW 500MG SABRIL TAB 500MG tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg

3 3 5 5 2 2

PA PA

Hydantoins DILANTIN CAP 30MG fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) PEGANONE TAB 250MG phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml

4 2 2 4 2 2 2 2 2 2

Succinimides CELONTIN CAP 300MG ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml

4 2 2

Valproic Acid

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 30

Drug Name divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg STAVZOR CAP 125MG STAVZOR CAP 250MG STAVZOR CAP 500MG valproate sodium inj 100 mg/ml valproate sodium syrup 250 mg/5ml (base equiv) valproic acid cap 250 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 4 4 4 2 2 2

ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine mirtazapine mirtazapine mirtazapine mirtazapine mirtazapine mirtazapine

orally disintegrating tab 15 mg 2 orally disintegrating tab 30 mg 2 orally disintegrating tab 45 mg 2 tab 7.5 mg 2 tab 15 mg 2 tab 30 mg 2 tab 45 mg 2

Antidepressants - Misc. APLENZIN TAB 174MG APLENZIN TAB 348MG APLENZIN TAB 522MG bupropion hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab sr 12hr 100 bupropion hcl tab sr 12hr 150 bupropion hcl tab sr 12hr 200 bupropion hcl tab sr 24hr 150 bupropion hcl tab sr 24hr 300 maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg

mg mg mg mg mg

4 4 4 2 2 2 2 2 2 2 2 2 2

Monoamine Oxidase Inhibitors (MAOIs) EMSAM DIS 6MG/24HR

4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 31

Drug Name EMSAM DIS 9MG/24HR EMSAM DIS 12MG/24H MARPLAN TAB 10MG phenelzine sulfate tab 15 mg tranylcypromine sulfate tab 10 mg

October 1, 2016 Drug Tier Requirements/Limits 4 4 4 2 2

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide oral soln 10 2 mg/5ml citalopram hydrobromide tab 10 mg (base 2 equiv) citalopram hydrobromide tab 20 mg (base 2 equiv) citalopram hydrobromide tab 40 mg (base 2 equiv) escitalopram oxalate soln 5 mg/5ml (base 2 equiv) escitalopram oxalate tab 5 mg (base equiv)2 escitalopram oxalate tab 10 mg (base 2 equiv) escitalopram oxalate tab 20 mg (base 2 equiv) fluoxetine hcl cap 10 mg 2 fluoxetine hcl cap 20 mg 2 fluoxetine hcl cap 40 mg 2 fluoxetine hcl cap delayed release 90 mg 2 fluoxetine hcl solution 20 mg/5ml 2 fluoxetine hcl tab 10 mg 2 fluoxetine hcl tab 20 mg 2 FLUOXETINE TAB 60MG 4 fluvoxamine maleate cap sr 24hr 100 mg 2 fluvoxamine maleate cap sr 24hr 150 mg 2 fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 paroxetine hcl tab 10 mg 2 paroxetine hcl tab 20 mg 2 paroxetine hcl tab 30 mg 2 paroxetine hcl tab 40 mg 2 paroxetine hcl tab sr 24hr 12.5 mg 2 paroxetine hcl tab sr 24hr 25 mg 2 paroxetine hcl tab sr 24hr 37.5 mg 2 sertraline hcl oral conc 20 mg/ml 2 sertraline hcl tab 25 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 32

Drug Name sertraline hcl tab 50 mg sertraline hcl tab 100 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2

Serotonin Modulators nefazodone hcl tab 50 mg nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg VIIBRYD KIT VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG

2 2 2 2 2 2 2 2 2 4 4 4 4 4

ST; ST; ST; ST; ST;

PA** PA** PA** PA** PA**

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine hcl enteric coated pellets cap 20 2 mg duloxetine hcl enteric coated pellets cap 30 2 mg duloxetine hcl enteric coated pellets cap 60 2 mg venlafaxine hcl cap sr 24hr 37.5 mg (base 2 equivalent) venlafaxine hcl cap sr 24hr 75 mg (base 2 equivalent) venlafaxine hcl cap sr 24hr 150 mg (base 2 equivalent) venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab 100 mg 2 venlafaxine hcl tab sr 24hr 37.5 mg (base 2 equivalent) venlafaxine hcl tab sr 24hr 75 mg (base 2 equivalent) venlafaxine hcl tab sr 24hr 150 mg (base 2 equivalent) venlafaxine hcl tab sr 24hr 225 mg (base 2 equivalent)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 33

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Tricyclic Agents§ amitriptyline hcl tab 10 mg

2

amitriptyline hcl tab 25 mg

2

amitriptyline hcl tab 50 mg

2

amitriptyline hcl tab 75 mg

2

amitriptyline hcl tab 100 mg

2

amitriptyline hcl tab 150 mg

2

amoxapine tab 25 mg

2

amoxapine tab 50 mg

2

amoxapine tab 100 mg

2

amoxapine tab 150 mg

2

clomipramine hcl cap 25 mg

2

clomipramine hcl cap 50 mg

2

clomipramine hcl cap 75 mg

2

desipramine hcl tab 10 mg

2

desipramine hcl tab 25 mg

2

QL (150 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older QL (30 tabs / 25 days); QL applies to members age 65 and older Members 65 and older subject to PA Members 65 and older subject to PA Members 65 and older subject to PA QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (60 tabs / 25 days); QL applies to members age 65 and older QL (150 caps / 25 days); QL applies to members age 65 and older QL (150 caps / 25 days); QL applies to members age 65 and older QL (90 caps / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older QL (90 tabs / 25 days); QL applies to members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 34

Drug Name desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imipramine pamoate cap 75 mg

October 1, 2016 Drug Tier Requirements/Limits 2 QL (90 tabs / 25 days); QL applies to members age 65 and older 2 QL (60 tabs / 25 days); QL applies to members age 65 and older 2 QL (30 tabs / 25 days); QL applies to members age 65 and older 2 QL (30 tabs / 25 days); QL applies to members age 65 and older 2 QL (90 caps / 25 days); QL applies to members age 65 and older 2 QL (90 caps / 25 days); QL applies to members age 65 and older 2 QL (90 caps / 25 days); QL applies to members age 65 and older 2 QL (60 caps / 25 days); QL applies to members age 65 and older 2 QL (30 caps / 25 days); QL applies to members age 65 and older 2 QL (30 caps / 25 days); QL applies to members age 65 and older 2 QL (450 mL / 25 days); QL applies to members age 65 and older 2 QL (120 tabs / 25 days); QL applies to members age 65 and older 2 QL (120 tabs / 25 days); QL applies to members age 65 and older 2 QL (60 tabs / 25 days); QL applies to members age 65 and older 2 QL (30 caps / 25 days); QL applies to members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 35

Drug Name imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg trimipramine maleate cap 100 mg

October 1, 2016 Drug Tier Requirements/Limits 2 QL (30 caps / 25 days); QL applies to members age 65 and older 2 Members 65 and older subject to PA 2 Members 65 and older subject to PA 2 QL (150 caps / 25 days); QL applies to members age 65 and older 2 QL (60 caps / 25 days); QL applies to members age 65 and older 2 QL (30 caps / 25 days); QL applies to members age 65 and older 2 Members 65 and older subject to PA 2 QL (750 mL / 25 days); QL applies to members age 65 and older 2 QL (90 tabs / 25 days); QL applies to members age 65 and older 2 QL (60 tabs / 25 days); QL applies to members age 65 and older 2 QL (60 caps / 25 days); QL applies to members age 65 and older 2 QL (60 caps / 25 days); QL applies to members age 65 and older 2 QL (30 caps / 25 days); QL applies to members age 65 and older

ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg miglitol tab 25 mg miglitol tab 50 mg miglitol tab 100 mg

2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 36

October 1, 2016 Drug Tier Requirements/Limits

Drug Name

Antidiabetic - Amylin Analogs SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG

4 4

PA PA

Antidiabetic Combinations glipizide-metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg glyburide-metformin tab 1.25-250 mg

2 2 2 2

glyburide-metformin tab 2.5-500 mg

2

glyburide-metformin tab 5-500 mg

2

JANUMET TAB 50-500MG JANUMET TAB 50-1000 JANUMET XR TAB 50-500MG JANUMET XR TAB 50-1000 JANUMET XR TAB 100-1000 JENTADUETO TAB 2.5-500 JENTADUETO TAB 2.5-850 JENTADUETO TAB 2.5-1000 pioglitazone hcl-glimepiride tab 30-2 mg pioglitazone hcl-glimepiride tab 30-4 mg pioglitazone hcl-metformin hcl tab 15-500 mg pioglitazone hcl-metformin hcl tab 15-850 mg repaglinide-metformin hcl tab 1-500 mg repaglinide-metformin hcl tab 2-500 mg

3 3 3 3 3 3 3 3 2 2 2

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

2 2 2

Biguanides metformin metformin metformin metformin metformin metformin metformin

hcl hcl hcl hcl hcl hcl hcl

tab tab tab tab tab tab tab

500 mg 2 850 mg 2 1000 mg 2 sr 24hr 500 mg 2 sr 24hr 750 mg 2 sr 24hr osmotic 500 mg 2 sr 24hr osmotic 1000 mg2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 37

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Diabetic Other GLUCAGON KIT 1MG PROGLYCEM SUS 50MG/ML

3 4

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG TRADJENTA TAB 5MG

3 3 3 3

Dopamine Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG

4

Incretin Mimetic Agents (GLP-1 Receptor Agonists) TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 VICTOZA INJ 18MG/3ML

3 3 3

Insulin APIDRA INJ SOLOSTAR APIDRA INJ U-100 HUMALOG INJ 100/ML HUMALOG KWIK INJ 100/ML HUMALOG KWIK INJ 200/ML HUMALOG MIX INJ 50/50 HUMALOG MIX INJ 50/50KWP HUMALOG MIX INJ 75/25KWP HUMALOG MIX SUS 75/25 HUMULIN INJ 70/30 HUMULIN INJ 70/30KWP HUMULIN N INJ U-100 HUMULIN N INJ U-100KWP HUMULIN R INJ U-100 HUMULIN R INJ U-500 LANTUS INJ 100/ML LANTUS INJ SOLOSTAR LEVEMIR INJ LEVEMIR INJ FLEXTOUC NOVOLIN INJ 70/30 NOVOLIN N INJ U-100 NOVOLIN R INJ U-100 NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/30

3 3 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3

OTC OTC OTC OTC OTC

OTC;RELION not covered OTC;RELION not covered OTC;RELION not covered

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 38

Drug Name NOVOLOG MIX INJ FLEXPEN

October 1, 2016 Drug Tier Requirements/Limits 3

Insulin Sensitizing Agents pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv)

2 2 2

Meglitinide Analogues nateglinide nateglinide repaglinide repaglinide repaglinide

tab tab tab tab tab

60 mg 120 mg 0.5 mg 1 mg 2 mg

2 2 2 2 2

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors FARXIGA TAB 5MG FARXIGA TAB 10MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG

3 3 3 3

Sulfonylureas chlorpropamide tab 100 mg chlorpropamide tab 250 mg glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide tab sr 24hr 2.5 mg glipizide tab sr 24hr 5 mg glipizide tab sr 24hr 10 mg glyburide micronized tab 1.5 mg

2 2 2 2 2 2 2 2 2 2 2

glyburide micronized tab 3 mg

2

glyburide micronized tab 6 mg

2

glyburide tab 1.25 mg

2

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 39

Drug Name glyburide tab 2.5 mg

glyburide tab 5 mg

tolazamide tab 250 mg tolazamide tab 500 mg tolbutamide tab 500 mg

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 2 2

ANTIDIARRHEALS Antiperistaltic Agents diphenoxylate w/ atropine liq 2.5-0.025 2 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 mg2 loperamide hcl cap 2 mg 2 MOTOFEN TAB 4

ANTIDOTES Antidotes VISTOGARD PAK 10GM

3

Antidotes - Chelating Agents CHEMET CAP 100MG EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG FERRIPROX TAB 500MG

4 5 5 5 5

PA PA PA PA

2 2 2 3 5

PA

4 4 4 2 2 2 2

QL QL QL QL QL QL QL

Opioid Antagonists naloxone hcl inj 0.4 mg/ml naloxone hcl inj 1 mg/ml naltrexone hcl tab 50 mg NARCAN SPR VIVITROL INJ 380MG

ANTIEMETICS 5-HT3 Receptor Antagonists§ ALOXI INJ 0.25MG/5 ANZEMET TAB 50MG ANZEMET TAB 100MG granisetron hcl inj 0.1 mg/ml granisetron hcl inj 1 mg/ml granisetron hcl inj 4 mg/4ml (1 mg/ml) granisetron hcl tab 1 mg

(10 mL / 21 days) (6 tablets / 21 days) (6 tablets / 21 days) (2 mL / 21 days) (2 mL / 21 days) (2 mL / 21 days) (12 tablets / 21 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 40

October 1, 2016 Drug Name Drug Tier Requirements/Limits ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 QL (20 mL / 21 days) ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2 QL (20 mL / 21 days) ondansetron hcl oral soln 4 mg/5ml 2 QL (200 mL / 21 days) ondansetron hcl tab 4 mg 2 QL (18 tablets / 21 days) ondansetron hcl tab 8 mg 2 QL (18 tablets / 21 days) ondansetron hcl tab 24 mg 2 QL (2 tablets / 21 days) ondansetron orally disintegrating tab 4 mg 2 QL (18 tablets / 21 days) ondansetron orally disintegrating tab 8 mg 2 QL (18 tablets / 21 days) SANCUSO DIS 3.1MG 4 QL (2 patches / 21 days) ZUPLENZ MIS 4MG 4 QL (18 films / 21 days) ZUPLENZ MIS 8MG 4 QL (18 films / 21 days)

Antiemetics - Anticholinergic ANTIVERT TAB 50MG dimenhydrinate tab 50 mg meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg TRANSDERM-SC DIS 1MG trimethobenzamide hcl cap 300 mg

3 2 2 2 4 2

trimethobenzamide hcl inj 100 mg/ml

2

univert tab 32mg

2

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

Antiemetics - Miscellaneous§ CESAMET CAP 1MG dronabinol cap 2.5 mg dronabinol cap 5 mg dronabinol cap 10 mg

4 2 2 2

QL QL QL QL

(18 (60 (60 (60

caps caps caps caps

/ / / /

25 25 25 25

days) days) days) days)

Substance P/Neurokinin 1 (NK1) Receptor Antagonists§ EMEND CAP 40MG

4

EMEND CAP 80MG EMEND CAP 125MG EMEND PAK 80 & 125

4 4 4

QL (3 capsules / 6 months) QL (4 capsules / 21 days) QL (2 capsules / 21 days) QL (2 packs / 21 days)

ANTIFUNGALS Antifungal - Glucan Synthesis Inhibitors (Echinocandins) CANCIDAS INJ 50MG CANCIDAS INJ 70MG ERAXIS INJ 50MG

4 4 4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 41

Drug Name ERAXIS INJ 100MG MYCAMINE INJ 50MG MYCAMINE INJ 100MG

October 1, 2016 Drug Tier Requirements/Limits 4 4 4

Antifungals ABELCET INJ 5MG/ML AMBISOME INJ 50MG AMPHOTEC INJ 50MG AMPHOTEC INJ 100MG amphotericin b for inj 50 mg BIO-STATIN CAP 500000 BIO-STATIN CAP 1000000 griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg LAMISIL GRA 125MG LAMISIL GRA 187.5MG nystatin oral powder nystatin tab 500000 unit terbinafine hcl tab 250 mg

4 4 4 4 2 3 3 2 2 2 2 4 4 2 2 2

PA PA

PA

Imidazole-Related Antifungals fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in dextrose inj 200 mg/100ml 2 fluconazole in dextrose inj 400 mg/200ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 2 fluconazole in nacl 0.9% inj 400 mg/200ml 2 fluconazole tab 50 mg 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 FLUCONAZOLE/ INJ NACL 100 4 itraconazole cap 100 mg 2 NOXAFIL SUS 40MG/ML 3 NOXAFIL TAB 100MG 3 SPORANOX SOL 10MG/ML 3 voriconazole for susp 40 mg/ml 2 voriconazole tab 50 mg 2 voriconazole tab 200 mg 2

PA

PA PA PA PA

ANTIHISTAMINES Antihistamines - Alkylamines brompheniramine tannate chew tab 12 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 42

Drug Name dexchlorpheniramine maleate syrup 2 mg/5ml

October 1, 2016 Drug Tier Requirements/Limits 2

Antihistamines - Ethanolamines arbinoxa sol 4mg/5ml carbinoxamine maleate soln 4 mg/5ml carbinoxamine maleate tab 4 mg clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)

2 2 2 2

clemastine fumarate tab 2.68 mg

2

diphenhydramine diphenhydramine diphenhydramine diphenhydramine

2 2 2 2

hcl hcl hcl hcl

cap 25 mg cap 50 mg elixir 12.5 mg/5ml inj 50 mg/ml

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

Antihistamines - Non-Sedating CLARINEX SYP 0.5MG/ML 4 desloratadine tab 5 mg 2 desloratadine tab orally disintegrating 2.5 2 mg desloratadine tab orally disintegrating 5 mg2 levocetirizine dihydrochloride soln 2.5 2 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 2

Antihistamines - Phenothiazines phenadoz sup 25mg promethazine hcl inj 25 mg/ml promethazine hcl inj 50 mg/ml promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl syrup 6.25 mg/5ml

2 2 2 2 2 2

promethazine hcl tab 12.5 mg

2

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 43

Drug Name promethazine hcl tab 25 mg

promethazine hcl tab 50 mg

promethegan sup 12.5mg promethegan sup 25mg promethegan sup 50mg

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 2 2

Antihistamines - Piperidines cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg

2 2

ANTIHYPERLIPIDEMICS Antihyperlipidemics - Combinations VYTORIN VYTORIN VYTORIN VYTORIN

TAB TAB TAB TAB

10-10MG 10-20MG 10-40MG 10-80MG

3 3 3 3

Antihyperlipidemics - Misc. omega-3-acid ethyl esters cap 1 gm

2

PA

Bile Acid Sequestrants cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm prevalite pow 4gm WELCHOL PAK 3.75GM WELCHOL TAB 625MG

2 2 2 2 2 2 2 2 3 3

Fibric Acid Derivatives choline fenofibrate cap dr 45 mg (fenofibric 2 acid equiv) choline fenofibrate cap dr 135 mg (fenofibric2 acid equiv) fenofibrate cap 50 mg 2 fenofibrate cap 150 mg 2 fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 44

Drug Name fenofibrate micronized cap 130 mg fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibrate tab 145 mg fenofibrate tab 160 mg fenofibric acid tab 35 mg fenofibric acid tab 105 mg gemfibrozil tab 600 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2

HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 mg (base equivalent) atorvastatin calcium tab 20 mg (base equivalent) atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) fluvastatin sodium cap 20 mg fluvastatin sodium cap 40 mg LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg rosuvastatin calcium tab 5 mg rosuvastatin calcium tab 10 mg rosuvastatin calcium tab 20 mg rosuvastatin calcium tab 40 mg simvastatin tab 5 mg simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 80 mg

2 2 2 2 2 2 4 4 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

ST

Intestinal Cholesterol Absorption Inhibitors ZETIA TAB 10MG

3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 45

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Nicotinic Acid Derivatives niacin tab cr 500 mg (antihyperlipidemic) 2 niacin tab cr 750 mg (antihyperlipidemic) 2 niacin tab cr 1000 mg (antihyperlipidemic) 2

PCSK-9 Inhibitors REPATHA INJ 140MG/ML REPATHA PUSH INJ 420/3.5 REPATHA SURE INJ 140MG/ML

5 5 5

PA PA PA

ANTIHYPERTENSIVES ACE Inhibitors benazepril hcl tab 5 mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg enalapril maleate tab 2.5 mg enalapril maleate tab 5 mg enalapril maleate tab 10 mg enalapril maleate tab 20 mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg lisinopril tab 2.5 mg lisinopril tab 5 mg lisinopril tab 10 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg quinapril hcl tab 5 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg ramipril cap 1.25 mg ramipril cap 2.5 mg

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 46

Drug Name ramipril cap 5 mg ramipril cap 10 mg trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2

Agents for Pheochromocytoma phenoxybenzamine hcl cap 10 mg

2

Angiotensin II Receptor Antagonists BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG candesartan cilexetil tab 4 mg candesartan cilexetil tab 8 mg candesartan cilexetil tab 16 mg candesartan cilexetil tab 32 mg EDARBI TAB 40MG EDARBI TAB 80MG eprosartan mesylate tab 600 mg irbesartan tab 75 mg irbesartan tab 150 mg irbesartan tab 300 mg losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg telmisartan tab 20 mg telmisartan tab 40 mg telmisartan tab 80 mg valsartan tab 40 mg valsartan tab 80 mg valsartan tab 160 mg valsartan tab 320 mg

4 4 4 2 2 2 2 4 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2

ST; PA** ST; PA** ST; PA**

ST; PA** ST; PA**

Antiadrenergic Antihypertensives clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 2 clonidine hcl tab 0.3 mg 2 clonidine hcl td patch weekly 0.1 mg/24hr 2 clonidine hcl td patch weekly 0.2 mg/24hr 2 clonidine hcl td patch weekly 0.3 mg/24hr 2 doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 47

Drug Name guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg methyldopa tab 250 mg methyldopa tab 500 mg methyldopate hcl inj 250 mg/5ml prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2

Antihypertensive Combinations amlodipine besylate-benazepril hcl cap 2 2.5-10 mg amlodipine besylate-benazepril hcl cap 5-102 mg amlodipine besylate-benazepril hcl cap 5-202 mg amlodipine besylate-benazepril hcl cap 5-402 mg amlodipine besylate-benazepril hcl cap 2 10-20 mg amlodipine besylate-benazepril hcl cap 2 10-40 mg amlodipine besylate-valsartan tab 5-160 2 mg amlodipine besylate-valsartan tab 5-320 2 mg amlodipine besylate-valsartan tab 10-160 2 mg amlodipine besylate-valsartan tab 10-320 2 mg amlodipine-valsartan-hydrochlorothiazide 2 tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide 2 tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide 2 tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide 2 tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide 2 tab 10-320-25 mg atenolol & chlorthalidone tab 50-25 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 48

October 1, 2016 Drug Name Drug Tier Requirements/Limits atenolol & chlorthalidone tab 100-25 mg 2 benazepril & hydrochlorothiazide tab 5-6.252 mg benazepril & hydrochlorothiazide tab 2 10-12.5 mg benazepril & hydrochlorothiazide tab 2 20-12.5 mg benazepril & hydrochlorothiazide tab 20-25 2 mg bisoprolol & hydrochlorothiazide tab 2 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 2 mg bisoprolol & hydrochlorothiazide tab 2 10-6.25 mg candesartan cilexetil-hydrochlorothiazide 2 tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide 2 tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide 2 tab 32-25 mg captopril & hydrochlorothiazide tab 25-15 2 mg captopril & hydrochlorothiazide tab 25-25 2 mg captopril & hydrochlorothiazide tab 50-15 2 mg captopril & hydrochlorothiazide tab 50-25 2 mg enalapril maleate & hydrochlorothiazide tab2 5-12.5 mg enalapril maleate & hydrochlorothiazide tab2 10-25 mg fosinopril sodium & hydrochlorothiazide tab 2 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 2 20-12.5 mg irbesartan-hydrochlorothiazide tab 2 150-12.5 mg irbesartan-hydrochlorothiazide tab 2 300-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 2 mg lisinopril & hydrochlorothiazide tab 20-12.5 2 mg

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 49

October 1, 2016 Drug Name Drug Tier Requirements/Limits lisinopril & hydrochlorothiazide tab 20-25 2 mg losartan potassium & hydrochlorothiazide 2 tab 50-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 100-12.5 mg losartan potassium & hydrochlorothiazide 2 tab 100-25 mg metoprolol & hydrochlorothiazide tab 50-252 mg metoprolol & hydrochlorothiazide tab 2 100-25 mg metoprolol & hydrochlorothiazide tab 2 100-50 mg moexipril-hydrochlorothiazide tab 7.5-12.5 2 mg moexipril-hydrochlorothiazide tab 15-12.5 2 mg moexipril-hydrochlorothiazide tab 15-25 mg2 nadolol & bendroflumethiazide tab 40-5 mg 2 nadolol & bendroflumethiazide tab 80-5 mg 2 propranolol & hydrochlorothiazide tab 40-252 mg propranolol & hydrochlorothiazide tab 80-252 mg quinapril-hydrochlorothiazide tab 10-12.5 2 mg quinapril-hydrochlorothiazide tab 20-12.5 2 mg quinapril-hydrochlorothiazide tab 20-25 mg 2 telmisartan-amlodipine tab 40-5 mg 2 telmisartan-amlodipine tab 40-10 mg 2 telmisartan-amlodipine tab 80-5 mg 2 telmisartan-amlodipine tab 80-10 mg 2 telmisartan-hydrochlorothiazide tab 2 40-12.5 mg telmisartan-hydrochlorothiazide tab 2 80-12.5 mg telmisartan-hydrochlorothiazide tab 80-25 2 mg trandolapril-verapamil hcl tab cr 1-240 mg 2 trandolapril-verapamil hcl tab cr 2-180 mg 2 trandolapril-verapamil hcl tab cr 2-240 mg 2 trandolapril-verapamil hcl tab cr 4-240 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 50

Drug Name valsartan-hydrochlorothiazide mg valsartan-hydrochlorothiazide mg valsartan-hydrochlorothiazide mg valsartan-hydrochlorothiazide mg valsartan-hydrochlorothiazide mg

October 1, 2016 Drug Tier Requirements/Limits tab 80-12.5 2 tab 160-12.5 2 tab 160-25

2

tab 320-12.5 2 tab 320-25

2

Direct Renin Inhibitors TEKTURNA TAB 150MG TEKTURNA TAB 300MG

4 4

ST; PA** ST; PA**

Selective Aldosterone Receptor Antagonists (SARAs) eplerenone tab 25 mg eplerenone tab 50 mg

2 2

Vasodilators hydralazine hcl inj 20 mg/ml hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg minoxidil tab 2.5 mg minoxidil tab 10 mg

2 2 2 2 2 2 2

ANTIMALARIALS Antimalarial Combinations atovaquone-proguanil hcl tab 62.5-25 mg 2 atovaquone-proguanil hcl tab 250-100 mg 2 COARTEM TAB 20-120MG 4

Antimalarials chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg DARAPRIM TAB 25MG hydroxychloroquine sulfate tab 200 mg mefloquine hcl tab 250 mg PRIMAQUINE TAB 26.3MG quinine sulfate cap 324 mg quinine sulfate tab 260 mg

2 2 4 2 2 4 2 2

ANTIMYASTHENIC/CHOLINERGIC AGENTS Antimyasthenic/Cholinergic Agents GUANIDINE TAB 125MG MESTINON SYP 60MG/5ML

4 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 51

Drug Name pyridostigmine bromide tab 60 mg pyridostigmine bromide tab cr 180 mg REGONOL INJ 5MG/ML

October 1, 2016 Drug Tier Requirements/Limits 2 2 4

ANTIMYCOBACTERIAL AGENTS Anti TB Combinations RIFAMATE CAP RIFATER TAB

3 3

Antimycobacterial Agents CAPASTAT SUL INJ 1GM cycloserine cap 250 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg PASER GRA 4GM PRIFTIN TAB 150MG pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg TRECATOR TAB 250MG

3 2 2 2 2 2 2 2 4 3 2 2 2 2 2 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alkylating Agents ALKERAN TAB 2MG BICNU INJ 100MG BUSULFEX INJ 6MG/ML carboplatin iv for inj 150 mg carboplatin iv soln 50 mg/5ml carboplatin iv soln 150 mg/15ml carboplatin iv soln 450 mg/45ml carboplatin iv soln 600 mg/60ml cisplatin inj 50 mg/50ml (1 mg/ml) cisplatin inj 100 mg/100ml (1 mg/ml) cisplatin inj 200 mg/200ml (1 mg/ml) CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm

3 3 3 2 2 2 2 2 2 2 2 3 3 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 52

Drug Name cyclophosphamide for inj 500 mg cyclophosphamide tab 25 mg cyclophosphamide tab 50 mg ELOXATIN INJ 200MG GLEOSTINE CAP 5MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 100MG GLIADEL WAF 7.7MG HEXALEN CAP 50MG ifosfamide for inj 1 gm ifosfamide iv inj 1 gm/20ml (50 mg/ml) ifosfamide iv inj 3 gm/60ml (50 mg/ml) LEUKERAN TAB 2MG melphalan hcl for inj 50 mg (base equiv) MYLERAN TAB 2MG oxaliplatin for iv inj 50 mg oxaliplatin for iv inj 100 mg oxaliplatin iv soln 50 mg/10ml oxaliplatin iv soln 100 mg/20ml TEMODAR INJ 100MG temozolomide cap 5 mg temozolomide cap 20 mg temozolomide cap 100 mg temozolomide cap 140 mg temozolomide cap 180 mg temozolomide cap 250 mg ZANOSAR INJ 1GM

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 3 3 3 3 3 3 3 2 2 2 3 2 3 2 2 2 2 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 3

Antimetabolites adrucil inj 500/10ml ALIMTA INJ 100MG ALIMTA INJ 500MG ARRANON INJ 5MG/ML azacitidine for inj 100 mg capecitabine tab 150 mg capecitabine tab 500 mg cladribine iv soln 10 mg/10ml (1 mg/ml) CLOLAR INJ 1MG/ML cytarabine for inj 1 gm cytarabine for inj 100 mg cytarabine for inj 500 mg cytarabine inj 20 mg/ml

2 3 3 3 5 5 5 2 3 2 2 2 2

PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 53

October 1, 2016 Drug Name Drug Tier Requirements/Limits cytarabine inj pf 20 mg/ml 2 cytarabine inj pf 100 mg/ml 2 decitabine for inj 50 mg 5 PA DEPOCYT INJ 50MG/5ML 3 floxuridine for inj 0.5 gm 2 fludarabine phosphate for inj 50 mg 2 fludarabine phosphate inj 25 mg/ml 2 fluorouracil inj 1 gm/20ml (50 mg/ml) 2 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 2 fluorouracil inj 5 gm/100ml (50 mg/ml) 2 fluorouracil inj 500 mg/10ml (50 mg/ml) 2 gemcitabine hcl for inj 1 gm 2 gemcitabine hcl for inj 2 gm 2 gemcitabine hcl for inj 200 mg 2 gemcitabine hcl inj 1 gm/26.3ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 2 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 2 mg/ml) (base equiv) mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj 250 mg/10ml (25 2 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj pf 100 mg/4ml (252 mg/ml) methotrexate sodium inj pf 200 mg/8ml (252 mg/ml) methotrexate sodium inj pf 250 mg/10ml 2 (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml 2 (25 mg/ml) methotrexate sodium tab 2.5 mg (base 2 equiv) TABLOID TAB 40MG 3 TREXALL TAB 5MG 4 TREXALL TAB 7.5MG 4 TREXALL TAB 10MG 4 TREXALL TAB 15MG 4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 54

October 1, 2016 Drug Tier Requirements/Limits

Drug Name

Antineoplastic - Angiogenesis Inhibitors ZALTRAP INJ 100/4ML ZALTRAP INJ 200/8ML

5 5

PA PA

5 5 5 5 5 5 5 5 5 5 5 5 5

PA PA PA PA PA PA PA PA PA PA PA PA PA

5 5 5 5

PA PA PA PA

Antineoplastic - Antibodies ARZERRA CON 100/5ML ARZERRA CON 1000/50 ERBITUX INJ 100MG ERBITUX INJ 200MG GAZYVA INJ 25MG/ML KADCYLA INJ 100MG KADCYLA INJ 160MG KEYTRUDA INJ 100MG/4M KEYTRUDA SOL 50MG RITUXAN INJ 100MG RITUXAN INJ 500MG YERVOY INJ 50MG YERVOY INJ 200MG

Antineoplastic - BCL-2 Inhibitors VENCLEXTA VENCLEXTA VENCLEXTA VENCLEXTA

TAB TAB TAB TAB

10MG 50MG 100MG START PK

Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAP 150MG

5

PA

Antineoplastic - Hormonal and Related Agents anastrozole tab 1 mg bicalutamide tab 50 mg DEPO-PROVERA INJ 400/ML ELIGARD INJ 7.5MG ELIGARD INJ 22.5MG ELIGARD INJ 30MG ELIGARD INJ 45MG EMCYT CAP 140MG exemestane tab 25 mg FARESTON TAB 60MG FASLODEX INJ 250MG FIRMAGON INJ 80MG FIRMAGON INJ 120MG flutamide cap 125 mg letrozole tab 2.5 mg leuprolide acetate inj kit 5 mg/ml

2 2 4 5 5 5 5 3 2 3 3 5 5 2 2 5

PA PA PA PA

PA PA

PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 55

Drug Name LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 22.5MG LUPRON DEPOT INJ 30MG LUPRON DEPOT INJ 45MG LYSODREN TAB 500MG megestrol acetate susp 40 mg/ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg NILANDRON TAB 150MG nilutamide tab 150 mg tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TRELSTAR INJ 11.25MG TRELSTAR MIX INJ 3.75MG TRELSTAR MIX INJ 22.5MG ZYTIGA TAB 250MG

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 3 2 2 2 3 2 2 $0 copay for women > 35 years for the primary prevention of breast cancer 2 $0 copay for women > 35 years for the primary prevention of breast cancer 5 PA 5 PA 5 PA 5 PA

Antineoplastic Antibiotics adriamycin inj 10mg 2 ADRIAMYCIN INJ 20MG 3 bleomycin sulfate for inj 15 unit 2 bleomycin sulfate for inj 30 unit 2 dactinomycin for inj 0.5 mg 2 daunorubicin hcl for inj 20 mg 2 daunorubicin hcl inj 5 mg/ml (base equiv) 2 DAUNOXOME INJ 2MG/ML 3 doxorubicin hcl for inj 10 mg 2 doxorubicin hcl for inj 50 mg 2 doxorubicin hcl inj 2 mg/ml 2 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)2 epirubicin hcl iv soln 200 mg/100ml (2 2 mg/ml) EPIRUBICIN INJ 50MG 3 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 2 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 2 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 56

October 1, 2016 Drug Name Drug Tier Requirements/Limits lipodox 50 inj 2mg/ml 2 lipodox inj 2mg/ml 2 mitomycin for iv soln 5 mg 2 mitomycin for iv soln 20 mg 2 mitomycin for iv soln 40 mg 2 mitoxantrone hcl inj conc 20 mg/10ml (2 5 PA mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2 5 PA mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 5 PA mg/ml)

Antineoplastic Combinations ifosfamide & mesna inj kit 1000-1000 mg

2

Antineoplastic Enzyme Inhibitors AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AFINITOR TAB 10MG BOSULIF TAB 100MG BOSULIF TAB 500MG CAPRELSA TAB 100MG CAPRELSA TAB 300MG COMETRIQ KIT 60MG COMETRIQ KIT 100MG COMETRIQ KIT 140MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG IBRANCE CAP 75MG IBRANCE CAP 100MG IBRANCE CAP 125MG ICLUSIG TAB 15MG ICLUSIG TAB 45MG imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG INLYTA TAB 1MG

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA

5

PA

5 5

PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 57

Drug Name INLYTA TAB 5MG JAKAFI TAB 5MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG LENVIMA CAP 8 MG LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LYNPARZA CAP 50MG MEKINIST TAB 0.5MG MEKINIST TAB 2MG NEXAVAR TAB 200MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SPRYCEL TAB 100MG SPRYCEL TAB 140MG STIVARGA TAB 40MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG TAFINLAR CAP 50MG TAFINLAR CAP 75MG TARCEVA TAB 25MG TARCEVA TAB 100MG TARCEVA TAB 150MG TORISEL SOL 25MG/ML TYKERB TAB 250MG VOTRIENT TAB 200MG XALKORI CAP 200MG XALKORI CAP 250MG ZELBORAF TAB 240MG ZOLINZA CAP 100MG ZYDELIG TAB 100MG ZYDELIG TAB 150MG ZYKADIA CAP 150MG

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 58

October 1, 2016 Drug Tier Requirements/Limits

Drug Name

Antineoplastic Enzymes ONCASPAR INJ 750/ML

5

PA

Antineoplastic Radiopharmaceuticals QUADRAMET INJ

3

Antineoplastics - Immunomodulators POMALYST POMALYST POMALYST POMALYST

CAP CAP CAP CAP

1MG 2MG 3MG 4MG

5 5 5 5

PA PA PA PA

5 5 5 2 2 2 5 5 5 5 3 3 3 5 3 3 2 3 3

PA PA PA

Antineoplastics Misc. ACTIMMUNE INJ 2MU/0.5 ALFERON N INJ 5MU/ML bexarotene cap 75 mg dacarbazine for inj 100 mg dacarbazine for inj 200 mg hydroxyurea cap 500 mg INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU MATULANE CAP 50MG NIPENT INJ 10MG PHOTOFRIN INJ 75MG SYNRIBO INJ 3.5MG THERACYS INJ TICE BCG INJ tretinoin cap 10 mg TRISENOX SOL 10MG/10M UVADEX INJ 20MCG/ML

PA PA PA PA

PA

Chemotherapy Adjuncts KEPIVANCE INJ 6.25MG

3

Chemotherapy Rescue/Antidote Agents amifostine crystalline for inj 500 mg dexrazoxane for inj 250 mg dexrazoxane for inj 500 mg leucovorin calcium for inj 50 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg leucovorin calcium for inj 350 mg LEUCOVORIN CALCIUM FOR INJ 500 MG leucovorin calcium tab 5 mg

2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 59

Drug Name leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg mesna inj 100 mg/ml MESNEX TAB 400MG

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 3

Mitotic Inhibitors ABRAXANE INJ 100MG 3 DOCEFREZ INJ 20MG 3 DOCEFREZ INJ 80MG 3 docetaxel for inj conc 20 mg/ml 2 docetaxel for inj conc 80 mg/4ml (20 2 mg/ml) DOCETAXEL INJ 20/0.5ML 3 DOCETAXEL INJ 20MG/2ML 3 DOCETAXEL INJ 80MG/2ML 3 DOCETAXEL INJ 80MG/8ML 3 DOCETAXEL INJ 140/7ML 3 DOCETAXEL INJ 160/8ML 3 DOCETAXEL INJ 160/16ML 3 DOCETAXEL INJ 200MG/20 3 DOCETAXEL INJ NON-ALCO 3 ETOPOPHOS INJ 100MG 3 etoposide cap 50 mg 2 etoposide inj 100 mg/5ml (20 mg/ml) 2 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)2 paclitaxel iv conc 150 mg/25ml (6 mg/ml) 2 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 2 TENIPOSIDE INJ 50MG/5ML 3 toposar inj 20mg/ml 2 toposar inj 100/5ml 2 VINBLASTINE INJ 10MG 3 vinblastine sulfate inj 1 mg/ml 2 vincasar pfs inj 1mg/ml 2 vincristine sulfate iv soln 1 mg/ml 2 vinorelbine tartrate inj 10 mg/ml (base 2 equiv) vinorelbine tartrate inj 50 mg/5ml (10 2 mg/ml) (base equiv)

Topoisomerase I Inhibitors CAMPTOSAR INJ 300/15ML HYCAMTIN CAP 0.25MG

3 5

PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 60

October 1, 2016 Drug Name Drug Tier Requirements/Limits HYCAMTIN CAP 1MG 5 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) 2 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 2 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 2 topotecan hcl for inj 4 mg 2 TOPOTECAN INJ 4MG/4ML 3

ANTIPARKINSON AGENTS Antiparkinson Adjuvants carbidopa tab 25 mg

2

Antiparkinson Anticholinergics benztropine mesylate inj 1 mg/ml benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg

2 2 2 2 2 2 2

Antiparkinson COMT Inhibitors entacapone tab 200 mg tolcapone tab 100 mg

2 2

Antiparkinson Dopaminergics amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg APOKYN INJ 10MG/ML bromocriptine mesylate cap 5 mg bromocriptine mesylate tab 2.5 mg carbidopa & levodopa orally disintegrating tab 10-100 mg carbidopa & levodopa orally disintegrating tab 25-100 mg carbidopa & levodopa orally disintegrating tab 25-250 mg carbidopa & levodopa tab 10-100 mg carbidopa & levodopa tab 25-100 mg carbidopa & levodopa tab 25-250 mg carbidopa & levodopa tab cr 25-100 mg carbidopa & levodopa tab cr 50-200 mg carbidopa-levodopa-entacapone tabs 12.5-50-200 mg carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

2 2 2 5 2 2 2

PA

2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 61

October 1, 2016 Drug Name Drug Tier Requirements/Limits carbidopa-levodopa-entacapone tabs 2 25-100-200 mg carbidopa-levodopa-entacapone tabs 2 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 2 37.5-150-200 mg carbidopa-levodopa-entacapone tabs 2 50-200-200 mg MIRAPEX ER TAB 3.75MG 3 pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg 2 pramipexole dihydrochloride tab 0.75 mg 2 pramipexole dihydrochloride tab 0.125 mg 2 pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 pramipexole dihydrochloride tab sr 24hr 2 0.75 mg pramipexole dihydrochloride tab sr 24hr 2 0.375 mg pramipexole dihydrochloride tab sr 24hr 1.52 mg pramipexole dihydrochloride tab sr 24hr 2 2.25 mg pramipexole dihydrochloride tab sr 24hr 3 2 mg pramipexole dihydrochloride tab sr 24hr 2 3.75 mg pramipexole dihydrochloride tab sr 24hr 4.52 mg ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TAB 0.5MG AZILECT TAB 1MG selegiline hcl cap 5 mg selegiline hcl tab 5 mg ZELAPAR TAB 1.25MG

3 3 2 2 4

ANTIPSYCHOTICS/ANTIMANIC AGENTS

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 62

October 1, 2016 Drug Tier Requirements/Limits

Drug Name

Antimanic Agents lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg LITHIUM SOL 8MEQ/5ML

2 2 2 2 2 2 4

Antipsychotics - Misc. GEODON INJ 20MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LATUDA TAB 120MG NUPLAZID TAB 17MG ziprasidone hcl cap 20 ziprasidone hcl cap 40 ziprasidone hcl cap 60 ziprasidone hcl cap 80

mg mg mg mg

4 3 3 3 3 3 5 2 2 2 2

ST; ST; ST; ST; ST; PA

PA** PA** PA** PA** PA**

ST; ST; ST; ST; ST; ST; ST; ST;

PA** PA** PA** PA** PA** PA** PA** PA**

Benzisoxazoles FANAPT PAK FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG FANAPT TAB 8MG FANAPT TAB 10MG FANAPT TAB 12MG INVEGA SUST INJ 39/0.25 INVEGA SUST INJ 78/0.5ML INVEGA SUST INJ 117/0.75 INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/1.5 paliperidone tab sr 24hr 1.5 mg paliperidone tab sr 24hr 3 mg paliperidone tab sr 24hr 6 mg paliperidone tab sr 24hr 9 mg RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG

4 4 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 3 3 3 3

PA PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 63

Drug Name risperidone orally disintegrating risperidone orally disintegrating mg risperidone orally disintegrating risperidone orally disintegrating risperidone orally disintegrating risperidone orally disintegrating risperidone soln 1 mg/ml risperidone tab 0.5 mg risperidone tab 0.25 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg

October 1, 2016 Drug Tier Requirements/Limits tab 0.5 mg 2 tab 0.25 2 tab tab tab tab

1 2 3 4

mg mg mg mg

2 2 2 2 2 2 2 2 2 2 2

decanoate im soln 50 mg/ml decanoate im soln 100 mg/ml lactate inj 5 mg/ml lactate oral conc 2 mg/ml tab 0.5 mg tab 1 mg tab 2 mg tab 5 mg tab 10 mg tab 20 mg

2 2 2 2 2 2 2 2 2 2

Butyrophenones haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol haloperidol

Dibenzapines clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 25 mg clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg clozapine tab 25 mg clozapine tab 50 mg clozapine tab 100 mg clozapine tab 200 mg loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg olanzapine for im inj 10 mg olanzapine orally disintegrating tab 5 mg olanzapine orally disintegrating tab 10 mg

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 64

October 1, 2016 Drug Name Drug Tier Requirements/Limits olanzapine orally disintegrating tab 15 mg 2 olanzapine orally disintegrating tab 20 mg 2 olanzapine tab 2.5 mg 2 olanzapine tab 5 mg 2 olanzapine tab 7.5 mg 2 olanzapine tab 10 mg 2 olanzapine tab 15 mg 2 olanzapine tab 20 mg 2 quetiapine fumarate tab 25 mg 2 quetiapine fumarate tab 50 mg 2 quetiapine fumarate tab 100 mg 2 quetiapine fumarate tab 200 mg 2 quetiapine fumarate tab 300 mg 2 quetiapine fumarate tab 400 mg 2 SAPHRIS SUB 2.5MG 4 ST; PA** SAPHRIS SUB 5MG 4 ST; PA** SAPHRIS SUB 10MG 4 ST; PA** SEROQUEL XR TAB 50MG 3 ST; PA** SEROQUEL XR TAB 150MG 3 ST; PA** SEROQUEL XR TAB 200MG 3 ST; PA** SEROQUEL XR TAB 300MG 3 ST; PA** SEROQUEL XR TAB 400MG 3 ST; PA**

Phenothiazines CHLORPROMAZ INJ 25MG/ML CHLORPROMAZ INJ 50MG/2ML chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg compro sup 25mg fluphenazine decanoate inj 25 mg/ml fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg

4 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 65

Drug Name perphenazine tab 16 mg prochlorperazine edisylate inj 5 mg/ml prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine suppos 25 mg thioridazine hcl tab 10 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2 2

Quinolinone Derivatives aripiprazole oral solution 1 mg/ml aripiprazole tab 2 mg aripiprazole tab 5 mg aripiprazole tab 10 mg ARIPIPRAZOLE TAB 10MG ODT aripiprazole tab 15 mg ARIPIPRAZOLE TAB 15MG ODT aripiprazole tab 20 mg aripiprazole tab 30 mg

2 2 2 2 2 2 2 2 2

Thioxanthenes thiothixene thiothixene thiothixene thiothixene

cap cap cap cap

1 mg 2 mg 5 mg 10 mg

2 2 2 2

ANTISEPTICS DISINFECTANTS Antiseptic Combinations IV PREP WIPE PAD

3

Chlorine Antiseptics PHISOHEX LIQ 3%

4

ANTIVIRALS Antiretrovirals abacavir sulfate tab 300 mg (base equiv) 2 abacavir sulfate-lamivudine-zidovudine tab 2 300-150-300 mg APTIVUS CAP 250MG 3 APTIVUS SOL 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 66

Drug Name ATRIPLA TAB COMPLERA TAB CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG didanosine delayed release capsule 125 didanosine delayed release capsule 200 didanosine delayed release capsule 250 didanosine delayed release capsule 400 EDURANT TAB 25MG EMTRIVA CAP 200MG EMTRIVA SOL 10MG/ML EPZICOM TAB 600-300 EVOTAZ TAB 300-150 FUZEON INJ 90MG GENVOYA TAB INTELENCE TAB 25MG INTELENCE TAB 100MG INTELENCE TAB 200MG INVIRASE CAP 200MG INVIRASE TAB 500MG ISENTRESS CHW 25MG ISENTRESS CHW 100MG ISENTRESS POW 100MG ISENTRESS TAB 400MG KALETRA SOL KALETRA TAB 100-25MG KALETRA TAB 200-50MG lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab 150-300 mg LEXIVA SUS 50MG/ML LEXIVA TAB 700MG nevirapine susp 50 mg/5ml nevirapine tab 200 mg nevirapine tab sr 24hr 100 mg nevirapine tab sr 24hr 400 mg NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG PREZCOBIX TAB 800-150 PREZISTA SUS 100MG/ML

October 1, 2016 Drug Tier Requirements/Limits 3 3 3 3 mg 2 mg 2 mg 2 mg 2 3 3 3 3 3 5 PA 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 3 3 2 2 2 2 3 3 3 3 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 67

Drug Name PREZISTA TAB 75MG PREZISTA TAB 150MG PREZISTA TAB 400MG PREZISTA TAB 600MG PREZISTA TAB 800MG RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG RETROVIR INJ 10MG/ML REYATAZ CAP 100MG REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG SELZENTRY TAB 150MG SELZENTRY TAB 300MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml STRIBILD TAB SUSTIVA CAP 50MG SUSTIVA CAP 200MG SUSTIVA TAB 600MG TIVICAY TAB 10MG TIVICAY TAB 25MG TIVICAY TAB 50MG TRIUMEQ TAB TRUVADA TAB 100-150 TRUVADA TAB 133-200 TRUVADA TAB 167-250 TRUVADA TAB 200-300 TYBOST TAB 150MG VIDEX SOL 2GM VIDEX SOL 4GM VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG

October 1, 2016 Drug Tier Requirements/Limits 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 68

Drug Name VITEKTA TAB 85MG VITEKTA TAB 150MG ZIAGEN SOL 20MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg

October 1, 2016 Drug Tier Requirements/Limits 3 3 3 2 2 2

CMV Agents cidofovir iv inj 75 mg/ml foscarnet sodium inj 24 mg/ml VALCYTE SOL 50MG/ML valganciclovir hcl tab 450 mg (base equivalent)

2 2 4 2

Hepatitis Agents adefovir dipivoxil tab 10 mg BARACLUDE SOL .05MG/ML entecavir tab 0.5 mg entecavir tab 1 mg EPIVIR HBV SOL 5MG/ML HARVONI TAB 90-400MG lamivudine tab 100 mg (hbv) PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEGASYS KIT REBETOL SOL 40MG/ML ribasphere cap 200mg ribasphere tab 200mg ribasphere tab 400mg ribasphere tab 600mg ribavirin cap 200 mg ribavirin tab 200 mg SOVALDI TAB 400MG TYZEKA TAB 600MG

2 3 2 2 3 5 2 5 5 5 5 5 2 2 2 2 2 2 5 5

PA

PA PA PA PA PA PA PA PA PA PA PA PA PA PA

Herpes Agents acyclovir cap 200 mg acyclovir sodium for inj 500 mg acyclovir sodium for inj 1000 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg famciclovir tab 125 mg

2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 69

Drug Name famciclovir tab 250 famciclovir tab 500 valacyclovir hcl tab valacyclovir hcl tab

mg mg 1 gm 500 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2

Influenza Agents§ RELENZA MIS DISKHALE rimantadine hydrochloride tab 100 mg TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML

3 2 3 3 3 3

QL (2 inhalers / 90 days) QL QL QL QL

(28 caps / 90 days) (14 caps / 90 days) (14 caps / 90 days) (180 mL / 90 days)

Respiratory Syncytial Virus (RSV) Agents VIRAZOLE INH 6GM

4

ASSORTED CLASSES Chelating Agents DEPEN TITRA TAB 250MG SYPRINE CAP 250MG

4 4

Immunomodulators REVLIMID CAP 2.5MG REVLIMID CAP 5MG REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 20MG REVLIMID CAP 25MG THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG

5 5 5 5 5 5 5 5 5 5

PA PA PA PA PA PA PA PA PA PA

Immunosuppressive Agents ATGAM INJ 250MG AZASAN TAB 75 MG AZASAN TAB 100MG azathioprine tab 50 mg CELLCEPT IV INJ 500MG cyclosporine cap 25 mg cyclosporine cap 100 mg cyclosporine iv soln 50 mg/ml cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg cyclosporine modified cap 100 mg cyclosporine modified oral soln 100 mg/ml

4 4 4 2 4 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 70

Drug Name gengraf cap 25mg gengraf cap 100mg gengraf sol 100mg/ml mycophenolate mofetil cap 250 mg mycophenolate mofetil for oral susp 200 mg/ml mycophenolate mofetil tab 500 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) NULOJIX INJ 250MG PROGRAF INJ 5MG/ML RAPAMUNE SOL 1MG/ML SANDIMMUNE SOL 100MG/ML SIMULECT INJ 10MG SIMULECT INJ 20MG sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg THYMOGLOBULN INJ 25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 4 4 3 4 4 4 2 2 2 2 2 2 4 3 3 3

Irrigation Solutions physiolyte sol physiosol sol irrigat tis-u-sol sol

2 2 2

Potassium Removing Resins kionex sus 15gm/60 2 sodium polystyrene sulfonate oral susp 15 2 gm/60ml sodium polystyrene sulfonate rectal susp 302 gm/120ml

Systemic Lupus Erythematosus Agents BENLYSTA INJ 120MG BENLYSTA INJ 400MG

5 5

PA PA

BETA BLOCKERS Alpha-Beta Blockers

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 71

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 4 4 4 4 2 2 2 2

Drug Name carvedilol tab 3.125 mg carvedilol tab 6.25 mg carvedilol tab 12.5 mg carvedilol tab 25 mg COREG CR CAP 10MG COREG CR CAP 20MG COREG CR CAP 40MG COREG CR CAP 80MG labetalol hcl iv soln 5 mg/ml labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg

Beta Blockers Cardio-Selective acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 25 mg atenolol tab 50 mg atenolol tab 100 mg betaxolol hcl tab 10 mg betaxolol hcl tab 20 mg bisoprolol fumarate tab 5 mg bisoprolol fumarate tab 10 mg BYSTOLIC TAB 2.5MG BYSTOLIC TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 20MG metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol succinate tab sr 24hr (tartrate equiv) metoprolol tartrate inj 1 mg/ml metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg metoprolol tartrate tab 100 mg

25 mg

2 2 2 2 2 2 2 2 2 4 4 4 4 2

50 mg

2

100 mg

2

200 mg

2 2 2 2 2

Beta Blockers Non-Selective LEVATOL TAB 20MG nadolol tab 20 mg nadolol tab 40 mg

4 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 72

Drug Name nadolol tab 80 mg pindolol tab 5 mg pindolol tab 10 mg propranolol hcl cap sr 24hr 60 mg propranolol hcl cap sr 24hr 80 mg propranolol hcl cap sr 24hr 120 mg propranolol hcl cap sr 24hr 160 mg propranolol hcl inj 1 mg/ml propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg sorine tab 80mg sorine tab 120mg sorine tab 160mg sorine tab 240mg sotalol hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg SOTALOL HCL INJ 150/10ML sotalol hcl tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg timolol maleate tab 5 mg timolol maleate tab 10 mg timolol maleate tab 20 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 2

BIOLOGICALS MISC Biologicals Misc ADAGEN INJ 250/ML

5

PA

CALCIUM CHANNEL BLOCKERS Calcium Channel Blockers afeditab tab 30mg cr afeditab tab 60mg cr amlodipine besylate tab 2.5 mg amlodipine besylate tab 5 mg amlodipine besylate tab 10 mg CARDENE IV INJ 40/200ML CARDENE IV SOL 20/200ML

2 2 2 2 2 4 4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 73

October 1, 2016 Drug Name Drug Tier Requirements/Limits CARDIZEM LA TAB 120MG 3 cartia xt cap 120/24hr 2 cartia xt cap 180/24hr 2 cartia xt cap 240/24hr 2 cartia xt cap 300/24hr 2 diltiazem hcl cap sr 12hr 60 mg 2 diltiazem hcl cap sr 12hr 90 mg 2 diltiazem hcl cap sr 12hr 120 mg 2 diltiazem hcl cap sr 24hr 120 mg 2 diltiazem hcl cap sr 24hr 180 mg 2 diltiazem hcl cap sr 24hr 240 mg 2 diltiazem hcl coated beads cap sr 24hr 120 2 mg diltiazem hcl coated beads cap sr 24hr 180 2 mg diltiazem hcl coated beads cap sr 24hr 240 2 mg diltiazem hcl coated beads cap sr 24hr 300 2 mg diltiazem hcl coated beads cap sr 24hr 360 2 mg diltiazem hcl extended release beads cap sr2 24hr 120 mg diltiazem hcl extended release beads cap sr2 24hr 180 mg diltiazem hcl extended release beads cap sr2 24hr 240 mg diltiazem hcl extended release beads cap sr2 24hr 300 mg diltiazem hcl extended release beads cap sr2 24hr 360 mg diltiazem hcl extended release beads cap sr2 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 2 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml)2 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml)2 diltiazem hcl tab 30 mg 2 diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 diltiazem hcl tab 120 mg 2 DILTIAZEM INJ 100MG 4 felodipine tab sr 24hr 2.5 mg 2 felodipine tab sr 24hr 5 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 74

October 1, 2016 Drug Name Drug Tier Requirements/Limits felodipine tab sr 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 matzim la tab 180mg/24 2 matzim la tab 240mg/24 2 matzim la tab 300mg/24 2 matzim la tab 360mg/24 2 matzim la tab 420mg/24 2 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedical xl tab 30mg 2 nifedical xl tab 60mg 2 nifedipine tab sr 24hr 30 mg 2 nifedipine tab sr 24hr 60 mg 2 nifedipine tab sr 24hr 90 mg 2 nifedipine tab sr 24hr osmotic release 30 mg2 nifedipine tab sr 24hr osmotic release 60 mg2 nifedipine tab sr 24hr osmotic release 90 mg2 nimodipine cap 30 mg 2 nisoldipine tab sr 24hr 8.5 mg 2 nisoldipine tab sr 24hr 17 mg 2 nisoldipine tab sr 24hr 20 mg 2 nisoldipine tab sr 24hr 25.5 mg 2 nisoldipine tab sr 24hr 30 mg 2 nisoldipine tab sr 24hr 34 mg 2 nisoldipine tab sr 24hr 40 mg 2 taztia xt cap 120mg/24 2 taztia xt cap 180mg/24 2 taztia xt cap 240mg/24 2 taztia xt cap 300mg/24 2 taztia xt cap 360mg/24 2 verapamil hcl cap sr 24hr 100 mg 2 verapamil hcl cap sr 24hr 120 mg 2 verapamil hcl cap sr 24hr 180 mg 2 verapamil hcl cap sr 24hr 200 mg 2 verapamil hcl cap sr 24hr 240 mg 2 verapamil hcl cap sr 24hr 300 mg 2 verapamil hcl cap sr 24hr 360 mg 2 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 2 verapamil hcl tab 80 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 75

Drug Name verapamil hcl verapamil hcl verapamil hcl verapamil hcl

tab tab tab tab

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2

120 mg cr 120 mg cr 180 mg cr 240 mg

CARDIOTONICS Cardiac Glycosides digox tab 0.25mg digox tab 0.125mg digoxin inj 0.25 mg/ml digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) LANOXIN PED INJ 0.1MG/ML LANOXIN TAB 0.0625MG LANOXIN TAB 0.1875MG

2 2 2 2 2 2 4 3 3

CARDIOVASCULAR AGENTS - MISC. Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin tab 2.5-10 mg amlodipine besylate-atorvastatin tab 2.5-20 mg amlodipine besylate-atorvastatin tab 2.5-40 mg amlodipine besylate-atorvastatin tab 5-10 mg amlodipine besylate-atorvastatin tab 5-20 mg amlodipine besylate-atorvastatin tab 5-40 mg amlodipine besylate-atorvastatin tab 5-80 mg amlodipine besylate-atorvastatin tab 10-10 mg amlodipine besylate-atorvastatin tab 10-20 mg amlodipine besylate-atorvastatin tab 10-40 mg amlodipine besylate-atorvastatin tab 10-80 mg ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB 97-103MG

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2

calcium

2 3 3 3

Prostaglandin Vasodilators

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 76

Drug Name epoprostenol sodium for inj 0.5 mg epoprostenol sodium for inj 1.5 mg REMODULIN INJ 1MG/ML REMODULIN INJ 2.5MG/ML REMODULIN INJ 5MG/ML REMODULIN INJ 10MG/ML TYVASO START SOL 0.6MG/ML VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA

Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS TAB 5MG LETAIRIS TAB 10MG TRACLEER TAB 62.5MG TRACLEER TAB 125MG

5 5 5 5

PA PA PA PA

Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA TAB 20MG 5 sildenafil citrate iv soln 10 mg/12.5ml (base5 equivalent) sildenafil citrate tab 20 mg 5

PA, ST PA PA

CEPHALOSPORINS Cephalosporins - 1st Generation cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm CEFAZOL/DEX SOL 1GM CEFAZOL/DEX SOL 2GM CEFAZOLIN INJ 1GM/50ML cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln 1 gm CEFAZOLIN SOL cephalexin cap 250 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml cephalexin tab 250 mg cephalexin tab 500 mg

2 2 2 2 4 4 4 2 2 2 2 2 4 2 2 2 2 2 2 2

Cephalosporins - 2nd Generation

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 77

Drug Name cefaclor cap 250 mg cefaclor cap 500 mg CEFACLOR ER TAB 500MG cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml CEFOTET/DEX INJ 1-3.58% CEFOTET/DEX INJ 2-2.08% CEFOTETAN DISODIUM FOR INJ 1 GM CEFOTETAN DISODIUM FOR INJ 2 GM CEFOTETAN DISODIUM FOR INJ 10 GM CEFOXITIN INJ 1GM CEFOXITIN INJ 2GM cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg CEFTIN SUS 125/5ML CEFTIN SUS 250/5ML CEFUROX/DEXT INJ 1.5GM CEFUROX/DEXT INJ 750MG cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg CEFUROXIME INJ 7.5GM CEFUROXIME INJ 75GM CEFUROXIME INJ 225GM cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 gm MEFOXIN INJ 1GM/50ML MEFOXIN INJ 2GM/50ML ZINACEF INJ 750MG ZINACEF/H20 INJ 1.5GM PB

October 1, 2016 Drug Tier Requirements/Limits 2 2 3 2 2 2 4 4 2 2 2 4 4 2 2 2 2 2 2 2 3 3 4 4 2 2 4 4 4 2 2 2 2 4 4 4 4

Cephalosporins - 3rd Generation CEDAX SUS 90MG/5ML cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml

4 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 78

Drug Name cefditoren pivoxil tab 200 mg (base equivalent) cefditoren pivoxil tab 400 mg (base equivalent) cefixime for susp 100 mg/5ml cefixime for susp 200 mg/5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 10 gm cefotaxime sodium for inj 500 mg cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg ceftazidime for inj 2 gm CEFTAZIDIME INJ 100GM CEFTAZIDIME/ SOL D5W 1GM CEFTAZIDIME/ SOL D5W 2GM ceftibuten cap 400 mg ceftibuten for susp 180 mg/5ml ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm CLAFORAN INJ 1GM CLAFORAN INJ 2GM FORTAZ INJ 1GM FORTAZ INJ 2GM FORTAZ INJ 500MG SUPRAX CAP 400MG SUPRAX CHW 100MG SUPRAX CHW 200MG SUPRAX SUS 500/5ML SUPRAX TAB 400MG tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 2 2 2 2 2 2 2 2 2 4 4 4 4 4 3 3 3 3 3 2 2 2

Cephalosporins - 4th Generation cefepime hcl for inj 1 gm

2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 79

Drug Name cefepime hcl for inj 2 gm CEFEPIME INJ 1GM CEFEPIME INJ 2GM CEFEPIME/DEX INJ 1GM MAXIPIME INJ 1GM MAXIPIME INJ 2GM

October 1, 2016 Drug Tier Requirements/Limits 2 4 4 4 4 4

Cephalosporins - 5th Generation TEFLARO INJ 400MG TEFLARO INJ 600MG

4 4

CONTRACEPTIVES Combination Contraceptives - Oral altavera tab alyacen tab 1/35 alyacen tab 7/7/7 amethia tab amethyst tab 90-20mcg apri tab aranelle tab aviane tab azurette tab 28 day BEYAZ TAB caziant pak cesia pak chateal tab 0.15/30 cryselle-28 tab 28 tabs cyclafem tab 1/35 cyclafem tab 7/7/7 dasetta tab 1/35 dasetta tab 7/7/7 drospirenone-ethinyl estradiol tab 3-0.03 mg elinest tab emoquette tab enpresse-28 tab falmina tab gianvi tab 3-0.02mg gildess fe tab 1.5/30 gildess fe tab 1/20 gildess tab 1.5/30 gildess tab 1/20 introvale tab jolessa tab

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 80

October 1, 2016 Drug Name Drug Tier Requirements/Limits junel 1.5/30 tab 1 junel 1/20 tab 1 junel fe tab 1.5/30 1 junel fe tab 1/20 1 kariva tab 28 day 1 kelnor tab 1/35 1 kurvelo tab 0.15/30 1 leena tab 1 lessina tab 1 levonest tab 1 levonorg-eth est tab 0.1-0.02mg(84) & eth 1 est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) 1 tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.15 1 mg-30 mcg levora-28 tab 0.15/30 1 LO LOESTRIN TAB 1 lomedia 24 tab fe 1 loryna tab 3-0.02mg 1 low-ogestrel tab 1 lutera tab 1 marlissa tab 0.15/30 1 MINASTRIN 24 CHW FE 1 mono-linyah tab 0.25-35 1 mononessa tab 1 myzilra tab 1 NATAZIA TAB 1 necon tab 0.5/35 1 necon tab 1/35 1 necon tab 1/50-28 1 necon tab 7/7/7 1 NECON TAB 10/11-28 1 norethindrone & ethinyl estradiol-fe chew 1 tab 0.8 mg-25 mcg norgestimate & ethinyl estradiol tab 0.25 1 mg-35 mcg norgestimate-eth estrad tab 1 0.18-25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 1 0.18-35/0.215-35/0.25-35 mg-mcg nortrel tab 0.5/35 1 nortrel tab 1/35 1

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 81

Drug Name nortrel tab 7/7/7 ocella tab 3-0.03mg ogestrel tab orsythia tab portia-28 tab previfem tab QUARTETTE TAB quasense tab reclipsen tab SAFYRAL TAB solia tab sprintec 28 tab 28 day sronyx tab syeda tab 3-0.03mg tilia fe tab tri-linyah tab tri-previfem tab tri-sprintec tab trinessa tab trivora-28 tab velivet pak vestura tab 3-0.02mg viorele tab wera tab 0.5/35 zarah tab 3-0.03mg zenchent fe chw 0.4mg-35 zenchent tab zovia 1/35e tab zovia 1/50e tab

October 1, 2016 Drug Tier Requirements/Limits 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Combination Contraceptives - Transdermal xulane dis 150-35

1

Combination Contraceptives - Vaginal NUVARING MIS

1

QL (13 / 300 days)

1

QL (1 unit / 300 days)

Copper Contraceptives - IUD PARAGARD IUD T380A

Emergency Contraceptives ELLA TAB 30MG levonorgestrel tab 0.75 mg levonorgestrel tab 1.5 mg

1 1 1

Progestin Contraceptives - IUD LILETTA IUD 52MG

1

QL (1 / 300 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 82

Drug Name MIRENA IUD SYSTEM SKYLA IUD 13.5MG

October 1, 2016 Drug Tier Requirements/Limits 1 QL (1 / 300 days) 1 QL (1 / 300 days)

Progestin Contraceptives - Implants IMPLANON IMP 68MG NEXPLANON IMP 68MG

1 1

QL (1 / 300 days) QL (1 / 300 days)

Progestin Contraceptives - Injectable DEPO-SQ PROV INJ 104 1 medroxyprogesterone acetate im susp 150 1 mg/ml

QL (4 inj / 300 days) QL (4 inj / 300 days)

Progestin Contraceptives - Oral camila tab 0.35mg errin tab 0.35mg heather tab 0.35mg jolivette tab 0.35mg nora-be tab 0.35mg norethindrone tab 0.35 mg

1 1 1 1 1 1

CORTICOSTEROIDS Glucocorticosteroids a-hydrocort inj 100mg 2 a-methapred inj 40mg 2 a-methapred inj 125mg 2 budesonide delayed release particles cap 3 2 mg cortisone acetate tab 25 mg 2 DEPO-MEDROL INJ 20MG/ML 4 DEXAMETHASON CON 1MG/ML 3 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone sod phosphate preservative2 free inj 10 mg/ml dexamethasone sodium phosphate inj 4 2 mg/ml dexamethasone sodium phosphate inj 10 2 mg/ml dexamethasone sodium phosphate inj 20 2 mg/5ml dexamethasone sodium phosphate inj 100 2 mg/10ml dexamethasone sodium phosphate inj 120 2 mg/30ml dexamethasone soln 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 2 dexamethasone tab 0.75 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 83

October 1, 2016 Drug Name Drug Tier Requirements/Limits dexamethasone tab 1 mg 2 dexamethasone tab 1.5 mg 2 dexamethasone tab 2 mg 2 dexamethasone tab 4 mg 2 dexamethasone tab 6 mg 2 DEXPAK PAK 6 DAY 4 DEXPAK PAK 10 DAY 4 DEXPAK PAK 13 DAY 4 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 MEDROL TAB 2MG 3 methylprednisolone acetate inj susp 40 2 mg/ml methylprednisolone acetate inj susp 80 2 mg/ml methylprednisolone sodium succinate for inj2 40 mg methylprednisolone sodium succinate for inj2 125 mg methylprednisolone sodium succinate for inj2 500 mg methylprednisolone sodium succinate for inj2 1000 mg methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab therapy pack 4 mg 2 (21) MILLIPRED DP PAK 5MG 4 MILLIPRED SOL 10MG/5ML 4 MILLIPRED TAB 5MG 4 prednisolone sod phos orally disintegr tab 2 10 mg (base eq) prednisolone sod phos orally disintegr tab 2 15 mg (base eq) prednisolone sod phos orally disintegr tab 2 30 mg (base eq) prednisolone sod phosph oral soln 6.7 2 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 2 mg/5ml (base equiv)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 84

October 1, 2016 Drug Name Drug Tier Requirements/Limits prednisolone sodium phosphate oral soln 252 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp solution2 equivalent) PREDNISONE CON 5MG/ML 3 prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2 prednisone tab 2.5 mg 2 prednisone tab 5 mg 2 prednisone tab 10 mg 2 prednisone tab 20 mg 2 prednisone tab 50 mg 2 prednisone tab therapy pack 5 mg (21) 2 prednisone tab therapy pack 5 mg (48) 2 prednisone tab therapy pack 10 mg (21) 2 prednisone tab therapy pack 10 mg (48) 2 SOLU-CORTEF INJ 100MG 4 SOLU-CORTEF INJ 250MG 4 SOLU-CORTEF INJ 500MG 4 SOLU-CORTEF INJ 1000MG 4 SOLU-MEDROL INJ 2GM 4 VERIPRED 20 SOL 20MG/5ML 4

Mineralocorticoids fludrocortisone acetate tab 0.1 mg

2

COUGH/COLD/ALLERGY Antitussives benzonatate cap 100 mg 2 benzonatate cap 200 mg 2 hydrocodone w/ homatropine syrup 5-1.5 2 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg 2 hydromet syp 5-1.5/5 2 tussigon tab 5-1.5mg 2

Cough/Cold/Allergy Combinations ALLFEN CDX LIQ cheratussin syp 100-10/5 NORTUSS-EX LIQ 200-20/5 prometh vc syp plain prometh vc/ syp codeine promethazine w/ codeine syrup 6.25-10 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml

3 2 3 2 2 2

OTC

2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 85

October 1, 2016 Drug Name Drug Tier Requirements/Limits pseudoephed-bromphen-dm syrup 30-2-10 2 mg/5ml tgq 50pse/3 syp brm/30dm 2

Misc. Respiratory Inhalants sodium sodium sodium sodium

chloride chloride chloride chloride

soln soln soln soln

nebu nebu nebu nebu

0.9% 3% 7% 10%

2 2 2 2

Mucolytics acetylcysteine inhal soln 10% acetylcysteine inhal soln 20%

2 2

DERMATOLOGICALS Acne Products ACANYA GEL 1.2-2.5% adapalene cream 0.1%

4 2

adapalene gel 0.1%

2

adapalene gel 0.3%

2

adapalene lotion 0.1%

2

amnesteem cap 10mg amnesteem cap 20mg amnesteem cap 40mg avar cleanse emu 10-5% avar-e emoll cre 10-5% avar-e green cre 10-5% avita cre 0.025%

2 2 2 2 2 2 2

avita gel 0.025%

2

AZELEX CRE 20% BENZAMYCIN GEL PAK benzepro aer 5.3% BENZIQ GEL 5.25% BENZIQ LS GEL 2.75%

4 3 2 3 3

ST; PA** PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA PA PA

PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older ST; PA**

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 86

Drug Name benziq wash liq 5.25% benzoyl per liq 10% wash benzoyl peroxide foam 5.3% benzoyl peroxide foam 9.8% benzoyl peroxide-erythromycin gel 5-3% bp wash liq 2.5% bp wash liq 7% BPO CLOTHS MIS 3% BPO CLOTHS MIS 6% BPO CLOTHS MIS 9% BPO GEL 4% BPO GEL 8% cerisa wash emu 10-1% claravis cap 10mg claravis cap 20mg claravis cap 30mg claravis cap 40mg clearplex x gel 10% clindamax gel 1% clindamax lot 10mg/ml clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% clindamycin phosphate foam 1% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate-benzoyl peroxide gel 1-5% EPIDUO FORTE GEL 0.3-2.5% EPIDUO GEL 0.1-2.5% ery pad 2% erythromycin gel 2% erythromycin pads 2% erythromycin soln 2% myorisan cap 10mg myorisan cap 20mg myorisan cap 40mg oscion clnsr lot 6% pr benzoyl liq 7% wash sss 10-5 aer 10-5% sulfacetamide sodium lotion 10% (acne)

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 3 2 3 3 3 2 2 PA 2 PA 2 PA 2 PA 2 2 2 2 2 2 2 2 2 2 4 4 2 2 2 2 2 2 2 2 2 2 2

PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 87

Drug Name sulfacetamide sodium w/ 9.8-4.8% sulfacetamide sodium w/ 10-2% sulfacetamide sodium w/ cloth 10-5% sulfacetamide sodium w/ pad 10-4% sulfacetamide sodium w/ 9.8-4.8% sulfacetamide sodium w/ 10-2% sulfacetamide sodium w/ 10-5% sulfacetamide sodium w/ 9.8-4.8% sulfacetamide sodium w/ 10-5% sulfacetamide sodium w/ sulfacetamide sodium w/ 9-4.5% sulfacleanse sus 8-4% TRETIN-X CRE 0.075%

sulfur cleanser

October 1, 2016 Drug Tier Requirements/Limits 2

sulfur cleanser

2

sulfur cleansing

2

sulfur cleansing

2

sulfur cream

2

sulfur cream

2

sulfur cream

2

sulfur lotion

2

sulfur lotion

2

sulfur wash 9-4% 2 sulfur wash 2 2 4

TRETIN-X CRE 0.0375%

4

tretinoin cream 0.1%

2

tretinoin cream 0.05%

2

tretinoin cream 0.025%

2

tretinoin gel 0.01%

2

tretinoin gel 0.05%

2

PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older PA; PA applies for members age 35 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 88

Drug Name tretinoin gel 0.025% tretinoin microsphere gel 0.1% tretinoin microsphere gel 0.04% VELTIN GEL ZIANA GEL

October 1, 2016 Drug Tier Requirements/Limits 2 PA; PA applies for members age 35 and older 2 PA; PA applies for members age 35 and older 2 PA; PA applies for members age 35 and older 4 PA; PA applies for members age 35 and older 4 PA; PA applies for members age 35 and older

Agents for External Genital and Perianal Warts VEREGEN OIN 15%

4

Anti-inflammatory Agents - Topical§ diclofenac sodium gel 1% VOLTAREN GEL 1%

2 4

Antibiotics - Topical ALTABAX OIN 1% CORTISPORIN CRE 0.5% CORTISPORIN OIN 1% gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% mupirocin oint 2%

4 4 4 2 2 2

Antifungals - Topical ciclopirox gel 0.77% 2 ciclopirox kit 8% 2 ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox olamine susp 0.77% (base equiv)2 ciclopirox shampoo 1% 2 ciclopirox solution 8% 2 clotrimazole cream 1% 2 CLOTRIMAZOLE CRY 4 clotrimazole soln 1% 2 clotrimazole w/ betamethasone cream 2 1-0.05% clotrimazole w/ betamethasone lotion 2 1-0.05% econazole nitrate cream 1% 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 89

Drug Name ERTACZO CRE 2% EXELDERM CRE 1% EXELDERM SOL 1% ketoconazole cream 2% ketoconazole shampoo 2% ketodan aer 2% MENTAX CRE 1% naftifine hcl cream 1% naftifine hcl cream 2% NAFTIN GEL 1% NAFTIN GEL 2% nyamyc pow 100000 nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm nystatin topical powder nystatin-triamcinolone cream 100000-0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 unit/gm-% nystop pow 100000 oxiconazole nitrate cream 1% OXISTAT LOT 1% XOLEGEL GEL 2%

October 1, 2016 Drug Tier Requirements/Limits 4 4 4 2 2 2 4 2 2 4 4 2 2 2 2 2 2 2 2 4 4

Antineoplastic or Premalignant Lesion Agents - Topical FLUOROPLEX CRE 1% fluorouracil cream 0.5% fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5% PANRETIN GEL 0.1% PICATO GEL 0.05% PICATO GEL 0.015% TARGRETIN GEL 1%

4 2 2 2 2 4 4 4 5

PA

Antipruritics - Topical doxepin hcl cream 5%

2

Antipsoriatics acitretin cap 10 mg acitretin cap 17.5 mg acitretin cap 25 mg calcipotriene cream 0.005% calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml)

2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 90

Drug Name calcitrene oin 0.005% calcitriol oint 3 mcg/gm methoxsalen rapid cap 10 mg 8-MOP CAP 10MG STELARA INJ 45MG/0.5 STELARA INJ 90MG/ML TAZORAC CRE 0.1% TAZORAC CRE 0.05% TAZORAC GEL 0.1% TAZORAC GEL 0.05%

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 4 6 PA, ST 6 PA, ST 3 PA 3 PA 3 PA 3 PA

Antiseborrheic Products selenium sulfide lotion 2.5% selenium sulfide-pyrithione zinc in urea shampoo 2.25%

2 2

Antivirals - Topical acyclovir oint 5% DENAVIR CRE 1%

2 4

Burn Products silver sulfadiazine cream 1% ssd cre 1% SULFAMYLON CRE 85MG/GM

2 2 4

Corticosteroids - Topical ala cort cre 1% alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% alphatrex gel 0.05% amcinonide cream 0.1% amcinonide lotion 0.1% AMCINONIDE OIN 0.1% apexicon oin 0.05% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate aerosol foam 0.12% betamethasone valerate cream 0.1%

2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 91

Drug Name betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1% calcipotriene-betamethasone dipropionate oint 0.005-0.064% CAPEX SHA 0.01% clobetasol propionate cream 0.05% clobetasol propionate foam 0.05% clobetasol propionate gel 0.05% clobetasol propionate lotion 0.05% clobetasol propionate oint 0.05% clobetasol propionate shampoo 0.05% clobetasol propionate soln 0.05% clobetasol propionate spray 0.05% clocortolone pivalate cream 0.1% CORDRAN 24X3 TAP 4MCG/CM CORDRAN LOT 0.05% CORDRAN OIN 0.05% DESONATE GEL 0.05% desonide cream 0.05% desonide lotion 0.05% desonide oint 0.05% DESOWEN OINT KIT 0.05% desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% desoximetasone oint 0.05% desoximetasone oint 0.25% diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% fluocin acet oil 0.01% sc fluocin acet oil body fluocinolone acetonide cream 0.01% fluocinolone acetonide cream 0.025% fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.1% fluocinonide cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% flurandrenolide cream 0.05% fluticasone propionate cream 0.05%

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 4 2 2 2 2 2 2 2 2 2 4 4 4 4 2 2 2 4 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 92

October 1, 2016 Drug Name Drug Tier Requirements/Limits fluticasone propionate lotion 0.05% 2 fluticasone propionate oint 0.005% 2 halobetasol propionate cream 0.05% 2 halobetasol propionate oint 0.05% 2 HALOG CRE 0.1% 4 HALOG OIN 0.1% 4 hydrocortisone butyrate cream 0.1% 2 hydrocortisone butyrate hydrophilic lipo 2 base cream 0.1% hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone cream 1% 2 hydrocortisone cream 2.5% 2 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 hydrocortisone oint 2.5% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 lokara lot 0.05% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 PEDIADERM HC KIT 4 PEDIADERM TA KIT 4 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 scalacort lot 2% 2 TACLONEX SUS 4 TEXACORT SOL 2.5% 4 triamcinolone acetonide aerosol soln 0.147 2 mg/gm triamcinolone acetonide cream 0.1% 2 triamcinolone acetonide cream 0.5% 2 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 2 triamcinolone acetonide oint 0.5% 2 triamcinolone acetonide oint 0.025% 2 TRIANEX OIN 0.05% 4 triderm cre 0.1% 2 VERDESO AER 0.05% 4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 93

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Emollients laclotion lot 12% 2 lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 lactic acid (ammonium lactate) lotion 12% 2

Enzymes - Topical SANTYL OIN 250/GM

4

Immunomodulating Agents - Topical imiquimod cream 5% ZYCLARA CRE 3.75% ZYCLARA PUMP CRE 2.5%

2 4 4

Immunosuppressive Agents - Topical ELIDEL CRE 1% tacrolimus oint 0.1% tacrolimus oint 0.03%

3 2 2

ST; PA** ST; PA** ST; PA**

Keratolytic/Antimitotic Agents CONDYLOX GEL 0.5% podofilox soln 0.5%

4 2

Local Anesthetics - Topical lidocaine hcl cream 3% lidocaine hcl gel 2% lidocaine hcl lotion 3% lidocaine hcl soln 4% lidocaine oint 5% lidocaine patch 5% lidocaine-prilocaine cream 2.5-2.5% lidocaine-prilocaine cream kit 2.5-2.5% pramox gel 1% SYNERA DIS 70-70MG

2 2 2 2 2 2 2 2 2 4

Rosacea Agents FINACEA GEL 15% metronidazole cream 0.75% metronidazole gel 0.75% metronidazole gel 1% metronidazole lotion 0.75% rosadan cre 0.75%

4 2 2 2 2 2

Scabicides Pediculicides acticin cre 5% EURAX CRE 10% EURAX LOT 10% lindane lotion 1%

2 4 4 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 94

Drug Name lindane shampoo 1% malathion lotion 0.5% permethrin cream 5% SKLICE LOT 0.5% spinosad susp 0.9% ULESFIA LOT 5%

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 4 2 4

Wound Care Products REGRANEX GEL 0.01%

4

DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Dietary Management Products folbic tab

2

DIGESTIVE AIDS Digestive Enzymes CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 36000UNT SUCRAID SOL 8500/ML VIOKACE TAB VIOKACE TAB 20880 ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 40000UNT

3 3 3 3 3 4 3 3 3 3 3 3 3 3 3

DIURETICS Carbonic Anhydrase Inhibitors acetazolamide cap sr 12hr 500 mg acetazolamide sodium for inj 500 mg acetazolamide tab 125 mg acetazolamide tab 250 mg methazolamide tab 25 mg methazolamide tab 50 mg

2 2 2 2 2 2

Diuretic Combinations ALDACTAZIDE TAB 50/50 amiloride & hydrochlorothiazide tab 5-50 mg

3 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 95

Drug Name spironolactone & hydrochlorothiazide tab 25-25 mg triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide cap 50-25 mg triamterene & hydrochlorothiazide tab 37.5-25 mg triamterene & hydrochlorothiazide tab 75-50 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2

Loop Diuretics bumetanide inj 0.25 mg/ml bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg EDECRIN TAB 25MG ethacrynate sodium for inj 50 mg ethacrynic acid tab 25 mg furosemide inj 10 mg/ml FUROSEMIDE ORAL SOLN 8 MG/ML furosemide oral soln 10 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg TORSEMIDE INJ 20MG/2ML TORSEMIDE INJ 50MG/5ML torsemide tab 5 mg torsemide tab 10 mg torsemide tab 20 mg torsemide tab 100 mg

2 2 2 2 4 2 2 2 2 2 2 2 2 4 4 2 2 2 2

Potassium Sparing Diuretics amiloride hcl tab 5 mg DYRENIUM CAP 50MG DYRENIUM CAP 100MG spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg

2 4 4 2 2 2

Thiazides and Thiazide-Like Diuretics chlorothiazide sodium for inj 500 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorthalidone tab 25 mg

2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 96

Drug Name chlorthalidone tab 50 mg chlorthalidone tab 100 mg DIURIL SUS 250/5ML hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg methyclothiazide tab 5 mg metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 4 2 2 2 2 2 2 2 2 2 2

ENDOCRINE AND METABOLIC AGENTS - MISC. Bone Density Regulators alendronate sodium oral soln 70 mg/75ml 2 alendronate sodium tab 5 mg 2 alendronate sodium tab 10 mg 2 alendronate sodium tab 35 mg 2 alendronate sodium tab 40 mg 2 alendronate sodium tab 70 mg 2 calcitonin (salmon) nasal soln 200 unit/act 2 FORTEO SOL 600/2.4 5 FOSAMAX + D TAB 70-2800 4 FOSAMAX + D TAB 70-5600 4 ibandronate sodium iv soln 3 mg/3ml (base2 equivalent) ibandronate sodium tab 150 mg (base 2 equivalent) MIACALCIN INJ 200/ML 4 pamidronate disodium for inj 30 mg 2 pamidronate disodium for inj 90 mg 2 pamidronate disodium iv soln 3 mg/ml 2 pamidronate disodium iv soln 9 mg/ml 2 PAMIDRONATE INJ 6MG/ML 4 PROLIA SOL 60MG/ML 5 risedronate sodium tab 5 mg 2 risedronate sodium tab 30 mg 2 risedronate sodium tab 35 mg 2 risedronate sodium tab 150 mg 2 risedronate sodium tab delayed release 35 2 mg

PA ST; PA** ST; PA**

PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 97

Drug Name XGEVA INJ zoledronic acid inj conc for iv infusion 4 mg/5ml zoledronic acid iv soln 5 mg/100ml ZOLEDRONIC INJ 4MG/100 ZOMETA INJ 4MG/100

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 5 5

PA PA PA

5 5 5

PA PA PA

Fertility Regulators chorionic gonadotropin for inj 10000 unit novarel inj 10000unt pregnyl inj 10000unt

Growth Hormone Receptor Antagonists SOMAVERT SOMAVERT SOMAVERT SOMAVERT SOMAVERT

INJ INJ INJ INJ INJ

10MG 15MG 20MG 25MG 30MG

5 5 5 5 5

PA PA PA PA PA

6 6 6 6 6 6 6 6 6 6 6 6 5 5 5 5 5 5 5 5 6 6 6 6 6

PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA, PA PA PA PA PA PA PA PA PA, PA, PA, PA, PA,

Growth Hormones GENOTROPIN INJ 0.2MG GENOTROPIN INJ 0.4MG GENOTROPIN INJ 0.6MG GENOTROPIN INJ 0.8MG GENOTROPIN INJ 1.2MG GENOTROPIN INJ 1.4MG GENOTROPIN INJ 1.6MG GENOTROPIN INJ 1.8MG GENOTROPIN INJ 1MG GENOTROPIN INJ 2MG GENOTROPIN INJ 5MG GENOTROPIN INJ 12MG HUMATROPE INJ 5MG HUMATROPE INJ 6MG HUMATROPE INJ 12MG HUMATROPE INJ 24MG NORDITROPIN INJ 5/1.5ML NORDITROPIN INJ 10/1.5ML NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML NUTROPIN AQ INJ 10MG/2ML NUTROPIN AQ INJ 20MG/2ML NUTROPIN AQ INJ NUSPIN 5 NUTROPIN INJ 10MG OMNITROPE INJ 5.8MG

ST ST ST ST ST ST ST ST ST ST ST ST

ST ST ST ST ST

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 98

Drug Name OMNITROPE INJ 5/1.5ML OMNITROPE INJ 10/1.5ML SAIZEN INJ 5MG SAIZEN INJ 8.8MG SEROSTIM INJ 4MG SEROSTIM INJ 5MG SEROSTIM INJ 6MG ZORBTIVE INJ 8.8MG

October 1, 2016 Drug Tier Requirements/Limits 6 PA, ST 6 PA, ST 6 PA, ST 6 PA, ST 5 PA 5 PA 5 PA 5 PA

Hormone Receptor Modulators raloxifene hcl tab 60 mg

2

$0 copay for women > 35 years for the primary prevention of breast cancer

Insulin-Like Growth Factors (Somatomedins) INCRELEX INJ 40MG/4ML

5

PA

LHRH/GnRH Agonist Analog Pituitary Suppressants LUPR DEP-PED INJ 7.5MG LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 30MG SYNAREL SOL 2MG/ML

5 5 5 5 3

PA PA PA PA

5 5 2 2 2 2 5 5 2 2 2 2 5 5 5 5 5 5 5 5

PA PA

Metabolic Modifiers ALDURAZYME INJ 2.9MG/5M BUPHENYL TAB 500MG calcitriol cap 0.5 mcg calcitriol cap 0.25 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml CARBAGLU TAB 200MG CYSTADANE POW doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg doxercalciferol inj 4 mcg/2ml (2 mcg/ml) ELAPRASE INJ 6MG/3ML FABRAZYME INJ 5MG FABRAZYME INJ 35MG KUVAN POW 100MG KUVAN POW 500MG KUVAN TAB 100MG MYOZYME INJ 50MG NAGLAZYME INJ 1MG/ML

PA

PA PA PA PA PA PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 99

Drug Name ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN CAP 10MG ORFADIN SUS 4MG/ML paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paricalcitol iv soln 2 mcg/ml paricalcitol iv soln 5 mcg/ml SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG sodium phenylbutyrate oral powder 3 gm/teaspoonful

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 2 2 2 2 2 5 PA 5 PA 5 PA 2 PA

Posterior Pituitary Hormones desmopressin acetate desmopressin acetate (refrigerated) desmopressin acetate 0.01% desmopressin acetate 0.01% (refrigerated) desmopressin acetate desmopressin acetate

inj 4 mcg/ml nasal soln 0.01%

2 2

nasal spray soln

2

nasal spray soln

2

tab 0.1 mg tab 0.2 mg

2 2

Prolactin Inhibitors cabergoline tab 0.5 mg

2

Somatostatic Agents octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMATULINE INJ 120/.5ML

5

PA

5

PA

5

PA

5

PA

5

PA

5 5 5 5 5 5

PA PA PA PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 100

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Vasopressin Receptor Antagonists SAMSCA TAB 15MG SAMSCA TAB 30MG

5 5

PA PA

ESTROGENS Estrogen Combinations CLIMARA PRO DIS WEEKLY 3 estradiol & norethindrone acetate tab 2 0.5-0.1 mg estradiol & norethindrone acetate tab 1-0.5 2 mg jinteli tab 1mg-5mcg 2 mimvey tab 1-0.5mg 2 norethindrone acetate-ethinyl estradiol tab 2 0.5 mg-2.5 mcg

Estrogens CENESTIN TAB 0.3MG

4

CENESTIN TAB 0.9MG

4

CENESTIN TAB 0.45MG

4

CENESTIN TAB 0.625MG

4

CENESTIN TAB 1.25MG

4

DEPO-ESTRADI INJ 5MG/ML DIVIGEL GEL 0.5MG

4 4

DIVIGEL GEL 0.25MG

4

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 101

October 1, 2016 Drug Tier Requirements/Limits 4 PA; High Risk Medications require PA for members age 65 and older ELESTRIN GEL 0.06% 4 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.3MG 4 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.9MG 4 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.45MG 4 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 0.625MG 4 PA; High Risk Medications require PA for members age 65 and older ENJUVIA TAB 1.25MG 4 PA; High Risk Medications require PA for members age 65 and older estradiol tab 0.5 mg 2 PA; High Risk Medications require PA for members age 65 and older estradiol tab 1 mg 2 PA; High Risk Medications require PA for members age 65 and older estradiol tab 2 mg 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch twice weekly 0.1 mg/24hr2 PA; High Risk Medications require PA for members age 65 and older

Drug Name DIVIGEL GEL 1MG/GM

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 102

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch twice weekly 0.025 2 PA; High Risk mg/24hr Medications require PA for members age 65 and older estradiol td patch twice weekly 0.075 2 PA; High Risk mg/24hr Medications require PA for members age 65 and older estradiol td patch twice weekly 0.0375 2 PA; High Risk mg/24hr Medications require PA for members age 65 and older estradiol td patch weekly 0.1 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.05 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.06 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.025 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.075 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and older estradiol td patch weekly 0.0375 mg/24hr 2 PA; High Risk (37.5 mcg/24hr) Medications require PA for members age 65 and older estradiol valerate im in oil 10 mg/ml 2 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2

Drug Name estradiol td patch twice weekly 0.05 mg/24hr

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 103

Drug Name ESTROGEL GEL

estropipate tab 0.75 mg

estropipate tab 1.5 mg

estropipate tab 3 mg

EVAMIST SPR 1.53MG

MENEST TAB 0.3MG

MENEST TAB 0.625MG

MENEST TAB 1.25MG

MENEST TAB 2.5MG

MENOSTAR DIS 14MCG

ortho-est tab 0.625

October 1, 2016 Drug Tier Requirements/Limits 4 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 104

Drug Name ortho-est tab 1.25

PREMARIN INJ 25MG PREMARIN TAB 0.3MG

PREMARIN TAB 0.9MG

PREMARIN TAB 0.45MG

PREMARIN TAB 0.625MG

PREMARIN TAB 1.25MG

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older 4 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older 4 PA; High Risk Medications require PA for members age 65 and older

FLUOROQUINOLONES Fluoroquinolones AVELOX INJ 4 ciprofloxacin 200 mg/100ml in d5w 2 ciprofloxacin 400 mg/200ml in d5w 2 ciprofloxacin for oral susp 250 mg/5ml (5%)2 (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 2 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 2 1000 mg(base eq)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 105

Drug Name FACTIVE TAB 320MG levofloxacin in d5w iv soln 250 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 25 mg/ml levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg moxifloxacin hcl tab 400 mg (base equiv) ofloxacin tab 200 mg ofloxacin tab 300 mg ofloxacin tab 400 mg

October 1, 2016 Drug Tier Requirements/Limits 4 2 2 2 2 2 2 2 2 2 2 2 2

GASTROINTESTINAL AGENTS - MISC. Gallstone Solubilizing Agents ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg

2 2 2

Gastrointestinal Antiallergy Agents cromolyn sodium oral conc 100 mg/5ml

2

Gastrointestinal Stimulants metoclopramide hcl inj 5 mg/ml 2 metoclopramide hcl orally disintegrating tab2 5 mg metoclopramide hcl soln 5 mg/5ml (10 2 mg/10ml) metoclopramide hcl tab 5 mg 2 metoclopramide hcl tab 10 mg 2

Inflammatory Bowel Agents APRISO CAP 0.375GM balsalazide disodium cap 750 mg CANASA SUP 1000MG CIMZIA KIT CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ML DIPENTUM CAP 250MG mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit REMICADE INJ 100MG sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg

3 2 3 6 6 6 4 2 2 6 2 2

PA, ST PA, ST PA, ST

PA, ST

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 106

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Intestinal Acidifiers enulose sol 10gm/15 generlac sol 10gm/15

2 2

Irritable Bowel Syndrome (IBS) Agents alosetron hcl tab 0.5 mg (base equiv) alosetron hcl tab 1 mg (base equiv) LINZESS CAP 145MCG LINZESS CAP 290MCG

2 2 3 3

PA PA

Peripheral Opioid Receptor Antagonists MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG

3 3

Phosphate Binder Agents calcium acetate (phosphate binder) cap 6672 mg (169 mg ca) calcium acetate (phosphate binder) tab 6672 mg FOSRENOL CHW 500MG 4 FOSRENOL CHW 750MG 4 FOSRENOL CHW 1000MG 4 FOSRENOL POW 750MG 4 FOSRENOL POW 1000MG 4 PHOSLYRA SOL 4 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3

GENITOURINARY AGENTS - MISCELLANEOUS Alkalinizers potassium citrate tab cr 5 meq (540 mg) 2 potassium citrate tab cr 10 meq (1080 mg) 2 potassium citrate tab cr 15 meq (1620 mg) 2

Cystinosis Agents CYSTAGON CAP 50MG CYSTAGON CAP 150MG

5 5

PA PA

Genitourinary Irrigants sodium chloride irrigation soln 0.9%

2

Interstitial Cystitis Agents ELMIRON CAP 100MG

4

Prostatic Hypertrophy Agents alfuzosin hcl tab sr 24hr 10 mg CARDURA XL TAB 4MG CARDURA XL TAB 8MG

2 4 4

ST; PA** ST; PA**

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 107

October 1, 2016 Drug Tier Requirements/Limits 4 QL (30 tabs / 25 days), PA CIALIS TAB 5MG 4 QL (30 tabs / 25 days), PA dutasteride cap 0.5 mg 2 dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 finasteride tab 5 mg 2 RAPAFLO CAP 4MG 4 ST; PA** RAPAFLO CAP 8MG 4 ST; PA** tamsulosin hcl cap 0.4 mg 2

Drug Name CIALIS TAB 2.5MG

Urinary Analgesics phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg

2 2

GOUT AGENTS Gout Agent Combinations colchicine w/ probenecid tab 0.5-500 mg

2

Gout Agents allopurinol sodium for inj 500 mg allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg ULORIC TAB 40MG ULORIC TAB 80MG

2 2 2 2 4 4

ST; PA** ST; PA**

Uricosurics probenecid tab 500 mg

2

HEMATOLOGICAL AGENTS - MISC. Bradykinin B2 Receptor Antagonists FIRAZYR INJ 30MG/3ML

5

PA

Hematorheologic Agents pentoxifylline tab cr 400 mg

2

Platelet Aggregation Inhibitors anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 aspirin-dipyridamole cap sr 12hr 25-200 mg2 BRILINTA TAB 60MG 3 BRILINTA TAB 90MG 3 cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 clopidogrel bisulfate tab 75 mg (base equiv)2 clopidogrel bisulfate tab 300 mg (base 2 equiv)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 108

Drug Name dipyridamole tab 25 mg

dipyridamole tab 50 mg

dipyridamole tab 75 mg

EFFIENT TAB 5MG EFFIENT TAB 10MG ticlopidine hcl tab 250 mg ZONTIVITY TAB 2.08MG

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 3 3 2 3

HEMATOPOIETIC AGENTS Agents for Gaucher Disease CEREZYME INJ 400UNIT ELELYSO INJ 200UNIT VPRIV INJ 400UNIT ZAVESCA CAP 100MG

5 5 5 5

PA PA PA PA

Agents for Sickle Cell Anemia DROXIA CAP 200MG DROXIA CAP 300MG DROXIA CAP 400MG

3 3 3

Cobalamins cyanocobalamin inj 1000 mcg/ml

2

Folic Acid/Folates folic acid tab 1 mg folic acid tab 400 mcg

2 1

folic acid tab 800 mcg

1

QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under

Hematopoietic Growth Factors ARANESP ARANESP ARANESP ARANESP

INJ INJ INJ INJ

10MCG 25MCG 40MCG 60MCG

5 5 5 5

PA PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 109

Drug Name ARANESP INJ 100MCG ARANESP INJ 150MCG ARANESP INJ 200MCG ARANESP INJ 300MCG ARANESP INJ 500MCG LEUKINE INJ 250MCG LEUKINE INJ 500 MCG NEULASTA INJ 6MG/0.6M NEULASTA KIT 6MG/0.6M NEUPOGEN INJ 300/0.5 NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/0.8 NEUPOGEN INJ 480MCG OMONTYS INJ 10MG/ML OMONTYS INJ 20MG/2ML PROCRIT INJ 2000/ML PROCRIT INJ 3000/ML PROCRIT INJ 4000/ML PROCRIT INJ 10000/ML PROCRIT INJ 20000/ML PROCRIT INJ 40000/ML PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA

Stem Cell Mobilizers MOZOBIL INJ

5

PA

HEMOSTATICS Hemostatics - Systemic tranexamic acid iv soln 1000 mg/10ml (1002 mg/ml) tranexamic acid tab 650 mg 2

HYPNOTICS Barbiturate Hypnotics phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital phenobarbital

elixir 20 mg/5ml tab 15 mg tab 16.2 mg tab 30 mg tab 32.4 mg tab 60 mg tab 64.8 mg tab 97.2 mg

2 2 2 2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 110

Drug Name phenobarbital tab 100 mg

October 1, 2016 Drug Tier Requirements/Limits 2

Non-Barbiturate Hypnotics§ eszopiclone tab 1 mg eszopiclone tab 2 mg eszopiclone tab 3 mg temazepam cap 7.5 mg temazepam cap 15 mg temazepam cap 22.5 mg temazepam cap 30 mg zaleplon cap 5 mg zaleplon cap 10 mg zolpidem tartrate tab 5 mg zolpidem tartrate tab 10 mg zolpidem tartrate tab cr 6.25 mg zolpidem tartrate tab cr 12.5 mg

2 2 2 2 2 2 2 2 2 2 2 2 2

Selective Melatonin Receptor Agonists§ ROZEREM TAB 8MG

4

ST; PA**

LAXATIVES Laxative Combinations COLYTE/FLAVR SOL PACKS gavilyte-c sol gavilyte-g sol gavilyte-h kit

3 2 2 1

gavilyte-n sol flav pk GOLYTELY SOL MOVIPREP SOL

2 3 3

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm PREPOPIK PAK

2

SUPREP BOWEL SOL PREP

4

$0 copay for members age 50 through 74

$0 copay for members age 50 through 74

2 2 1

$0 copay for members age 50 through 74 $0 copay for members age 50 through 74

Laxatives - Miscellaneous KRISTALOSE PAK 10GM KRISTALOSE PAK 20GM lactulose solution 10 gm/15ml

4 4 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 111

Drug Name polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder

October 1, 2016 Drug Tier Requirements/Limits 2 2

Saline Laxatives OSMOPREP TAB 1.5GM

4

LOCAL ANESTHETICS-Parenteral Local Anesthetics - Amides LIDO/DEXTROS INJ 5-7.5% lidocaine hcl local inj 0.5% lidocaine hcl local inj 1% lidocaine hcl local inj 1.5% lidocaine hcl local inj 2% lidocaine hcl local preservative 0.5% lidocaine hcl local preservative 1% lidocaine hcl local preservative 2% lidocaine hcl local preservative 4%

4 2 2 2 2 free (pf) inj 2 free (pf) inj 2 free (pf) inj 2 free (pf) inj 2

MACROLIDES Azithromycin azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg azithromycin powd pack for susp 1 gm azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg ZMAX SUS 2GM

2 2 2 2 2 2 2 4

Clarithromycin clarithromycin clarithromycin clarithromycin clarithromycin clarithromycin

for susp 125 mg/5ml for susp 250 mg/5ml tab 250 mg tab 500 mg tab sr 24hr 500 mg

2 2 2 2 2

Erythromycins e.e.s. 400 tab 400mg E.E.S. GRAN SUS 200/5ML ERY-TAB TAB 250MG EC ERY-TAB TAB 333MG EC ERY-TAB TAB 500MG EC ERYPED SUS 200/5ML

2 3 2 2 2 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 112

Drug Name ERYPED SUS 400/5ML ERYTHROCIN INJ 500MG ERYTHROCIN INJ 1000MG erythrocin tab 250mg erythromycin ethylsuccinate tab 400 mg erythromycin tab 250 mg erythromycin tab 500 mg erythromycin w/ delayed release particles cap 250 mg PCE TAB 333MG EC PCE TAB 500MG EC

October 1, 2016 Drug Tier Requirements/Limits 3 4 4 2 2 2 2 2 4 4

Fidaxomicin DIFICID TAB 200MG

3

PA

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

QL (1 OTC QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1 QL (1

MEDICAL DEVICES Contraceptives CAYA DPR FC2 FEMALE MIS CONDOM FEMCAP MIS 22MM FEMCAP MIS 26MM FEMCAP MIS 30MM OMNIFLEX DPR ORTHO COIL DPR KIT 50 ORTHO COIL DPR KIT 100 ORTHO COIL DPR KIT 105 ORTHO FLAT DPR KIT 55 ORTHO FLAT DPR KIT 60 ORTHO FLAT DPR KIT 65 ORTHO FLAT DPR KIT 70 ORTHO FLAT DPR KIT 75 ORTHO FLAT DPR KIT 80 ORTHO FLAT DPR KIT 85 ORTHO FLAT DPR KIT 90 ORTHO FLAT DPR KIT 95 ORTHO FLEX DPR 65MM ORTHO FLEX DPR 70MM ORTHO FLEX DPR 75MM ORTHO FLEX DPR 80MM PRENTIF MIS 22MM PRENTIF MIS 25MM PRENTIF MIS 28MM PRENTIF MIS 31MM PRENTIF MIS FITTING

/ 300 days) / / / / / / / / / / / / / / / / / / / / / / / / /

300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300 300

days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days) days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 113

Drug Name WIDE-SEAL DPR WIDE-SEAL DPR WIDE-SEAL DPR WIDE-SEAL DPR WIDE-SEAL DPR WIDE-SEAL DPR WIDE-SEAL DPR WIDE-SEAL DPR

KIT KIT KIT KIT KIT KIT KIT KIT

60 65 70 75 80 85 90 95

October 1, 2016 Drug Tier Requirements/Limits 1 QL (1 / 300 days) 1 QL (1 / 300 days) 1 QL (1 / 300 days) 1 QL (1 / 300 days) 1 QL (1 / 300 days) 1 QL (1 / 300 days) 1 QL (1 / 300 days) 1 QL (1 / 300 days)

Diabetic Supplies BD SWAB REG PAD SNGL USE INSULIN SYRG MIS 1ML/31G ONETOUCH KIT ULTRA 2 ONETOUCH KIT VERIO ONETOUCH MIS LANC DEV ONETOUCH MIS REMOTE ONETOUCH SOL VERIO ONETOUCH TES ULTRA BL ONETOUCH US MIS LANCETS

3 3 3 3 3 3 3 3 3

OTC OTC OTC OTC OTC OTC OTC OTC OTC

Parenteral Therapy Supplies HUMATROPEN MIS FOR 6MG HUMATROPEN MIS FOR 12MG HUMATROPEN MIS FOR 24MG

3 3 3

Respiratory Therapy Supplies AEROCHAMBER MIS PLUS FLEXICHAMBER MIS MASK SM OPTICHAMBER MIS FACE MAS PANDA MASK MIS PEDIATRI

3 3 3 3

OTC OTC

MIGRAINE PRODUCTS Migraine Combinations§ CAFERGOT TAB 1-100MG

3

Migraine Products§ dihydroergotamine mesylate inj 1 mg/ml 2 dihydroergotamine mesylate nasal spray 4 2 mg/ml ERGOMAR SUB 2MG 4

QL (8 kits / 25 days)

Serotonin Agonists§ almotriptan malate tab 6.25 mg almotriptan malate tab 12.5 mg frovatriptan succinate tab 2.5 mg (base equivalent) naratriptan hcl tab 1 mg (base equiv)

2 2 2

QL (12 tabs / 25 days) QL (12 tabs / 25 days) QL (18 tabs / 25 days)

2

QL (12 tabs / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 114

October 1, 2016 Drug Tier Requirements/Limits 2 QL (12 tabs / 25 days) 4 QL (12 tabs / 25 days), ST; PA** RELPAX TAB 40MG 4 QL (12 tabs / 25 days), ST; PA** rizatriptan benzoate oral disintegrating tab 2 QL (18 tabs / 25 days) 5 mg (base eq) rizatriptan benzoate oral disintegrating tab 2 QL (18 tabs / 25 days) 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 QL (18 tabs / 25 days) equivalent) rizatriptan benzoate tab 10 mg (base 2 QL (18 tabs / 25 days) equivalent) sumatriptan nasal spray 5 mg/act 2 QL (24 sprays / 25 days) sumatriptan nasal spray 20 mg/act 2 QL (12 sprays / 25 days) sumatriptan succinate inj 4 mg/0.5ml 2 QL (12 units / 25 days) sumatriptan succinate inj 6 mg/0.5ml 2 QL (12 vials per 25 days) sumatriptan succinate solution auto-injector2 QL (6 kits / 25 days) 4 mg/0.5ml sumatriptan succinate solution auto-injector2 QL (12 units / 25 days) 6 mg/0.5ml sumatriptan succinate solution cartridge 4 2 QL (12 units / 25 days) mg/0.5ml sumatriptan succinate solution cartridge 6 2 QL (12 units / 25 days) mg/0.5ml sumatriptan succinate solution prefilled 2 QL (12 units / 25 days) syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg 2 QL (12 tabs / 25 days) sumatriptan succinate tab 50 mg 2 QL (12 tabs / 25 days) sumatriptan succinate tab 100 mg 2 QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab 2.5 mg2 QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab 5 mg 2 QL (12 tabs / 25 days) zolmitriptan tab 2.5 mg 2 QL (12 tabs / 25 days) zolmitriptan tab 5 mg 2 QL (12 tabs / 25 days) ZOMIG NASAL SPR 5MG 4 QL (12 sprays / 25 days) ZOMIG SPR 2.5MG 4 QL (12 sprays / 25 days)

Drug Name naratriptan hcl tab 2.5 mg (base equiv) RELPAX TAB 20MG

MINERALS Chloride

ELECTROLYTES

AMMONIUM CHL INJ 5MEQ/ML

4

Electrolyte Mixtures ISOLYTE-S INJ kcl 20 meq/l (0.15%) in nacl 0.9% inj kcl 20 meq/l (0.15%) in nacl 0.45% inj

4 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 115

Drug Name kcl 40 meq/l (0.3%) in nacl 0.9% inj NORMOSOL -R INJ PLASMA-LYTE INJ -148 PLASMA-LYTE INJ -A

October 1, 2016 Drug Tier Requirements/Limits 2 4 4 4

Fluoride fluor-a-day dro 0.125mg

1

FLUORABON DRO

1

fluoritab chw 0.5mg f

1

fluoritab chw 0.25mg f

1

fluoritab chw 2.2mg flura-drops dro 0.25mg f

2 1

flura-drops dro 0.125mg

1

ludent chw 0.5mg f

1

ludent chw 0.25mg f

1

ludent chw 1mg f LURIDE CHW 0.5MG F

2 1

LURIDE CHW 0.25MG F

1

LURIDE DRO 0.5MG/ML

1

nafrinse chw 1mg f 2 sodium fluoride chew tab 0.5 mg f (from 1.11 mg naf) sodium fluoride chew tab 0.25 mg f (from 1 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 1 mg/ml naf) sodium fluoride tab 0.5 mg f (from 1.1 mg 1 naf) sodium fluoride tab 1 mg f (from 2.2 mg 2 naf)

$0 applies under $0 applies under $0 applies under $0 applies under $0 applies under $0 applies under $0 applies under $0 applies under

for ages 5 and for ages 5 and for ages 5 and for ages 5 and

for ages 5 and for ages 5 and for ages 5 and for ages 5 and

$0 applies for ages 5 and under $0 applies for ages 5 and under $0 applies for ages 5 and under $0 applies for ages 5 and under $0 applies for ages 5 and under

$0 applies for ages 5 and under $0 applies for ages 5 and under

Magnesium MAGNESIUM SU INJ 2GM/50ML

4

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 116

October 1, 2016 Drug Name Drug Tier Requirements/Limits MAGNESIUM SU INJ 4G/100ML 4 MAGNESIUM SU INJ 20/500ML 4 MAGNESIUM SU INJ 40G/1000 4 MAGNESIUM SU INJ 80MG/ML 4 magnesium sulfate 1% in d5w 2 magnesium sulfate inj 50% 2 magnesium sulfate iv soln 2 gm/50ml (40 2 mg/ml) magnesium sulfate iv soln 4 gm/50ml (80 2 mg/ml) magnesium sulfate iv soln 4 gm/100ml (40 2 mg/ml) magnesium sulfate iv soln 20 gm/500ml (402 mg/ml) magnesium sulfate iv soln 40 gm/1000ml 2 (40 mg/ml) MG SO4/D5W INJ 10MG/ML 4 MG SO4/D5W INJ 20MG/ML 4

Potassium klor-con 8 tab 8meq er 2 klor-con 10 tab 10meq er 2 KLOR-CON M15 TAB 15MEQ ER 3 klor-con m20 tab 20meq er 2 potassium chloride cap cr 8 meq 2 potassium chloride cap cr 10 meq 2 potassium chloride inj 2 meq/ml 2 potassium chloride inj 10 meq/50ml 2 potassium chloride inj 10 meq/100ml 2 potassium chloride inj 20 meq/50ml 2 potassium chloride inj 20 meq/100ml 2 potassium chloride inj 40 meq/100ml 2 potassium chloride microencapsulated crys 2 cr tab 10 meq potassium chloride microencapsulated crys 2 cr tab 20 meq potassium chloride oral soln 10% (20 2 meq/15ml) potassium chloride oral soln 20% (40 2 meq/15ml) potassium chloride tab cr 8 meq (600 mg) 2 potassium chloride tab cr 10 meq 2 potassium chloride tab cr 20 meq (1500 mg)2

Sodium

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 117

Drug Name sodium chloride sodium chloride sodium chloride sodium chloride sodium chloride sodium chloride sodium chloride sodium chloride

flush iv soln 0.9% inj 0.9% inj 0.45% inj 2.5 meq/ml (14.6%) inj 3% inj 4 meq/ml (23.4%) inj 5% iv soln 0.9%

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2

MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine hcl laryngotracheal soln 4% lidocaine hcl viscous soln 2%

2 2

Anti-infectives - Throat clotrimazole troche 10 mg nystatin susp 100000 unit/ml ORAVIG TAB 50MG

2 2 4

Antiseptics - Mouth/Throat chlorhexidine gluconate soln 0.12% periogard sol 0.12%

2 2

Steroids - Mouth/Throat oralone pst 0.1% 2 triamcinolone acetonide dental paste 0.1% 2

Throat Products - Misc. cevimeline hcl cap 30 mg pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg

2 2 2

MULTIVITAMINS Ped MV w/ Fluoride multi-vit/fl dro 0.5mg/ml multi-vit/fl dro 0.25mg multivit/fl chw 0.5mg multivit/fl chw 0.25mg multivit/fl chw 1mg mvc-fluoride chw 0.5mg mvc-fluoride chw 1mg QUFLORA PED CHW 0.5MG QUFLORA PED CHW 0.25MG QUFLORA PED CHW 1MG quflora ped dro 0.5mg/ml quflora ped dro 0.25mg tri-vit/fl dro 0.5mg

2 2 2 2 2 2 2 4 4 4 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 118

Drug Name tri-vit/fl dro 0.25mg tri-vit/fluo dro 0.25mg tri-vita/fl dro 0.25mg vit a/c/d/fl dro 0.25mg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2

Ped Multi Vitamins w/Fl FE multi-vit/fe dro /fl 0.25 multi-vit/fl dro /fe 0.25 tri-vit/fe dro /fl 0.25

2 2 2

Prenatal Vitamins CITRANATAL CITRANATAL CITRANATAL CITRANATAL CITRANATAL CITRANATAL prenatabs rx

CAP MIS MIS PAK PAK TAB tab

HARMONY 90 DHA B-CALM ASSURE DHA RX

3 3 3 3 3 3 2

MUSCULOSKELETAL THERAPY AGENTS Central Muscle Relaxants baclofen tab 10 mg baclofen tab 20 mg carisoprodol tab 250 mg

2 2 2

carisoprodol tab 350 mg

2

chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 5 mg

2 2

cyclobenzaprine hcl tab 7.5 mg

2

cyclobenzaprine hcl tab 10 mg

2

PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older PA; High Risk Medications require PA for members age 65 and older

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 119

Drug Name metaxalone tab 400 mg

metaxalone tab 800 mg

methocarbamol tab 500 mg

methocarbamol tab 750 mg

orphenadrine citrate inj 30 mg/ml orphenadrine citrate tab sr 12hr 100 mg

tizanidine tizanidine tizanidine tizanidine tizanidine

hcl hcl hcl hcl hcl

cap 2 mg (base equivalent) cap 4 mg (base equivalent) cap 6 mg (base equivalent) tab 2 mg (base equivalent) tab 4 mg (base equivalent)

October 1, 2016 Drug Tier Requirements/Limits 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 PA; High Risk Medications require PA for members age 65 and older 2 2 PA; High Risk Medications require PA for members age 65 and older 2 2 2 2 2

Direct Muscle Relaxants dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dantrolene sodium cap 100 mg

2 2 2

Muscle Relaxant Combinations orphenadrine w/ aspirin & caffeine tab 25-385-30 mg

2

PA; High Risk Medications require PA for members age 65 and older

NASAL AGENTS - SYSTEMIC AND TOPICAL Nasal Anti-infectives BACTROBAN OIN NASAL 2%

4

Nasal Antiallergy§ azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray)

2

QL (2 bottles / 25 days)

2

QL (2 bottles / 25 days)

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 120

Drug Name olopatadine hcl nasal soln 0.6%

October 1, 2016 Drug Tier Requirements/Limits 2 QL (1 container / 25 days)

Nasal Anticholinergics ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray)

Nasal Steroids§ budesonide nasal susp 32 mcg/act

2

flunisolide nasal soln 25 mcg/act (0.025%) 2 fluticasone propionate nasal susp 50 mcg/act triamcinolone acetonide nasal aerosol suspension 55 mcg/act

2 2

QL (2 days) QL (3 days) QL (1 days) QL (1 days)

containers / 25 containers / 25 container / 25 container / 25

Sympathomimetic Decongestants TYZINE PED DRO 0.05% TYZINE SOL 0.1%

4 4

NEUROMUSCULAR AGENTS ALS Agents riluzole tab 50 mg

2

Neuromuscular Blocking Agent - Neurotoxins BOTOX INJ 100UNIT BOTOX INJ 200UNIT XEOMIN INJ 50 UNIT XEOMIN INJ 100UNIT XEOMIN INJ 200UNIT

5 5 5 5 5

PA PA PA PA PA

OPHTHALMIC AGENTS Artificial Tears and Lubricants LACRISERT MIS 5MG OP

4

Beta-blockers - Ophthalmic betaxolol hcl ophth soln 0.5% 2 BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 BETOPTIC-S SUS 0.25% OP 3 carteolol hcl ophth soln 1% 2 COMBIGAN SOL 0.2/0.5% 3 dorzolamide hcl-timolol maleate ophth soln 2 22.3-6.8 mg/ml ISTALOL SOL 0.5% OP 4 levobunolol hcl ophth soln 0.5% 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 121

October 1, 2016 Drug Name Drug Tier Requirements/Limits levobunolol hcl ophth soln 0.25% 2 metipranolol ophth soln 0.3% 2 timolol maleate ophth gel forming soln 0.5%2 timolol maleate ophth gel forming soln 2 0.25% timolol maleate ophth soln 0.5% 2 timolol maleate ophth soln 0.25% 2 TIMOPTIC OCU SOL 0.5% OP 3 TIMOPTIC OCU SOL 0.25% OP 3

Cycloplegic Mydriatics atropine sulfate ophth soln 1% homatropaire sol 5% op homatropine hbr ophth soln 5% ISO HOMATROP SOL 2% OP tropicamide ophth soln 0.5% tropicamide ophth soln 1%

2 2 2 4 2 2

Miotics PHOSPHOLINE SOL 0.125%OP PILOPINE HS GEL 4% OP

4 4

Ophthalmic Adrenergic Agents ALPHAGAN P SOL 0.1% apraclonidine hcl ophth soln 0.5% (base equivalent) brimonidine tartrate ophth soln 0.2% brimonidine tartrate ophth soln 0.15% IOPIDINE SOL 1% OP

4 2 2 2 4

Ophthalmic Anti-infectives AZASITE SOL 1% bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint BESIVANCE SUS 0.6% CILOXAN OIN 0.3% OP ciprofloxacin hcl ophth soln 0.3% erythromycin ophth oint 5 mg/gm gatifloxacin ophth soln 0.5% gentak oin 0.3% op gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% ilotycin oin op levofloxacin ophth soln 0.5% MOXEZA SOL 0.5% NATACYN SUS 5% OP

4 2 2 4 3 2 2 2 2 2 2 2 2 4 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 122

October 1, 2016 Drug Name Drug Tier Requirements/Limits neomycin-polymy-gramicid op sol 2 1.75-10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 polycin oin op 2 polymyxin b-trimethoprim ophth soln 100002 unit/ml-0.1% romycin oin op 2 sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 2 TOBREX OIN 0.3% OP 3 trifluridine ophth soln 1% 2 VIGAMOX DRO 0.5% 3 ZIRGAN GEL 0.15% 4

Ophthalmic Decongestants naphazoline hcl ophth soln 0.1% phenylephrine hcl ophth soln 2.5% phenylephrine hcl ophth soln 10%

2 2 2

Ophthalmic Immunomodulators RESTASIS EMU 0.05%

4

Ophthalmic Local Anesthetics parcaine sol 0.5% op proparacaine hcl ophth soln 0.5%

2 2

Ophthalmic Steroids ALREX SUS 0.2% bacitracin-polymyxin-neomycin-hc ophth oint 1% BLEPHAMIDE OIN S.O.P. BLEPHAMIDE SUS OP dexamethasone sodium phosphate ophth soln 0.1% DUREZOL EMU 0.05% FLAREX SUS 0.1% OP fluorometholone ophth susp 0.1% FML FORTE SUS 0.25% OP FML OIN 0.1% OP LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% MAXIDEX SUS 0.1% OP neomycin-polymyxin-dexamethasone ophth oint 0.1%

4 2 3 3 2 4 4 2 4 4 4 4 4 4 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 123

Drug Name neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp poly-dex oin 0.1% op PRED MILD SUS 0.12% OP PRED SOD PHO SOL 1% OP prednisolone acetate ophth susp 1% sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% tobramycin-dexamethasone ophth susp 0.3-0.1% VEXOL SUS 1% OP

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 3 3 2 2 3 2 4

Ophthalmics - Misc. ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 AZOPT SUS 1% OP 4 BEPREVE DRO 1.5% 4 bromfenac sodium ophth soln 0.09% (base 2 equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base 2 equivalent) cromolyn sodium ophth soln 4% 2 diclofenac sodium ophth soln 0.1% 2 dorzolamide hcl ophth soln 2% 2 EMADINE SOL 0.05% OP 4 epinastine hcl ophth soln 0.05% 2 flurbiprofen sodium ophth soln 0.03% 2 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 LASTACAFT SOL 0.25% 4 NEVANAC SUS 0.1% 4 olopatadine hcl ophth soln 0.1% (base 2 equivalent) PATADAY SOL 0.2% 4

Prostaglandins - Ophthalmic bimatoprost ophth soln 0.03% latanoprost ophth soln 0.005% LUMIGAN SOL 0.01% TRAVATAN Z DRO 0.004% ZIOPTAN DRO 0.0015%

2 2 4 4 4

ST; PA** ST; PA** ST; PA**

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 124

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

OTIC AGENTS Otic Agents - Miscellaneous acetic acid 2% in aluminum acetate otic soln2 acetic acid otic soln 2% 2

Otic Anti-infectives ofloxacin otic soln 0.3%

2

Otic Combinations CIPRO HC SUS OTIC CIPRODEX SUS 0.3-0.1% CORTISPORIN SUS -TC OTIC neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%

4 3 4 2 2

Otic Steroids fluocinolone acetonide (otic) oil 0.01% 2 hydrocortisone w/ acetic acid otic soln 1-2%2

PASSIVE IMMUNIZING AGENTS Immune Serums BIVIGAM INJ 10% CARIMUNE NF INJ 3GM CARIMUNE NF INJ 6GM CARIMUNE NF INJ 12GM FLEBOGAMMA INJ 10/200ML FLEBOGAMMA INJ 20/400ML FLEBOGAMMA INJ DIF 5% FLEBOGAMMA INJ DIF 10% GAMASTAN S/D INJ GAMMAGARD INJ 1GM/10ML GAMMAGARD INJ 2.5GM/25 GAMMAGARD INJ 5GM/50ML GAMMAGARD INJ 10GM/100 GAMMAGARD INJ 20GM/200 GAMMAGARD INJ 30GM/300 GAMMAGARD SD INJ 2.5GM HU GAMMAGARD SD INJ 5GM HU GAMMAGARD SD INJ 10GM HU GAMMAKED INJ 1GM/10ML GAMMAKED INJ 2.5GM/25 GAMMAKED INJ 5GM/50ML GAMMAKED INJ 10GM/100 GAMMAKED INJ 20GM/200

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 125

Drug Name GAMMAPLEX INJ 2.5GM GAMMAPLEX INJ 5GM GAMMAPLEX INJ 10GM GAMMAPLEX INJ 20GM GAMUNEX-C INJ 1GM/10ML GAMUNEX-C INJ 2.5GM/25 GAMUNEX-C INJ 5GM/50ML GAMUNEX-C INJ 10GM/100 GAMUNEX-C INJ 20GM/200 GAMUNEX-C INJ 40/400ML HIZENTRA INJ 1GM/5ML HIZENTRA INJ 2GM/10ML HIZENTRA INJ 4GM/20ML HIZENTRA INJ 10/50ML OCTAGAM INJ 1GM OCTAGAM INJ 2.5GM OCTAGAM INJ 2GM/20ML OCTAGAM INJ 5GM OCTAGAM INJ 5GM/50ML OCTAGAM INJ 10/100ML OCTAGAM INJ 10GM OCTAGAM INJ 20/200ML OCTAGAM INJ 25GM PRIVIGEN INJ 5 GRAMS PRIVIGEN INJ 10GRAMS PRIVIGEN INJ 20GRAMS PRIVIGEN INJ 40GRAMS

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA

PENICILLINS Aminopenicillins amoxicillin (trihydrate) cap 250 mg 2 amoxicillin (trihydrate) cap 500 mg 2 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 amoxicillin (trihydrate) for susp 125 mg/5ml2 amoxicillin (trihydrate) for susp 200 mg/5ml2 amoxicillin (trihydrate) for susp 250 mg/5ml2 amoxicillin (trihydrate) for susp 400 mg/5ml2 amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 126

Drug Name ampicillin for susp 250 mg/5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj 2 gm ampicillin sodium for inj 10 gm ampicillin sodium for inj 125 mg ampicillin sodium for inj 250 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 2 gm ampicillin sodium for iv soln 10 gm

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2

Natural Penicillins BICILLIN L-A INJ 600000 4 BICILLIN L-A INJ 1200000 4 BICILLIN L-A INJ 2400000 4 PEN G PROC INJ 600000 4 PENICILL GK/ INJ DEX 1MU 4 PENICILL GK/ INJ DEX 2MU 4 PENICILL GK/ INJ DEX 3MU 4 penicillin g potassium for inj 5000000 unit 2 penicillin g potassium for inj 20000000 unit 2 penicillin g sodium for inj 5000000 unit 2 penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2 penicillin v potassium tab 250 mg 2 penicillin v potassium tab 500 mg 2 pfizerpen-g inj 20mu 2

Penicillin Combinations amoxicillin & k clavulanate chew tab 2 200-28.5 mg amoxicillin & k clavulanate chew tab 400-572 mg amoxicillin & k clavulanate for susp 2 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 2 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 2 mg/5ml amoxicillin & k clavulanate for susp 2 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg 2 amoxicillin & k clavulanate tab 875-125 mg 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 127

October 1, 2016 Drug Name Drug Tier Requirements/Limits amoxicillin & k clavulanate tab sr 12hr 2 1000-62.5 mg ampicillin & sulbactam sodium for inj 1-0.5 2 gm ampicillin & sulbactam sodium for inj 2-1 gm2 ampicillin & sulbactam sodium for inj 10-5 2 gm ampicillin & sulbactam sodium for iv soln 2 1-0.5 gm ampicillin & sulbactam sodium for iv soln 2 2-1 gm ampicillin & sulbactam sodium for iv soln 2 10-5 gm AUGMENTIN SUS 125/5ML 3 BICILLIN C-R INJ 900/300 4 BICILLIN C-R INJ 1200000 4 piperacillin sod-tazobactam na for inj 3.3752 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2.25 2 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 4.5 2 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 2 gm (36-4.5 gm) ZOSYN SOL 2-0.25GM 4 ZOSYN SOL 3-0.375G 4 ZOSYN SOL 4-0.50GM 4

Penicillinase-Resistant Penicillins BACTOCILL INJ DEX 1GM BACTOCILL INJ DEX 2GM dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg NAFCILLIN INJ 1GM/50ML NAFCILLIN INJ 2GM/100 nafcillin sodium for inj 1 gm nafcillin sodium for inj 2 gm nafcillin sodium for inj 10 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 2 gm oxacillin sodium for inj 1 gm oxacillin sodium for inj 2 gm oxacillin sodium for inj 10 gm

4 4 2 2 4 4 2 2 2 2 2 2 2 2

PROGESTINS

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 128

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Progestins medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg medroxyprogesterone acetate tab 10 mg megestrol acetate susp 625 mg/5ml norethindrone acetate tab 5 mg progesterone micronized cap 100 mg progesterone micronized cap 200 mg

2 2 2 2 2 2 2

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Agents for Chemical Dependency acamprosate calcium tab delayed release 333 mg disulfiram tab 250 mg disulfiram tab 500 mg

2

PA

2 2

Anti-Cataplectic Agents XYREM SOL 500MG/ML

3

PA

Antidementia Agents donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg EXELON SOL 2MG/ML galantamine hydrobromide cap sr 24hr 8 mg galantamine hydrobromide cap sr 24hr 16 mg galantamine hydrobromide cap sr 24hr 24 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 12 mg memantine hcl oral solution 2 mg/ml

2

memantine hcl tab 5 mg

2

2 2 2 2 3 2

PA

2 2 2 2 2 2 2

PA; PA applies for members less than 30 years of age PA; PA applies for members less than 30 years of age

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 129

October 1, 2016 Drug Name Drug Tier Requirements/Limits memantine hcl tab 5 mg (28) & 10 mg (21)2 PA; PA applies for titration pak members less than 30 years of age memantine hcl tab 10 mg 2 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 7MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 14MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 21MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 28MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP TITRATIO 3 PA; PA applies for members less than 30 years of age rivastigmine tartrate cap 1.5 mg 2 PA rivastigmine tartrate cap 3 mg 2 PA rivastigmine tartrate cap 4.5 mg 2 PA rivastigmine tartrate cap 6 mg 2 PA rivastigmine td patch 24hr 4.6 mg/24hr 2 PA rivastigmine td patch 24hr 9.5 mg/24hr 2 PA rivastigmine td patch 24hr 13.3 mg/24hr 2 PA

Fibromyalgia Agents SAVELLA SAVELLA SAVELLA SAVELLA SAVELLA

MIS TAB TAB TAB TAB

TITR PAK 12.5MG 25MG 50MG 100MG

4 4 4 4 4

Movement Disorder Drug Therapy tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg

5 5

PA PA

5 5 5 5 5

PA PA PA PA PA

Multiple Sclerosis Agents AMPYRA TAB 10MG AUBAGIO TAB 7MG AUBAGIO TAB 14MG BETASERON INJ 0.3MG COPAXONE INJ 20MG/ML

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 130

Drug Name COPAXONE INJ 40MG/ML GILENYA CAP 0.5MG glatopa inj 20mg/ml REBIF INJ 22/0.5 REBIF INJ 44/0.5 REBIF REBIDO INJ 22/0.5 REBIF REBIDO INJ 44/0.5 REBIF REBIDO INJ TITRATN REBIF TITRTN INJ PACK TYSABRI INJ 300/15ML

October 1, 2016 Drug Tier Requirements/Limits 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA

Postherpetic Neuralgia (PHN) Agents GRALISE STAR MIS 300/600 GRALISE TAB 300MG GRALISE TAB 600MG

4 4 4

ST; PA** ST; PA** ST; PA**

Pseudobulbar Affect (PBA) Agents NUEDEXTA CAP 20-10MG

3

Psychotherapeutic and Neurological Agents - Misc. ergoloid mesylates tab 1 mg pimozide tab 1 mg pimozide tab 2 mg

2 2 2

Smoking Deterrents buproban tab 150mg

1

bupropion hcl (smoking deterrent) tab sr 12hr 150 mg CHANTIX PAK 0.5& 1MG

1

CHANTIX PAK 1MG

1

CHANTIX TAB 0.5MG

1

CHANTIX TAB 1MG

1

nicotine polacrilex gum 2 mg

1

nicotine polacrilex gum 4 mg

1

nicotine polacrilex lozenge 2 mg

1

nicotine polacrilex lozenge 4 mg

1

nicotine td patch 24hr 7 mg/24hr

1

1

$0 limited to 2 treatment cycles/year $0 limited to 2 treatment cycles/year $0 limited to 2 treatment cycles/year $0 limited to 2 treatment cycles/year $0 limited to 2 treatment cycles/year $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year OTC; $0 limited to 2 treatment cycles/year

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 131

Drug Name nicotine td patch 24hr 14 mg/24hr nicotine td patch 24hr 21 mg/24hr NICOTROL INH NICOTROL NS SPR 10MG/ML sm nicotine dis 7mg/24hr sm nicotine dis 14mg/24h sm nicotine dis 21mg thrive gum 4mg mint

October 1, 2016 Drug Tier Requirements/Limits 1 OTC; $0 limited to 2 treatment cycles/year 1 OTC; $0 limited to 2 treatment cycles/year 1 QL (max 168 days per year); $0 limited to 2 treatment cycles/year 1 QL (max 168 days per year); $0 limited to 2 treatment cycles/year 1 OTC; $0 limited to 2 treatment cycles/year 1 OTC; $0 limited to 2 treatment cycles/year 1 OTC; $0 limited to 2 treatment cycles/year 1 OTC; $0 limited to 2 treatment cycles/year

RESPIRATORY AGENTS - MISC. Alpha-Proteinase Inhibitor (Human) ARALAST NP INJ 400MG ARALAST NP INJ 500MG ARALAST NP INJ 800MG ARALAST NP INJ 1000MG GLASSIA INJ PROLASTIN-C INJ 1000MG ZEMAIRA INJ 1000MG

5 5 5 5 5 5 5

PA PA PA PA PA PA PA

5 5 5 5

PA PA PA PA

Cystic Fibrosis Agents KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG ORKAMBI TAB 200-125

SULFONAMIDES Sulfonamides SULFADIAZINE TAB 500MG

4

TETRACYCLINES Tetracyclines avidoxy tab 100mg demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxy 100 inj 100mg doxycycline hyclate cap 50 mg

2 2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 132

October 1, 2016 Drug Name Drug Tier Requirements/Limits doxycycline hyclate cap 100 mg 2 doxycycline hyclate for inj 100 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 75 2 mg doxycycline hyclate tab delayed release 1002 mg doxycycline hyclate tab delayed release 1502 mg doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25 2 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 150 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 minocycline hcl tab sr 24hr 45 mg 2 minocycline hcl tab sr 24hr 90 mg 2 minocycline hcl tab sr 24hr 135 mg 2 morgidox cap 1x100mg 2 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 VIBRAMYCIN SYP 50MG/5ML 4

THYROID AGENTS Antithyroid Agents methimazole tab 5 mg methimazole tab 10 mg propylthiouracil tab 50 mg

2 2 2

Thyroid Hormones levothyroxine levothyroxine levothyroxine levothyroxine

sodium sodium sodium sodium

tab tab tab tab

25 50 75 88

mcg mcg mcg mcg

2 2 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 133

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

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 134

Drug Name unithroid tab unithroid tab unithroid tab unithroid tab unithroid tab unithroid tab unithroid tab

75mcg 88mcg 100mcg 112mcg 125mcg 200mcg 300mcg

October 1, 2016 Drug Tier Requirements/Limits 2 2 2 2 2 2 2

TOXOIDS Toxoid Combinations ADACEL INJ BOOSTRIX INJ DAPTACEL INJ

1 1 1

DIP/TET PED INJ 25-5LFU

1

INFANRIX INJ

1

KINRIX INJ

1

PEDIARIX INJ 0.5ML

1

PENTACEL INJ

1

TENIVAC INJ 5-2LF

1

TET/DIP TOX INJ 2-2 LF

1

TRIPEDIA SUS P/F

1

$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 19 and older $0 copay for members age 19 and older $0 copay for members age 18 and younger

ULCER DRUGS Antispasmodics ATROPEN INJ 0.5MG 4 ATROPEN INJ 0.25MG 4 ATROPEN INJ 1MG 4 ATROPEN INJ 2MG 4 atropine sulfate inj 0.1 mg/ml 2 atropine sulfate inj 0.4 mg/ml 2 atropine sulfate inj 0.8 mg/ml 2 atropine sulfate inj 0.05 mg/ml 2 atropine sulfate inj 1 mg/ml 2 CANTIL TAB 25MG 4 chlordiazepoxide hcl-clidinium bromide cap 2 5-2.5 mg

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 135

Drug Name CUVPOSA SOL 1MG/5ML dicyclomine hcl cap 10 mg dicyclomine hcl inj 10 mg/ml dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg ed-spaz tab 0.125mg glycopyrrolate inj 0.2 mg/ml glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg hyomax-sl sub 0.125mg hyoscyamine sulfate tab 0.125 mg hyoscyamine sulfate tab disp 0.125 mg hyoscyamine sulfate tab sl 0.125 mg hyoscyamine sulfate tab sr 12hr 0.375 mg methscopolamine bromide tab 2.5 mg methscopolamine bromide tab 5 mg nulev tab 0.125mg oscimin sr tab 0.375mg oscimin sub 0.125mg oscimin tab 0.125mg symax fastab tab 0.125mg symax-sl sub 0.125mg

October 1, 2016 Drug Tier Requirements/Limits 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

H-2 Antagonists cimetidine hcl soln 300 mg/5ml 2 cimetidine tab 200 mg 2 cimetidine tab 300 mg 2 cimetidine tab 400 mg 2 cimetidine tab 800 mg 2 famotidine for susp 40 mg/5ml 2 famotidine in nacl 0.9% iv soln 20 mg/50ml2 famotidine inj 20 mg/2ml 2 famotidine inj 40 mg/4ml 2 famotidine inj 200 mg/20ml 2 famotidine inj 500 mg/50ml 2 famotidine tab 20 mg 2 famotidine tab 40 mg 2 nizatidine cap 150 mg 2 nizatidine cap 300 mg 2 nizatidine oral soln 15 mg/ml 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 136

October 1, 2016 Drug Name Drug Tier Requirements/Limits ranitidine hcl cap 150 mg 2 ranitidine hcl cap 300 mg 2 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 ranitidine hcl inj 150 mg/6ml (25 mg/ml) 2 ranitidine hcl inj 1000 mg/40ml (25 mg/ml)2 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2 ranitidine hcl tab 150 mg 2 ranitidine hcl tab 300 mg 2 ZANTAC INJ 50/50ML 4 ZANTAC TAB 25MG EF 4

Misc. Anti-Ulcer CARAFATE SUS 1GM/10ML sucralfate tab 1 gm

4 2

Proton Pump Inhibitors§ DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR esomeprazole magnesium cap delayed release 20 mg (base eq) esomeprazole magnesium cap delayed release 40 mg (base eq) esomeprazole sodium for intravenous soln 20 mg (base equiv) esomeprazole sodium for intravenous soln 40 mg (base equiv) lansoprazole cap delayed release 15 mg lansoprazole cap delayed release 30 mg NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR omeprazole cap delayed release 10 mg omeprazole cap delayed release 20 mg omeprazole cap delayed release 40 mg pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) rabeprazole sodium ec tab 20 mg

4 4 2

ST; PA** ST; PA**

2 2 2 2 2 4 4 4 4 4 2 2 2 2 2 2

Ulcer Drugs - Prostaglandins misoprostol tab 100 mcg misoprostol tab 200 mcg

2 2

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 137

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

URINARY ANTI-INFECTIVES Urinary Anti-infectives methenamine hippurate tab 1 gm 2 MONUROL PAK GRANULES 4 nitrofurantoin macrocrystalline cap 25 mg 2

nitrofurantoin macrocrystalline cap 50 mg 2

nitrofurantoin macrocrystalline cap 100 mg 2

nitrofurantoin monohydrate macrocrystalline cap 100 mg

2

nitrofurantoin susp 25 mg/5ml

2

PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year PA; High Risk Medications require PA for members age 65 and older; PA applies to greater than cumulative 90 days of therapy per year

URINARY ANTISPASMODICS Beta-3 Adrenergic Agonists MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG

4 4

ST; PA** ST; PA**

Urinary Antispasmodics

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 138

October 1, 2016 Drug Name Drug Tier Requirements/Limits bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2 darifenacin hydrobromide tab sr 24hr 7.5 2 mg (base equiv) darifenacin hydrobromide tab sr 24hr 15 mg2 (base equiv) flavoxate hcl tab 100 mg 2 GELNIQUE GEL 3% 4 ST; PA** GELNIQUE GEL 10% 4 ST; PA** oxybutynin chloride syrup 5 mg/5ml 2 oxybutynin chloride tab 5 mg 2 oxybutynin chloride tab sr 24hr 5 mg 2 oxybutynin chloride tab sr 24hr 10 mg 2 oxybutynin chloride tab sr 24hr 15 mg 2 OXYTROL DIS 3.9MG/24 4 ST; PA** tolterodine tartrate cap sr 24hr 2 mg 2 tolterodine tartrate cap sr 24hr 4 mg 2 tolterodine tartrate tab 1 mg 2 tolterodine tartrate tab 2 mg 2 TOVIAZ TAB 4MG 4 ST; PA** TOVIAZ TAB 8MG 4 ST; PA** trospium chloride cap sr 24hr 60 mg 2 trospium chloride tab 20 mg 2 VESICARE TAB 5MG 4 ST; PA** VESICARE TAB 10MG 4 ST; PA**

VACCINES Bacterial Vaccines ACTHIB INJ

1

BEXSERO INJ HIBERIX SOL 10MCG

1 1

MENACTRA INJ MENHIBRIX INJ

1 1

MENOMUNE INJ A/C/Y/W MENVEO INJ PEDVAX HIB INJ

1 1 1

PNEUMOVAX 23 INJ 25/0.5 PREVNAR 13 INJ

1 1

$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 18 and younger

$0 copay for members age 18 and younger

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 139

Drug Name TRUMENBA INJ

October 1, 2016 Drug Tier Requirements/Limits 1

Mixed Vaccine Combinations COMVAX INJ

1

$0 copay for members age 18 and younger

Viral Vaccines AFLURIA INJ 2015-16 AFLURIA INJ PF 15-16 CERVARIX INJ ENGERIX-B INJ 10/0.5ML ENGERIX-B INJ 20MCG/ML FLUBLOK SOL 2015-16 FLUCELVAX INJ 2015-16 FLUMIST QUAD SUS 2014-15 FLUVIRIN INJ 2015-16 FLUZONE HD INJ PF 15-16 FLUZONE INJ INTRADRM FLUZONE QUAD INJ 15-16 FLUZONE SPLT INJ 2015-16 GARDASIL 9 INJ GARDASIL INJ HAVRIX INJ 720UNIT HAVRIX INJ 1440UNIT INFLUENZA A SPR 09 H1N1 IPOL INJ INACTIVE

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

M-M-R II INJ PROQUAD INJ

1 1

RECOMBIVA HB INJ 5MCG/0.5 RECOMBIVA HB INJ 10MCG/ML RECOMBIVA-HB INJ 40MCG/ML ROTARIX SUS

1 1 1 1

ROTATEQ SOL

1

TWINRIX INJ

1

VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ ZOSTAVAX INJ

1 1 1 1

$0 copay for members age 18 and younger $0 copay for members age 18 and younger

$0 copay for members age 18 and younger $0 copay for members age 18 and younger $0 copay for members age 19 and older

$0 copay for members age 19 and older

VAGINAL PRODUCTS

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 140

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Spermicides CONCEPTROL GEL 4% ENCARE SUP 100MG GYNOL II GEL 3% SHUR-SEAL GEL 2% TODAY SPONGE MIS VCF VAGINAL AER CONTRACP VCF VAGINAL MIS CONTRACP

1 1 1 1 1 1 1

OTC OTC OTC OTC OTC OTC OTC

Vaginal Anti-infectives CLEOCIN SUP 100MG 3 clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 metronidazole vaginal gel 0.75% 2 miconazole 3 kit combo pk 2 miconazole 3 sup 200mg 2 terconazole vaginal cream 0.4% 2 terconazole vaginal suppos 80 mg 2 vandazole gel 0.75% 2 zazole cre 0.4% 2 zazole cre 0.8% 2 zazole sup 80mg 2

Vaginal Estrogens ESTRACE VAG CRE 0.1MG/GM ESTRING MIS 2MG FEMRING MIS 0.1MG/24 FEMRING MIS 0.05/24H PREMARIN VAG CRE 0.625MG VAGIFEM TAB 10MCG

3 4 4 4 4 4

Vaginal Progestins CRINONE GEL 4% VAG CRINONE GEL 8% VAG

3 3

VASOPRESSORS Anaphylaxis Therapy Agents epinephrine hcl inj 1 mg/ml epinephrine hcl soln prefilled syringe 0.1 mg/ml epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK

2 2 2 2 3 3

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 141

Drug Name

October 1, 2016 Drug Tier Requirements/Limits

Vasopressors midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg midodrine hcl tab 10 mg

2 2 2

VITAMINS Oil Soluble Vitamins BABY SUPER DRO DAILY D3

1

bio-d-mulsio liq 400unit

1

child vit d chw 400unit

1

CHOLECALCIFEROL CAP 400 UNIT

1

D-VI-SOL LIQ 400UNIT

1

DDROPS BOOST LIQ 600/.028

1

decara cap 50000unt ergocalciferol cap 50000 unit MEPHYTON TAB 5MG pedia d-vite dro 400unit

2 2 3 1

sm vitamin d tab 400unit

1

VITAMIN D2 TAB 400UNIT

1

VITAMIN D3 LIQ 1000UNIT

1

VITAMIN D3 LIQ 1200UNIT

1

OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC

for ages

OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older OTC; $0 applies 65 and older

for ages

for ages for ages for ages for ages for ages

for ages for ages for ages for ages

PA - Prior Authorization (applies to pharmacy benefit only) QL - Quantity Limits ST - Step Therapy (Tier 1 - Preventive, Tier 2 - Generics, Tier 3 - Preferred Brands, Tier 4 - Non-Preferred Brands, Tier 5 - Preferred Specialty Medications, Tier 6 - Non-Preferred Specialty Medications) 142

Index 8 8-MOP CAP 10MG .............................91 A abacavir sulfate tab 300 mg (base equiv) ......................................................66 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg .........................66 ABELCET INJ 5MG/ML ........................42 ABRAXANE INJ 100MG .......................60 ABSTRAL SUB 100MCG ......................11 ABSTRAL SUB 200MCG ......................11 ABSTRAL SUB 300MCG ......................11 ABSTRAL SUB 400MCG ......................11 ABSTRAL SUB 600MCG ......................11 ABSTRAL SUB 800MCG ......................11 acamprosate calcium tab delayed release 333 mg ......................................... 129 ACANYA GEL 1.2-2.5% ......................86 acarbose tab 100 mg.........................36 acarbose tab 25 mg ..........................36 acarbose tab 50 mg ..........................36 acebutolol hcl cap 200 mg .................72 acebutolol hcl cap 400 mg .................72 acetaminophen w/ codeine soln 120-12 mg/5ml ...........................................15 acetaminophen w/ codeine tab 300-15 mg ......................................................15 acetaminophen w/ codeine tab 300-30 mg ......................................................15 acetaminophen w/ codeine tab 300-60 mg ......................................................15 acetazolamide cap sr 12hr 500 mg ......95 acetazolamide sodium for inj 500 mg ..95 acetazolamide tab 125 mg .................95 acetazolamide tab 250 mg .................95 acetic acid 2% in aluminum acetate otic soln............................................... 125 acetic acid otic soln 2% ................... 125 acetylcysteine inhal soln 10% .............86 acetylcysteine inhal soln 20% .............86 acitretin cap 10 mg ...........................90 acitretin cap 17.5 mg ........................90 acitretin cap 25 mg ...........................90 ACTEMRA INJ 162/0.9 ........................ 8 ACTEMRA INJ 200/10ML ..................... 8

October 1, 2016

ACTEMRA INJ 400/20ML ...................... 8 ACTEMRA INJ 80MG/4ML ..................... 8 ACTHIB INJ ................................... 139 acticin cre 5%.................................. 94 ACTIMMUNE INJ 2MU/0.5 .................. 59 acyclovir cap 200 mg ........................ 69 acyclovir oint 5% ............................. 91 acyclovir sodium for inj 1000 mg ....... 69 acyclovir sodium for inj 500 mg ......... 69 acyclovir sodium iv soln 50 mg/ml...... 69 acyclovir susp 200 mg/5ml ................ 69 acyclovir tab 400 mg ........................ 69 acyclovir tab 800 mg ........................ 69 ADACEL INJ ................................... 135 ADAGEN INJ 250/ML ......................... 73 adapalene cream 0.1% ..................... 86 adapalene gel 0.1% .......................... 86 adapalene gel 0.3% .......................... 86 adapalene lotion 0.1% ...................... 86 ADCIRCA TAB 20MG ......................... 77 adefovir dipivoxil tab 10 mg .............. 69 adriamycin inj 10mg ......................... 56 ADRIAMYCIN INJ 20MG ..................... 56 adrucil inj 500/10ml ......................... 53 ADVAIR DISKU AER 100/50 ............... 24 ADVAIR DISKU AER 250/50 ............... 24 ADVAIR DISKU AER 500/50 ............... 24 ADVAIR HFA AER 115/21 .................. 24 ADVAIR HFA AER 230/21 .................. 24 ADVAIR HFA AER 45/21 .................... 24 AEROCHAMBER MIS PLUS ............... 114 afeditab tab 30mg cr ........................ 73 afeditab tab 60mg cr ........................ 73 AFINITOR DIS TAB 2MG .................... 57 AFINITOR DIS TAB 3MG .................... 57 AFINITOR DIS TAB 5MG .................... 57 AFINITOR TAB 10MG ........................ 57 AFINITOR TAB 2.5MG ....................... 57 AFINITOR TAB 5MG .......................... 57 AFINITOR TAB 7.5MG ....................... 57 AFLURIA INJ 2015-16 ..................... 140 AFLURIA INJ PF 15-16 .................... 140 a-hydrocort inj 100mg ...................... 83 ala cort cre 1% ................................ 91 alagesic lq sol .................................. 10 143

October 1, 2016

ALBENZA TAB 200MG ........................18 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ..........................................25 albuterol sulfate soln nebu 0.5% (5 mg/ml) ............................................24 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .....................................24 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .....................................25 albuterol sulfate syrup 2 mg/5ml ........25 albuterol sulfate tab 2 mg ..................25 albuterol sulfate tab 4 mg ..................25 albuterol sulfate tab sr 12hr 4 mg .......25 albuterol sulfate tab sr 12hr 8 mg .......25 alclometasone dipropionate cream 0.05% ......................................................91 alclometasone dipropionate oint 0.05% ......................................................91 ALDACTAZIDE TAB 50/50 ..................95 ALDURAZYME INJ 2.9MG/5M ..............99 alendronate sodium oral soln 70 mg/75ml ......................................................97 alendronate sodium tab 10 mg ...........97 alendronate sodium tab 35 mg ...........97 alendronate sodium tab 40 mg ...........97 alendronate sodium tab 5 mg .............97 alendronate sodium tab 70 mg ...........97 ALFERON N INJ 5MU/ML ....................59 alfuzosin hcl tab sr 24hr 10 mg......... 107 ALIMTA INJ 100MG ...........................53 ALIMTA INJ 500MG ...........................53 ALINIA SUS 100/5ML ........................19 ALINIA TAB 500MG ...........................19 ALKERAN TAB 2MG ...........................52 ALLFEN CDX LIQ ...............................85 allopurinol sodium for inj 500 mg ...... 108 allopurinol tab 100 mg..................... 108 allopurinol tab 300 mg..................... 108 almotriptan malate tab 12.5 mg ....... 114 almotriptan malate tab 6.25 mg ....... 114 ALOCRIL SOL 2% ............................ 124 ALOMIDE SOL 0.1% OP ................... 124 alosetron hcl tab 0.5 mg (base equiv) 107 alosetron hcl tab 1 mg (base equiv) .. 107 ALOXI INJ 0.25MG/5 .........................40 ALPHAGAN P SOL 0.1% ................... 122 alphatrex gel 0.05% ..........................91

ALPRAZOLAM CON 1 MG/ML .............. 22 alprazolam orally disintegrating tab 0.25 mg ................................................. 22 alprazolam orally disintegrating tab 0.5 mg ................................................. 22 alprazolam orally disintegrating tab 1 mg ...................................................... 22 alprazolam orally disintegrating tab 2 mg ...................................................... 22 alprazolam tab 0.25 mg .................... 22 alprazolam tab 0.5 mg ...................... 22 alprazolam tab 1 mg ......................... 22 alprazolam tab 2 mg ......................... 22 ALREX SUS 0.2% ........................... 123 ALTABAX OIN 1% ............................. 89 altavera tab ..................................... 80 alyacen tab 1/35 .............................. 80 alyacen tab 7/7/7 ............................. 80 amantadine hcl cap 100 mg ............... 61 amantadine hcl syrup 50 mg/5ml ....... 61 amantadine hcl tab 100 mg ............... 61 AMBISOME INJ 50MG........................ 42 amcinonide cream 0.1% ................... 91 amcinonide lotion 0.1% .................... 91 AMCINONIDE OIN 0.1% .................... 91 a-methapred inj 125mg .................... 83 a-methapred inj 40mg ...................... 83 amethia tab ..................................... 80 amethyst tab 90-20mcg .................... 80 amifostine crystalline for inj 500 mg ... 59 amikacin sulfate inj 1 gm/4ml (250 mg/ml) ............................................. 7 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ............................................. 7 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 95 amiloride hcl tab 5 mg ...................... 96 aminophylline inj 25 mg/ml ............... 25 amiodarone hcl inj 150 mg/3ml (50 mg/ml) ........................................... 23 amiodarone hcl inj 450 mg/9ml (50 mg/ml) ........................................... 23 amiodarone hcl inj 900 mg/18ml (50 mg/ml) ........................................... 23 amiodarone hcl tab 200 mg ............... 23 amiodarone hcl tab 400 mg ............... 23 amitriptyline hcl tab 10 mg ................ 34 144

October 1, 2016

amitriptyline hcl tab 100 mg ..............34 amitriptyline hcl tab 150 mg ..............34 amitriptyline hcl tab 25 mg ................34 amitriptyline hcl tab 50 mg ................34 amitriptyline hcl tab 75 mg ................34 amlodipine besylate tab 10 mg ...........73 amlodipine besylate tab 2.5 mg ..........73 amlodipine besylate tab 5 mg .............73 amlodipine besylate-atorvastatin calcium tab 10-10 mg ...................................76 amlodipine besylate-atorvastatin calcium tab 10-20 mg ...................................76 amlodipine besylate-atorvastatin calcium tab 10-40 mg ...................................76 amlodipine besylate-atorvastatin calcium tab 10-80 mg ...................................76 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg ..................................76 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg ..................................76 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg ..................................76 amlodipine besylate-atorvastatin calcium tab 5-10 mg .....................................76 amlodipine besylate-atorvastatin calcium tab 5-20 mg .....................................76 amlodipine besylate-atorvastatin calcium tab 5-40 mg .....................................76 amlodipine besylate-atorvastatin calcium tab 5-80 mg .....................................76 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................48 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................48 amlodipine besylate-benazepril hcl cap 2.5-10 mg .......................................48 amlodipine besylate-benazepril hcl cap 5-10 mg ..........................................48 amlodipine besylate-benazepril hcl cap 5-20 mg ..........................................48 amlodipine besylate-benazepril hcl cap 5-40 mg ..........................................48 amlodipine besylate-valsartan tab 10-160 mg ..................................................48 amlodipine besylate-valsartan tab 10-320 mg ..................................................48 amlodipine besylate-valsartan tab 5-160

mg ................................................. 48 amlodipine besylate-valsartan tab 5-320 mg ................................................. 48 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 48 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 48 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 48 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 48 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg.............................. 48 AMMONIUM CHL INJ 5MEQ/ML ......... 115 amnesteem cap 10mg ...................... 86 amnesteem cap 20mg ...................... 86 amnesteem cap 40mg ...................... 86 amoxapine tab 100 mg ..................... 34 amoxapine tab 150 mg ..................... 34 amoxapine tab 25 mg ....................... 34 amoxapine tab 50 mg ....................... 34 amoxicillin & k clavulanate chew tab 200-28.5 mg ................................. 127 amoxicillin & k clavulanate chew tab 400-57 mg .................................... 127 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ........................... 127 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ........................... 127 amoxicillin & k clavulanate for susp 400-57 mg/5ml.............................. 127 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ........................... 127 amoxicillin & k clavulanate tab 250-125 mg ............................................... 127 amoxicillin & k clavulanate tab 500-125 mg ............................................... 127 amoxicillin & k clavulanate tab 875-125 mg ............................................... 127 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ............................... 128 amoxicillin (trihydrate) cap 250 mg .. 126 amoxicillin (trihydrate) cap 500 mg .. 126 amoxicillin (trihydrate) chew tab 125 mg .................................................... 126 amoxicillin (trihydrate) chew tab 250 mg .................................................... 126 145

October 1, 2016

amoxicillin (trihydrate) for susp 125 mg/5ml ......................................... 126 amoxicillin (trihydrate) for susp 200 mg/5ml ......................................... 126 amoxicillin (trihydrate) for susp 250 mg/5ml ......................................... 126 amoxicillin (trihydrate) for susp 400 mg/5ml ......................................... 126 amoxicillin (trihydrate) tab 500 mg ... 126 amoxicillin (trihydrate) tab 875 mg ... 126 amphetamine-dextroamphetamine cap sr 24hr 10 mg ....................................... 5 amphetamine-dextroamphetamine cap sr 24hr 15 mg ....................................... 5 amphetamine-dextroamphetamine cap sr 24hr 20 mg ....................................... 5 amphetamine-dextroamphetamine cap sr 24hr 25 mg ....................................... 5 amphetamine-dextroamphetamine cap sr 24hr 30 mg ....................................... 5 amphetamine-dextroamphetamine cap sr 24hr 5 mg......................................... 5 amphetamine-dextroamphetamine tab 10 mg ................................................... 5 amphetamine-dextroamphetamine tab 12.5 mg ........................................... 5 amphetamine-dextroamphetamine tab 15 mg ................................................... 5 amphetamine-dextroamphetamine tab 20 mg ................................................... 5 amphetamine-dextroamphetamine tab 30 mg ................................................... 5 amphetamine-dextroamphetamine tab 5 mg ................................................... 5 amphetamine-dextroamphetamine tab 7.5 mg ............................................. 5 AMPHOTEC INJ 100MG ......................42 AMPHOTEC INJ 50MG ........................42 amphotericin b for inj 50 mg ..............42 ampicillin & sulbactam sodium for inj 1-0.5 gm ....................................... 128 ampicillin & sulbactam sodium for inj 10-5 gm ................................................ 128 ampicillin & sulbactam sodium for inj 2-1 gm ................................................ 128 ampicillin & sulbactam sodium for iv soln 1-0.5 gm ....................................... 128

ampicillin & sulbactam sodium for iv soln 10-5 gm........................................ 128 ampicillin & sulbactam sodium for iv soln 2-1 gm ......................................... 128 ampicillin cap 250 mg ..................... 126 ampicillin cap 500 mg ..................... 126 ampicillin for susp 125 mg/5ml ........ 126 ampicillin for susp 250 mg/5ml ........ 127 ampicillin sodium for inj 1 gm .......... 127 ampicillin sodium for inj 10 gm ........ 127 ampicillin sodium for inj 125 mg ...... 127 ampicillin sodium for inj 2 gm .......... 127 ampicillin sodium for inj 250 mg ...... 127 ampicillin sodium for inj 500 mg ...... 127 ampicillin sodium for iv soln 1 gm .... 127 ampicillin sodium for iv soln 10 gm ... 127 ampicillin sodium for iv soln 2 gm .... 127 AMPYRA TAB 10MG......................... 130 ANADROL-50 TAB 50MG.................... 17 anagrelide hcl cap 0.5 mg ............... 108 anagrelide hcl cap 1 mg .................. 108 anastrozole tab 1 mg ........................ 55 ANDROXY TAB 10MG ........................ 17 ANTIVERT TAB 50MG ........................ 41 ANZEMET TAB 100MG ....................... 40 ANZEMET TAB 50MG ......................... 40 apexicon oin 0.05% .......................... 91 APIDRA INJ SOLOSTAR ..................... 38 APIDRA INJ U-100 ............................ 38 APLENZIN TAB 174MG ...................... 31 APLENZIN TAB 348MG ...................... 31 APLENZIN TAB 522MG ...................... 31 APOKYN INJ 10MG/ML ...................... 61 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 122 apri tab ........................................... 80 APRISO CAP 0.375GM ..................... 106 APTIVUS CAP 250MG ........................ 66 APTIVUS SOL ................................... 66 ARALAST NP INJ 1000MG ................ 132 ARALAST NP INJ 400MG .................. 132 ARALAST NP INJ 500MG .................. 132 ARALAST NP INJ 800MG .................. 132 aranelle tab ..................................... 80 ARANESP INJ 100MCG .................... 110 ARANESP INJ 10MCG ...................... 109 ARANESP INJ 150MCG .................... 110 146

October 1, 2016

ARANESP INJ 200MCG ..................... 110 ARANESP INJ 25MCG ....................... 109 ARANESP INJ 300MCG ..................... 110 ARANESP INJ 40MCG ....................... 109 ARANESP INJ 500MCG ..................... 110 ARANESP INJ 60MCG ....................... 109 arbinoxa sol 4mg/5ml........................43 ARCALYST INJ 220MG ........................ 8 ARCAPTA CAP 75MCG ........................25 ARGATROBAN INJ 125/125 ................27 argatroban inj 250 mg/2.5ml (concentrate for iv infusion) ...............27 ARGATROBAN INJ 250/250 ................27 aripiprazole oral solution 1 mg/ml .......66 aripiprazole tab 10 mg.......................66 ARIPIPRAZOLE TAB 10MG ODT ...........66 aripiprazole tab 15 mg.......................66 ARIPIPRAZOLE TAB 15MG ODT ...........66 aripiprazole tab 2 mg ........................66 aripiprazole tab 20 mg.......................66 aripiprazole tab 30 mg.......................66 aripiprazole tab 5 mg ........................66 armodafinil tab 150 mg ...................... 6 armodafinil tab 200 mg ...................... 6 armodafinil tab 250 mg ...................... 6 armodafinil tab 50 mg ........................ 6 ARRANON INJ 5MG/ML ......................53 ARZERRA CON 100/5ML.....................55 ARZERRA CON 1000/50 .....................55 ASMANEX 120 AER 220MCG ...............24 ASMANEX 30 AER 110MCG .................24 ASMANEX 60 AER 220MCG .................24 ASMANEX HFA AER 100 MCG..............24 ASMANEX HFA AER 200 MCG..............24 aspirin chew tab 81 mg .....................11 aspirin low tab 81mg ec .....................11 aspirin tab 325 mg ............................11 aspirin tab 81 mg .............................11 aspirin tab delayed release 325 mg .....11 aspirin-dipyridamole cap sr 12hr 25-200 mg ................................................ 108 astramorph inj 1mg/2ml ....................11 astramorph inj 2mg/2ml ....................11 atenolol & chlorthalidone tab 100-25 mg ......................................................49 atenolol & chlorthalidone tab 50-25 mg ......................................................48

atenolol tab 100 mg ......................... 72 atenolol tab 25 mg ........................... 72 atenolol tab 50 mg ........................... 72 ATGAM INJ 250MG ........................... 70 atorvastatin calcium tab 10 mg (base equivalent) ...................................... 45 atorvastatin calcium tab 20 mg (base equivalent) ...................................... 45 atorvastatin calcium tab 40 mg (base equivalent) ...................................... 45 atorvastatin calcium tab 80 mg (base equivalent) ...................................... 45 atovaquone susp 750 mg/5ml ............ 19 atovaquone-proguanil hcl tab 250-100 mg ...................................................... 51 atovaquone-proguanil hcl tab 62.5-25 mg ...................................................... 51 ATRIPLA TAB ................................... 67 ATROPEN INJ 0.25MG ..................... 135 ATROPEN INJ 0.5MG ....................... 135 ATROPEN INJ 1MG.......................... 135 ATROPEN INJ 2MG.......................... 135 atropine sulfate inj 0.05 mg/ml ........ 135 atropine sulfate inj 0.1 mg/ml.......... 135 atropine sulfate inj 0.4 mg/ml.......... 135 atropine sulfate inj 0.8 mg/ml.......... 135 atropine sulfate inj 1 mg/ml ............ 135 atropine sulfate ophth soln 1% ........ 122 AUBAGIO TAB 14MG ....................... 130 AUBAGIO TAB 7MG......................... 130 AUGMENTIN SUS 125/5ML .............. 128 avar cleanse emu 10-5% .................. 86 avar-e emoll cre 10-5% .................... 86 avar-e green cre 10-5% .................... 86 AVELOX INJ ................................... 105 aviane tab ....................................... 80 avidoxy tab 100mg......................... 132 avita cre 0.025% ............................. 86 avita gel 0.025%.............................. 86 azacitidine for inj 100 mg .................. 53 AZACTAM/DEX INJ 1GM .................... 18 AZACTAM/DEX INJ 2GM .................... 18 AZASAN TAB 100MG ......................... 70 AZASAN TAB 75 MG ......................... 70 AZASITE SOL 1% ........................... 122 azathioprine tab 50 mg ..................... 70 azelastine hcl nasal spray 0.1% (137 147

October 1, 2016

mcg/spray) .................................... 120 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) .................................... 120 azelastine hcl ophth soln 0.05% ....... 124 AZELEX CRE 20% .............................86 AZILECT TAB 0.5MG ..........................62 AZILECT TAB 1MG.............................62 azithromycin for susp 100 mg/5ml .... 112 azithromycin for susp 200 mg/5ml .... 112 azithromycin iv for soln 500 mg ........ 112 azithromycin powd pack for susp 1 gm .................................................... 112 azithromycin tab 250 mg ................. 112 azithromycin tab 500 mg ................. 112 azithromycin tab 600 mg ................. 112 AZOPT SUS 1% OP ......................... 124 aztreonam for inj 1 gm ......................18 aztreonam for inj 2 gm ......................18 azurette tab 28 day ...........................80 B BABY SUPER DRO DAILY D3 ............. 142 bacitracin ophth oint 500 unit/gm ..... 122 bacitracin-polymyxin b ophth oint ..... 122 bacitracin-polymyxin-neomycin-hc ophth oint 1% ......................................... 123 baclofen tab 10 mg ......................... 119 baclofen tab 20 mg ......................... 119 BACTOCILL INJ DEX 1GM ................. 128 BACTOCILL INJ DEX 2GM ................. 128 BACTROBAN OIN NASAL 2% ............ 120 balsalazide disodium cap 750 mg ...... 106 BANZEL SUS 40MG/ML ......................28 BANZEL TAB 200MG ..........................28 BANZEL TAB 400MG ..........................28 BARACLUDE SOL .05MG/ML ...............69 BD SWAB REG PAD SNGL USE .......... 114 benazepril & hydrochlorothiazide tab 10-12.5 mg ......................................49 benazepril & hydrochlorothiazide tab 20-12.5 mg ......................................49 benazepril & hydrochlorothiazide tab 20-25 mg ........................................49 benazepril & hydrochlorothiazide tab 5-6.25 mg .......................................49 benazepril hcl tab 10 mg ...................46 benazepril hcl tab 20 mg ...................46 benazepril hcl tab 40 mg ...................46

benazepril hcl tab 5 mg..................... 46 BENICAR TAB 20MG ......................... 47 BENICAR TAB 40MG ......................... 47 BENICAR TAB 5MG ........................... 47 BENLYSTA INJ 120MG ....................... 71 BENLYSTA INJ 400MG ....................... 71 BENZAMYCIN GEL PAK ...................... 86 benzepro aer 5.3% ........................... 86 BENZIQ GEL 5.25% .......................... 86 BENZIQ LS GEL 2.75% ..................... 86 benziq wash liq 5.25% ...................... 87 benzonatate cap 100 mg ................... 85 benzonatate cap 200 mg ................... 85 benzoyl per liq 10% wash ................. 87 benzoyl peroxide foam 5.3% ............. 87 benzoyl peroxide foam 9.8% ............. 87 benzoyl peroxide-erythromycin gel 5-3% ...................................................... 87 benztropine mesylate inj 1 mg/ml ...... 61 benztropine mesylate tab 0.5 mg ....... 61 benztropine mesylate tab 1 mg .......... 61 benztropine mesylate tab 2 mg .......... 61 BEPREVE DRO 1.5% ....................... 124 BESIVANCE SUS 0.6% .................... 122 betamethasone dipropionate augmented cream 0.05%................................... 91 betamethasone dipropionate augmented lotion 0.05% ................................... 91 betamethasone dipropionate augmented oint 0.05% ...................................... 91 betamethasone dipropionate cream 0.05% ............................................ 91 betamethasone dipropionate lotion 0.05% ...................................................... 91 betamethasone dipropionate oint 0.05% ...................................................... 91 betamethasone valerate aerosol foam 0.12% ............................................ 91 betamethasone valerate cream 0.1% . 91 betamethasone valerate lotion 0.1% .. 92 betamethasone valerate oint 0.1% ..... 92 BETASERON INJ 0.3MG ................... 130 betaxolol hcl ophth soln 0.5% .......... 121 betaxolol hcl tab 10 mg .................... 72 betaxolol hcl tab 20 mg .................... 72 bethanechol chloride tab 10 mg ....... 139 bethanechol chloride tab 25 mg ....... 139 148

October 1, 2016

bethanechol chloride tab 5 mg .......... 139 bethanechol chloride tab 50 mg ........ 139 BETIMOL SOL 0.25% ....................... 121 BETIMOL SOL 0.5% ........................ 121 BETOPTIC-S SUS 0.25% OP ............. 121 bexarotene cap 75 mg .......................59 BEXSERO INJ ................................. 139 BEYAZ TAB.......................................80 bicalutamide tab 50 mg .....................55 BICILLIN C-R INJ 1200000 ............... 128 BICILLIN C-R INJ 900/300 ............... 128 BICILLIN L-A INJ 1200000 ............... 127 BICILLIN L-A INJ 2400000 ............... 127 BICILLIN L-A INJ 600000 ................. 127 BICNU INJ 100MG .............................52 BILTRICIDE TAB 600MG ....................18 bimatoprost ophth soln 0.03% ......... 124 bio-d-mulsio liq 400unit ................... 142 BIO-STATIN CAP 1000000 .................42 BIO-STATIN CAP 500000 ...................42 bisoprolol & hydrochlorothiazide tab 10-6.25 mg ......................................49 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg .....................................49 bisoprolol & hydrochlorothiazide tab 5-6.25 mg .......................................49 bisoprolol fumarate tab 10 mg ............72 bisoprolol fumarate tab 5 mg .............72 BIVIGAM INJ 10% ........................... 125 bleomycin sulfate for inj 15 unit ..........56 bleomycin sulfate for inj 30 unit ..........56 BLEPHAMIDE OIN S.O.P. .................. 123 BLEPHAMIDE SUS OP ...................... 123 BOOSTRIX INJ ................................ 135 BOSULIF TAB 100MG .........................57 BOSULIF TAB 500MG .........................57 BOTOX INJ 100UNIT........................ 121 BOTOX INJ 200UNIT........................ 121 bp wash liq 2.5% ..............................87 bp wash liq 7% .................................87 BPO CLOTHS MIS 3% ........................87 BPO CLOTHS MIS 6% ........................87 BPO CLOTHS MIS 9% ........................87 BPO GEL 4% ....................................87 BPO GEL 8% ....................................87 BREO ELLIPTA INH 100-25 .................25 BREO ELLIPTA INH 200-25 .................25

BRILINTA TAB 60MG ....................... 108 BRILINTA TAB 90MG ....................... 108 brimonidine tartrate ophth soln 0.15% .................................................... 122 brimonidine tartrate ophth soln 0.2% 122 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 124 bromfenac sodium ophth soln 0.09% (base equivalent) ........................... 124 bromocriptine mesylate cap 5 mg....... 61 bromocriptine mesylate tab 2.5 mg .... 61 brompheniramine tannate chew tab 12 mg ................................................. 42 BROVANA NEB 15MCG ...................... 25 budesonide delayed release particles cap 3 mg .............................................. 83 budesonide inhalation susp 0.25 mg/2ml ...................................................... 24 budesonide inhalation susp 0.5 mg/2ml ...................................................... 24 budesonide inhalation susp 1 mg/2ml . 24 budesonide nasal susp 32 mcg/act ... 121 bumetanide inj 0.25 mg/ml ............... 96 bumetanide tab 0.5 mg ..................... 96 bumetanide tab 1 mg ....................... 96 bumetanide tab 2 mg ....................... 96 BUPHENYL TAB 500MG ..................... 99 buprenorphine hcl inj 0.3 mg/ml (base equiv) ............................................. 16 buprenorphine hcl sl tab 2 mg (base equiv) ............................................. 16 buprenorphine hcl sl tab 8 mg (base equiv) ............................................. 16 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ...................... 16 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)............................... 16 buproban tab 150mg ...................... 131 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg ................................. 131 bupropion hcl tab 100 mg ................. 31 bupropion hcl tab 75 mg ................... 31 bupropion hcl tab sr 12hr 100 mg ...... 31 bupropion hcl tab sr 12hr 150 mg ...... 31 bupropion hcl tab sr 12hr 200 mg ...... 31 bupropion hcl tab sr 24hr 150 mg ...... 31 bupropion hcl tab sr 24hr 300 mg ...... 31 149

October 1, 2016

buspirone hcl tab 10 mg ....................21 buspirone hcl tab 15 mg ....................21 buspirone hcl tab 30 mg ....................21 buspirone hcl tab 5 mg ......................21 buspirone hcl tab 7.5 mg ...................21 BUSULFEX INJ 6MG/ML ......................52 butalbital-acetaminophen-caffeine cap 50-300-40 mg ..................................11 butalbital-acetaminophen-caffeine cap 50-325-40 mg ..................................11 butalbital-acetaminophen-caffeine tab 50-325-40 mg ..................................11 butalbital-aspirin-caffeine cap 50-325-40 mg ..................................................11 butalbital-aspirin-caffeine tab 50-325-40 mg ..................................................11 butorphanol tartrate inj 1 mg/ml ........16 butorphanol tartrate inj 2 mg/ml ........16 butorphanol tartrate nasal soln 10 mg/ml ......................................................16 BUTRANS DIS 10MCG/HR ..................16 BUTRANS DIS 15MCG/HR ..................17 BUTRANS DIS 20MCG/HR ..................17 BUTRANS DIS 5MCG/HR ....................16 BUTRANS DIS 7.5/HR ........................16 BYSTOLIC TAB 10MG .........................72 BYSTOLIC TAB 2.5MG ........................72 BYSTOLIC TAB 20MG .........................72 BYSTOLIC TAB 5MG ..........................72 C cabergoline tab 0.5 mg .................... 100 CAFERGOT TAB 1-100MG ................. 114 calcipotriene cream 0.005% ...............90 calcipotriene oint 0.005% ..................90 calcipotriene soln 0.005% (50 mcg/ml) ......................................................90 calcipotriene-betamethasone dipropionate oint 0.005-0.064% .........92 calcitonin (salmon) nasal soln 200 unit/act ......................................................97 calcitrene oin 0.005%........................91 calcitriol cap 0.25 mcg .......................99 calcitriol cap 0.5 mcg ........................99 calcitriol inj 1 mcg/ml ........................99 calcitriol oint 3 mcg/gm .....................91 calcitriol oral soln 1 mcg/ml ...............99 calcium acetate (phosphate binder) cap

667 mg (169 mg ca)....................... 107 calcium acetate (phosphate binder) tab 667 mg ......................................... 107 camila tab 0.35mg ........................... 83 CAMPTOSAR INJ 300/15ML ................ 60 CANASA SUP 1000MG ..................... 106 CANCIDAS INJ 50MG ........................ 41 CANCIDAS INJ 70MG ........................ 41 candesartan cilexetil tab 16 mg.......... 47 candesartan cilexetil tab 32 mg.......... 47 candesartan cilexetil tab 4 mg ........... 47 candesartan cilexetil tab 8 mg ........... 47 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg................................ 49 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg................................ 49 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 49 CANTIL TAB 25MG .......................... 135 CAPASTAT SUL INJ 1GM .................... 52 capecitabine tab 150 mg ................... 53 capecitabine tab 500 mg ................... 53 CAPEX SHA 0.01% ........................... 92 CAPITAL/COD SUS 120-12/5 ............. 15 CAPRELSA TAB 100MG ...................... 57 CAPRELSA TAB 300MG ...................... 57 captopril & hydrochlorothiazide tab 25-15 mg ................................................. 49 captopril & hydrochlorothiazide tab 25-25 mg ................................................. 49 captopril & hydrochlorothiazide tab 50-15 mg ................................................. 49 captopril & hydrochlorothiazide tab 50-25 mg ................................................. 49 captopril tab 100 mg ........................ 46 captopril tab 12.5 mg ....................... 46 captopril tab 25 mg .......................... 46 captopril tab 50 mg .......................... 46 CARAFATE SUS 1GM/10ML .............. 137 CARBAGLU TAB 200MG ..................... 99 carbamazepine cap sr 12hr 100 mg .... 28 carbamazepine cap sr 12hr 200 mg .... 28 carbamazepine cap sr 12hr 300 mg .... 28 carbamazepine chew tab 100 mg ....... 28 carbamazepine susp 100 mg/5ml ....... 28 carbamazepine tab 200 mg ............... 28 carbamazepine tab sr 12hr 100 mg .... 28 150

October 1, 2016

carbamazepine tab sr 12hr 200 mg .....28 carbamazepine tab sr 12hr 400 mg .....28 carbidopa & levodopa orally disintegrating tab 10-100 mg .................................61 carbidopa & levodopa orally disintegrating tab 25-100 mg .................................61 carbidopa & levodopa orally disintegrating tab 25-250 mg .................................61 carbidopa & levodopa tab 10-100 mg ..61 carbidopa & levodopa tab 25-100 mg ..61 carbidopa & levodopa tab 25-250 mg ..61 carbidopa & levodopa tab cr 25-100 mg ......................................................61 carbidopa & levodopa tab cr 50-200 mg ......................................................61 carbidopa tab 25 mg .........................61 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ...............................61 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg .............................61 carbidopa-levodopa-entacapone tabs 25-100-200 mg ................................62 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg............................62 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg .............................62 carbidopa-levodopa-entacapone tabs 50-200-200 mg ................................62 carbinoxamine maleate soln 4 mg/5ml 43 carbinoxamine maleate tab 4 mg ........43 carboplatin iv for inj 150 mg ..............52 carboplatin iv soln 150 mg/15ml .........52 carboplatin iv soln 450 mg/45ml .........52 carboplatin iv soln 50 mg/5ml ............52 carboplatin iv soln 600 mg/60ml .........52 CARDENE IV INJ 40/200ML ................73 CARDENE IV SOL 20/200ML ...............73 CARDIZEM LA TAB 120MG .................74 CARDURA XL TAB 4MG .................... 107 CARDURA XL TAB 8MG .................... 107 CARIMUNE NF INJ 12GM .................. 125 CARIMUNE NF INJ 3GM .................... 125 CARIMUNE NF INJ 6GM .................... 125 carisoprodol tab 250 mg .................. 119 carisoprodol tab 350 mg .................. 119 carteolol hcl ophth soln 1% .............. 121 cartia xt cap 120/24hr .......................74

cartia xt cap 180/24hr ...................... 74 cartia xt cap 240/24hr ...................... 74 cartia xt cap 300/24hr ...................... 74 carvedilol tab 12.5 mg ...................... 72 carvedilol tab 25 mg ......................... 72 carvedilol tab 3.125 mg .................... 72 carvedilol tab 6.25 mg ...................... 72 CAYA DPR ..................................... 113 CAYSTON INH 75MG ......................... 18 caziant pak ...................................... 80 CEDAX SUS 90MG/5ML ..................... 78 cefaclor cap 250 mg ......................... 78 cefaclor cap 500 mg ......................... 78 CEFACLOR ER TAB 500MG ................. 78 cefaclor for susp 125 mg/5ml ............ 78 cefaclor for susp 250 mg/5ml ............ 78 cefaclor for susp 375 mg/5ml ............ 78 cefadroxil cap 500 mg....................... 77 cefadroxil for susp 250 mg/5ml .......... 77 cefadroxil for susp 500 mg/5ml .......... 77 cefadroxil tab 1 gm .......................... 77 CEFAZOL/DEX SOL 1GM .................... 77 CEFAZOL/DEX SOL 2GM .................... 77 CEFAZOLIN INJ 1GM/50ML ................ 77 cefazolin sodium for inj 1 gm ............. 77 cefazolin sodium for inj 10 gm ........... 77 cefazolin sodium for inj 20 gm ........... 77 cefazolin sodium for inj 500 mg ......... 77 cefazolin sodium for iv soln 1 gm ....... 77 CEFAZOLIN SOL ............................... 77 cefdinir cap 300 mg .......................... 78 cefdinir for susp 125 mg/5ml ............. 78 cefdinir for susp 250 mg/5ml ............. 78 cefditoren pivoxil tab 200 mg (base equivalent) ...................................... 79 cefditoren pivoxil tab 400 mg (base equivalent) ...................................... 79 cefepime hcl for inj 1 gm................... 79 cefepime hcl for inj 2 gm................... 80 CEFEPIME INJ 1GM ........................... 80 CEFEPIME INJ 2GM ........................... 80 CEFEPIME/DEX INJ 1GM .................... 80 cefixime for susp 100 mg/5ml............ 79 cefixime for susp 200 mg/5ml............ 79 cefotaxime sodium for inj 1 gm .......... 79 cefotaxime sodium for inj 10 gm ........ 79 cefotaxime sodium for inj 2 gm .......... 79 151

October 1, 2016

cefotaxime sodium for inj 500 mg .......79 CEFOTET/DEX INJ 1-3.58% ................78 CEFOTET/DEX INJ 2-2.08% ................78 CEFOTETAN DISODIUM FOR INJ 1 GM .78 CEFOTETAN DISODIUM FOR INJ 10 GM ......................................................78 CEFOTETAN DISODIUM FOR INJ 2 GM .78 CEFOXITIN INJ 1GM ..........................78 CEFOXITIN INJ 2GM ..........................78 cefoxitin sodium for inj 10 gm ............78 cefoxitin sodium for iv soln 1 gm ........78 cefoxitin sodium for iv soln 2 gm ........78 cefpodoxime proxetil for susp 100 mg/5ml ......................................................79 cefpodoxime proxetil for susp 50 mg/5ml ......................................................79 cefpodoxime proxetil tab 100 mg ........79 cefpodoxime proxetil tab 200 mg ........79 cefprozil for susp 125 mg/5ml ............78 cefprozil for susp 250 mg/5ml ............78 cefprozil tab 250 mg .........................78 cefprozil tab 500 mg .........................78 ceftazidime for inj 2 gm .....................79 CEFTAZIDIME INJ 100GM...................79 CEFTAZIDIME/ SOL D5W 1GM ............79 CEFTAZIDIME/ SOL D5W 2GM ............79 ceftibuten cap 400 mg .......................79 ceftibuten for susp 180 mg/5ml ..........79 CEFTIN SUS 125/5ML ........................78 CEFTIN SUS 250/5ML ........................78 ceftriaxone sodium for inj 1 gm ..........79 ceftriaxone sodium for inj 10 gm ........79 ceftriaxone sodium for inj 2 gm ..........79 ceftriaxone sodium for inj 250 mg .......79 ceftriaxone sodium for inj 500 mg .......79 ceftriaxone sodium for iv soln 1 gm .....79 ceftriaxone sodium for iv soln 2 gm .....79 CEFUROX/DEXT INJ 1.5GM.................78 CEFUROX/DEXT INJ 750MG ................78 cefuroxime axetil tab 250 mg .............78 cefuroxime axetil tab 500 mg .............78 CEFUROXIME INJ 225GM ...................78 CEFUROXIME INJ 7.5GM ....................78 CEFUROXIME INJ 75GM .....................78 cefuroxime sodium for inj 1.5 gm .......78 cefuroxime sodium for inj 7.5 gm .......78 cefuroxime sodium for inj 750 mg .......78

cefuroxime sodium for iv soln 1.5 gm . 78 celecoxib cap 100 mg ......................... 8 celecoxib cap 200 mg ......................... 9 celecoxib cap 400 mg ......................... 9 celecoxib cap 50 mg ........................... 8 CELLCEPT IV INJ 500MG ................... 70 CELONTIN CAP 300MG ...................... 30 CENESTIN TAB 0.3MG ..................... 101 CENESTIN TAB 0.45MG ................... 101 CENESTIN TAB 0.625MG ................. 101 CENESTIN TAB 0.9MG ..................... 101 CENESTIN TAB 1.25MG ................... 101 cephalexin cap 250 mg ..................... 77 cephalexin cap 500 mg ..................... 77 cephalexin cap 750 mg ..................... 77 cephalexin for susp 125 mg/5ml ........ 77 cephalexin for susp 250 mg/5ml ........ 77 cephalexin tab 250 mg...................... 77 cephalexin tab 500 mg...................... 77 CEREZYME INJ 400UNIT .................. 109 cerisa wash emu 10-1% .................... 87 CERVARIX INJ ................................ 140 CESAMET CAP 1MG .......................... 41 cesia pak......................................... 80 cevimeline hcl cap 30 mg ................ 118 CHANTIX PAK 0.5& 1MG ................. 131 CHANTIX PAK 1MG ......................... 131 CHANTIX TAB 0.5MG ...................... 131 CHANTIX TAB 1MG ......................... 131 chateal tab 0.15/30 .......................... 80 CHEMET CAP 100MG ......................... 40 cheratussin syp 100-10/5 .................. 85 child vit d chw 400unit .................... 142 chloramphenicol sodium succinate for iv inj 1 gm .......................................... 19 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg ................................. 135 chlorhexidine gluconate soln 0.12%.. 118 chloroquine phosphate tab 250 mg ..... 51 chloroquine phosphate tab 500 mg ..... 51 chlorothiazide sodium for inj 500 mg .. 96 chlorothiazide tab 250 mg ................. 96 chlorothiazide tab 500 mg ................. 96 CHLORPROMAZ INJ 25MG/ML ............ 65 CHLORPROMAZ INJ 50MG/2ML .......... 65 chlorpromazine hcl tab 10 mg ............ 65 chlorpromazine hcl tab 100 mg .......... 65 152

October 1, 2016

chlorpromazine hcl tab 200 mg ...........65 chlorpromazine hcl tab 25 mg ............65 chlorpromazine hcl tab 50 mg ............65 chlorpropamide tab 100 mg ...............39 chlorpropamide tab 250 mg ...............39 chlorthalidone tab 100 mg .................97 chlorthalidone tab 25 mg ...................96 chlorthalidone tab 50 mg ...................97 chlorzoxazone tab 500 mg ............... 119 CHOLECALCIFEROL CAP 400 UNIT .... 142 cholestyramine light powder 4 gm/dose ......................................................44 cholestyramine light powder packets 4 gm ......................................................44 cholestyramine powder 4 gm/dose ......44 cholestyramine powder packets 4 gm ..44 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ........................44 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ........................44 chorionic gonadotropin for inj 10000 unit ......................................................98 CIALIS TAB 2.5MG .......................... 108 CIALIS TAB 5MG ............................. 108 ciclopirox gel 0.77% ..........................89 ciclopirox kit 8% ...............................89 ciclopirox olamine cream 0.77% (base equiv) .............................................89 ciclopirox olamine susp 0.77% (base equiv) .............................................89 ciclopirox shampoo 1% ......................89 ciclopirox solution 8% .......................89 cidofovir iv inj 75 mg/ml ....................69 cilostazol tab 100 mg ...................... 108 cilostazol tab 50 mg ........................ 108 CILOXAN OIN 0.3% OP .................... 122 cimetidine hcl soln 300 mg/5ml ........ 136 cimetidine tab 200 mg ..................... 136 cimetidine tab 300 mg ..................... 136 cimetidine tab 400 mg ..................... 136 cimetidine tab 800 mg ..................... 136 CIMZIA KIT .................................... 106 CIMZIA KIT STARTER ...................... 106 CIMZIA PREFL KIT 200MG/ML ........... 106 CIPRO HC SUS OTIC ....................... 125 CIPRODEX SUS 0.3-0.1% ................ 125 ciprofloxacin 200 mg/100ml in d5w ... 105

ciprofloxacin 400 mg/200ml in d5w .. 105 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)........................ 105 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) .................... 105 ciprofloxacin hcl ophth soln 0.3% ..... 122 ciprofloxacin hcl tab 100 mg (base equiv) .................................................... 105 ciprofloxacin hcl tab 250 mg (base equiv) .................................................... 105 ciprofloxacin hcl tab 500 mg (base equiv) .................................................... 105 ciprofloxacin hcl tab 750 mg (base equiv) .................................................... 105 ciprofloxacin iv soln 200 mg/20ml (1%) .................................................... 105 ciprofloxacin iv soln 400 mg/40ml (1%) .................................................... 105 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) .......................... 105 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) .......................... 105 cisplatin inj 100 mg/100ml (1 mg/ml) . 52 cisplatin inj 200 mg/200ml (1 mg/ml) . 52 cisplatin inj 50 mg/50ml (1 mg/ml) .... 52 citalopram hydrobromide oral soln 10 mg/5ml ........................................... 32 citalopram hydrobromide tab 10 mg (base equiv) ............................................. 32 citalopram hydrobromide tab 20 mg (base equiv) ............................................. 32 citalopram hydrobromide tab 40 mg (base equiv) ............................................. 32 CITRANATAL CAP HARMONY ............ 119 CITRANATAL MIS 90 DHA ................ 119 CITRANATAL MIS B-CALM ............... 119 CITRANATAL PAK ASSURE ............... 119 CITRANATAL PAK DHA .................... 119 CITRANATAL TAB RX ...................... 119 cladribine iv soln 10 mg/10ml (1 mg/ml) ...................................................... 53 CLAFORAN INJ 1GM .......................... 79 CLAFORAN INJ 2GM .......................... 79 claravis cap 10mg ............................ 87 claravis cap 20mg ............................ 87 claravis cap 30mg ............................ 87 claravis cap 40mg ............................ 87 153

October 1, 2016

CLARINEX SYP 0.5MG/ML...................43 clarithromycin for susp 125 mg/5ml .. 112 clarithromycin for susp 250 mg/5ml .. 112 clarithromycin tab 250 mg ............... 112 clarithromycin tab 500 mg ............... 112 clarithromycin tab sr 24hr 500 mg .... 112 clearplex x gel 10% ..........................87 clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) .......................43 clemastine fumarate tab 2.68 mg .......43 CLEOCIN SUP 100MG ...................... 141 CLIMARA PRO DIS WEEKLY .............. 101 clindamax gel 1% .............................87 clindamax lot 10mg/ml ......................87 clindamycin hcl cap 150 mg ...............19 clindamycin hcl cap 300 mg ...............19 clindamycin hcl cap 75 mg .................19 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) .........................19 clindamycin phosphate foam 1% ........87 clindamycin phosphate gel 1% ...........87 clindamycin phosphate inj 300 mg/2ml 19 clindamycin phosphate inj 600 mg/4ml 19 clindamycin phosphate inj 9 gm/60ml .19 clindamycin phosphate inj 900 mg/6ml 19 clindamycin phosphate iv soln 300 mg/2ml ...........................................19 clindamycin phosphate iv soln 600 mg/4ml ...........................................19 clindamycin phosphate iv soln 900 mg/6ml ...........................................20 clindamycin phosphate lotion 1% ........87 clindamycin phosphate soln 1% ..........87 clindamycin phosphate swab 1% ........87 clindamycin phosphate vaginal cream 2% .................................................... 141 clindamycin phosphate-benzoyl peroxide gel 1-5% .........................................87 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% ......................87 clobetasol propionate cream 0.05% ....92 clobetasol propionate foam 0.05% ......92 clobetasol propionate gel 0.05% .........92 clobetasol propionate lotion 0.05% .....92 clobetasol propionate oint 0.05% ........92 clobetasol propionate shampoo 0.05% 92 clobetasol propionate soln 0.05% .......92

clobetasol propionate spray 0.05% ..... 92 clocortolone pivalate cream 0.1%....... 92 CLOLAR INJ 1MG/ML......................... 53 clomipramine hcl cap 25 mg .............. 34 clomipramine hcl cap 50 mg .............. 34 clomipramine hcl cap 75 mg .............. 34 clonazepam tab 0.5 mg ..................... 27 clonazepam tab 1 mg ....................... 27 clonazepam tab 2 mg ....................... 27 clonidine hcl tab 0.1 mg .................... 47 clonidine hcl tab 0.2 mg .................... 47 clonidine hcl tab 0.3 mg .................... 47 clonidine hcl td patch weekly 0.1 mg/24hr ...................................................... 47 clonidine hcl td patch weekly 0.2 mg/24hr ...................................................... 47 clonidine hcl td patch weekly 0.3 mg/24hr ...................................................... 47 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 108 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 108 clorazepate dipotassium tab 15 mg .... 22 clorazepate dipotassium tab 3.75 mg.. 22 clorazepate dipotassium tab 7.5 mg ... 22 clotrimazole cream 1% ..................... 89 CLOTRIMAZOLE CRY ......................... 89 clotrimazole soln 1% ........................ 89 clotrimazole troche 10 mg ............... 118 clotrimazole w/ betamethasone cream 1-0.05% ......................................... 89 clotrimazole w/ betamethasone lotion 1-0.05% ......................................... 89 clozapine orally disintegrating tab 100 mg ...................................................... 64 clozapine orally disintegrating tab 12.5 mg ................................................. 64 clozapine orally disintegrating tab 150 mg ...................................................... 64 clozapine orally disintegrating tab 200 mg ...................................................... 64 clozapine orally disintegrating tab 25 mg ...................................................... 64 clozapine tab 100 mg ....................... 64 clozapine tab 200 mg ....................... 64 clozapine tab 25 mg ......................... 64 clozapine tab 50 mg ......................... 64 154

October 1, 2016

COARTEM TAB 20-120MG ..................51 CODEINE SULF SOL 30MG/5ML...........11 codeine sulfate tab 15 mg ..................12 codeine sulfate tab 30 mg ..................12 codeine sulfate tab 60 mg ..................12 colchicine tab 0.6 mg ...................... 108 colchicine w/ probenecid tab 0.5-500 mg .................................................... 108 colestipol hcl granule packets 5 gm .....44 colestipol hcl granules 5 gm ...............44 colestipol hcl tab 1 gm .......................44 colocort ene 100mg ..........................17 COLYTE/FLAVR SOL PACKS .............. 111 COMBIGAN SOL 0.2/0.5% ................ 121 COMBIVENT AER 20-100....................25 COMETRIQ KIT 100MG ......................57 COMETRIQ KIT 140MG ......................57 COMETRIQ KIT 60MG ........................57 COMPLERA TAB ................................67 compro sup 25mg .............................65 COMVAX INJ................................... 140 CONCEPTROL GEL 4% ..................... 141 CONDYLOX GEL 0.5%........................94 COPAXONE INJ 20MG/ML ................. 130 COPAXONE INJ 40MG/ML ................. 131 CORDRAN 24X3 TAP 4MCG/CM ...........92 CORDRAN LOT 0.05% .......................92 CORDRAN OIN 0.05% .......................92 COREG CR CAP 10MG ........................72 COREG CR CAP 20MG ........................72 COREG CR CAP 40MG ........................72 COREG CR CAP 80MG ........................72 cortisone acetate tab 25 mg ...............83 CORTISPORIN CRE 0.5% ...................89 CORTISPORIN OIN 1% ......................89 CORTISPORIN SUS -TC OTIC ............ 125 COUMADIN INJ 5 MG .........................26 CREON CAP 12000UNT ......................95 CREON CAP 24000UNT ......................95 CREON CAP 3000UNIT .......................95 CREON CAP 36000UNT ......................95 CREON CAP 6000UNIT .......................95 CRINONE GEL 4% VAG .................... 141 CRINONE GEL 8% VAG .................... 141 CRIXIVAN CAP 200MG .......................67 CRIXIVAN CAP 400MG .......................67 cromolyn sodium ophth soln 4% ....... 124

cromolyn sodium oral conc 100 mg/5ml .................................................... 106 cromolyn sodium soln nebu 20 mg/2ml ...................................................... 23 cryselle-28 tab 28 tabs ..................... 80 CUBICIN SOL 500MG ........................ 19 CUVPOSA SOL 1MG/5ML ................. 136 cyanocobalamin inj 1000 mcg/ml ..... 109 cyclafem tab 1/35 ............................ 80 cyclafem tab 7/7/7 ........................... 80 cyclobenzaprine hcl tab 10 mg ......... 119 cyclobenzaprine hcl tab 5 mg ........... 119 cyclobenzaprine hcl tab 7.5 mg ........ 119 CYCLOPHOSPH CAP 25MG ................. 52 CYCLOPHOSPH CAP 50MG ................. 52 cyclophosphamide for inj 1 gm .......... 52 cyclophosphamide for inj 2 gm .......... 52 cyclophosphamide for inj 500 mg ....... 53 cyclophosphamide tab 25 mg............. 53 cyclophosphamide tab 50 mg............. 53 cycloserine cap 250 mg..................... 52 CYCLOSET TAB 0.8MG ...................... 38 cyclosporine cap 100 mg ................... 70 cyclosporine cap 25 mg ..................... 70 cyclosporine iv soln 50 mg/ml ............ 70 cyclosporine modified cap 100 mg ...... 70 cyclosporine modified cap 25 mg ........ 70 cyclosporine modified cap 50 mg ........ 70 cyclosporine modified oral soln 100 mg/ml ...................................................... 70 cyproheptadine hcl syrup 2 mg/5ml .... 44 cyproheptadine hcl tab 4 mg ............. 44 CYSTADANE POW ............................. 99 CYSTAGON CAP 150MG ................... 107 CYSTAGON CAP 50MG .................... 107 cytarabine for inj 1 gm ..................... 53 cytarabine for inj 100 mg .................. 53 cytarabine for inj 500 mg .................. 53 cytarabine inj 20 mg/ml .................... 53 cytarabine inj pf 100 mg/ml .............. 54 cytarabine inj pf 20 mg/ml ................ 54 D dacarbazine for inj 100 mg ................ 59 dacarbazine for inj 200 mg ................ 59 dactinomycin for inj 0.5 mg ............... 56 DALIRESP TAB 500MCG .................... 24 danazol cap 100 mg ......................... 17 155

October 1, 2016

danazol cap 200 mg ..........................17 danazol cap 50 mg ............................17 dantrolene sodium cap 100 mg ......... 120 dantrolene sodium cap 25 mg .......... 120 dantrolene sodium cap 50 mg .......... 120 dapsone tab 100 mg .........................19 dapsone tab 25 mg ...........................19 DAPTACEL INJ ................................ 135 DARAPRIM TAB 25MG ........................51 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) ............................. 139 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) ............................. 139 dasetta tab 1/35 ...............................80 dasetta tab 7/7/7..............................80 daunorubicin hcl for inj 20 mg ............56 daunorubicin hcl inj 5 mg/ml (base equiv) ......................................................56 DAUNOXOME INJ 2MG/ML ..................56 DDROPS BOOST LIQ 600/.028 .......... 142 decara cap 50000unt ....................... 142 decitabine for inj 50 mg .....................54 demeclocycline hcl tab 150 mg ......... 132 demeclocycline hcl tab 300 mg ......... 132 DENAVIR CRE 1% .............................91 DEPEN TITRA TAB 250MG ..................70 DEPOCYT INJ 50MG/5ML ....................54 DEPO-ESTRADI INJ 5MG/ML ............. 101 DEPO-MEDROL INJ 20MG/ML ..............83 DEPO-PROVERA INJ 400/ML ...............55 DEPO-SQ PROV INJ 104 .....................83 desipramine hcl tab 10 mg .................34 desipramine hcl tab 100 mg ...............35 desipramine hcl tab 150 mg ...............35 desipramine hcl tab 25 mg .................34 desipramine hcl tab 50 mg .................35 desipramine hcl tab 75 mg .................35 desloratadine tab 5 mg ......................43 desloratadine tab orally disintegrating 2.5 mg ..................................................43 desloratadine tab orally disintegrating 5 mg ..................................................43 desmopressin acetate inj 4 mcg/ml ... 100 desmopressin acetate nasal soln 0.01% (refrigerated) ................................. 100 desmopressin acetate nasal spray soln 0.01% ........................................... 100

desmopressin acetate nasal spray soln 0.01% (refrigerated) ...................... 100 desmopressin acetate tab 0.1 mg ..... 100 desmopressin acetate tab 0.2 mg ..... 100 DESONATE GEL 0.05% ..................... 92 desonide cream 0.05% ..................... 92 desonide lotion 0.05% ...................... 92 desonide oint 0.05%......................... 92 DESOWEN OINT KIT 0.05% ............... 92 desoximetasone cream 0.05% ........... 92 desoximetasone cream 0.25% ........... 92 desoximetasone gel 0.05%................ 92 desoximetasone oint 0.05% .............. 92 desoximetasone oint 0.25% .............. 92 DEXAMETHASON CON 1MG/ML .......... 83 dexamethasone elixir 0.5 mg/5ml ...... 83 dexamethasone sod phosphate preservative free inj 10 mg/ml ........... 83 dexamethasone sodium phosphate inj 10 mg/ml ............................................ 83 dexamethasone sodium phosphate inj 100 mg/10ml ......................................... 83 dexamethasone sodium phosphate inj 120 mg/30ml ......................................... 83 dexamethasone sodium phosphate inj 20 mg/5ml ........................................... 83 dexamethasone sodium phosphate inj 4 mg/ml ............................................ 83 dexamethasone sodium phosphate ophth soln 0.1% ..................................... 123 dexamethasone soln 0.5 mg/5ml ....... 83 dexamethasone tab 0.5 mg ............... 83 dexamethasone tab 0.75 mg ............. 83 dexamethasone tab 1 mg .................. 84 dexamethasone tab 1.5 mg ............... 84 dexamethasone tab 2 mg .................. 84 dexamethasone tab 4 mg .................. 84 dexamethasone tab 6 mg .................. 84 dexchlorpheniramine maleate syrup 2 mg/5ml ........................................... 43 DEXILANT CAP 30MG DR ................. 137 DEXILANT CAP 60MG DR ................. 137 dexmethylphenidate hcl cap sr 24 hr 10 mg ................................................... 6 dexmethylphenidate hcl cap sr 24 hr 15 mg ................................................... 6 dexmethylphenidate hcl cap sr 24 hr 20 156

October 1, 2016

mg ................................................... 6 dexmethylphenidate hcl cap sr 24 hr 30 mg ................................................... 6 dexmethylphenidate hcl cap sr 24 hr 40 mg ................................................... 6 dexmethylphenidate hcl cap sr 24 hr 5 mg ....................................................... 6 dexmethylphenidate hcl tab 10 mg ...... 6 dexmethylphenidate hcl tab 2.5 mg ..... 6 dexmethylphenidate hcl tab 5 mg ........ 6 DEXPAK PAK 10 DAY .........................84 DEXPAK PAK 13 DAY .........................84 DEXPAK PAK 6 DAY ...........................84 dexrazoxane for inj 250 mg ...............59 dexrazoxane for inj 500 mg ...............59 dextroamphetamine sulfate cap sr 24hr 10 mg .............................................. 5 dextroamphetamine sulfate cap sr 24hr 15 mg .............................................. 5 dextroamphetamine sulfate cap sr 24hr 5 mg ................................................... 5 dextroamphetamine sulfate oral solution 5 mg/5ml.......................................... 5 dextroamphetamine sulfate tab 10 mg . 5 dextroamphetamine sulfate tab 5 mg ... 5 diazepam con 5mg/ml .......................22 diazepam oral soln 1 mg/ml ...............22 diazepam tab 10 mg .........................22 diazepam tab 2 mg ...........................22 diazepam tab 5 mg ...........................22 diclofenac potassium tab 50 mg ........... 9 diclofenac sodium gel 1% ..................89 diclofenac sodium ophth soln 0.1% ... 124 diclofenac sodium tab delayed release 25 mg ................................................... 9 diclofenac sodium tab delayed release 50 mg ................................................... 9 diclofenac sodium tab delayed release 75 mg ................................................... 9 diclofenac sodium tab sr 24hr 100 mg .. 9 diclofenac w/ misoprostol tab delayed release 50-0.2 mg ............................. 9 diclofenac w/ misoprostol tab delayed release 75-0.2 mg ............................. 9 dicloxacillin sodium cap 250 mg ........ 128 dicloxacillin sodium cap 500 mg ........ 128 dicyclomine hcl cap 10 mg ............... 136

dicyclomine hcl inj 10 mg/ml ........... 136 dicyclomine hcl oral soln 10 mg/5ml . 136 dicyclomine hcl tab 20 mg ............... 136 didanosine delayed release capsule 125 mg ................................................. 67 didanosine delayed release capsule 200 mg ................................................. 67 didanosine delayed release capsule 250 mg ................................................. 67 didanosine delayed release capsule 400 mg ................................................. 67 DIFICID TAB 200MG ....................... 113 diflorasone diacetate cream 0.05%..... 92 diflorasone diacetate oint 0.05% ........ 92 diflunisal tab 500 mg ........................ 11 digox tab 0.125mg ........................... 76 digox tab 0.25mg ............................. 76 digoxin inj 0.25 mg/ml...................... 76 digoxin oral soln 0.05 mg/ml ............. 76 digoxin tab 125 mcg (0.125 mg) ........ 76 digoxin tab 250 mcg (0.25 mg) .......... 76 dihydroergotamine mesylate inj 1 mg/ml .................................................... 114 dihydroergotamine mesylate nasal spray 4 mg/ml ........................................ 114 DILANTIN CAP 30MG ........................ 30 DILATRATE SR CAP 40MG ................. 20 diltiazem hcl cap sr 12hr 120 mg ....... 74 diltiazem hcl cap sr 12hr 60 mg ......... 74 diltiazem hcl cap sr 12hr 90 mg ......... 74 diltiazem hcl cap sr 24hr 120 mg ....... 74 diltiazem hcl cap sr 24hr 180 mg ....... 74 diltiazem hcl cap sr 24hr 240 mg ....... 74 diltiazem hcl coated beads cap sr 24hr 120 mg ................................................. 74 diltiazem hcl coated beads cap sr 24hr 180 mg ................................................. 74 diltiazem hcl coated beads cap sr 24hr 240 mg ................................................. 74 diltiazem hcl coated beads cap sr 24hr 300 mg ................................................. 74 diltiazem hcl coated beads cap sr 24hr 360 mg ................................................. 74 diltiazem hcl extended release beads cap sr 24hr 120 mg ................................ 74 diltiazem hcl extended release beads cap sr 24hr 180 mg ................................ 74 157

October 1, 2016

diltiazem hcl extended release beads cap sr 24hr 240 mg ................................74 diltiazem hcl extended release beads cap sr 24hr 300 mg ................................74 diltiazem hcl extended release beads cap sr 24hr 360 mg ................................74 diltiazem hcl extended release beads cap sr 24hr 420 mg ................................74 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) ............................................74 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) ......................................................74 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) ............................................74 diltiazem hcl tab 120 mg ...................74 diltiazem hcl tab 30 mg .....................74 diltiazem hcl tab 60 mg .....................74 diltiazem hcl tab 90 mg .....................74 DILTIAZEM INJ 100MG ......................74 dimenhydrinate tab 50 mg .................41 DIP/TET PED INJ 25-5LFU ................ 135 DIPENTUM CAP 250MG .................... 106 diphenhydramine hcl cap 25 mg .........43 diphenhydramine hcl cap 50 mg .........43 diphenhydramine hcl elixir 12.5 mg/5ml ......................................................43 diphenhydramine hcl inj 50 mg/ml ......43 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ...........................................40 diphenoxylate w/ atropine tab 2.5-0.025 mg ..................................................40 dipyridamole tab 25 mg ................... 109 dipyridamole tab 50 mg ................... 109 dipyridamole tab 75 mg ................... 109 disopyramide phosphate cap 100 mg ..22 disopyramide phosphate cap 150 mg ..22 disulfiram tab 250 mg ..................... 129 disulfiram tab 500 mg ..................... 129 DIURIL SUS 250/5ML ........................97 divalproex sodium cap delayed release sprinkle 125 mg................................31 divalproex sodium tab delayed release 125 mg ...........................................31 divalproex sodium tab delayed release 250 mg ...........................................31 divalproex sodium tab delayed release 500 mg ...........................................31

divalproex sodium tab sr 24 hr 250 mg31 divalproex sodium tab sr 24 hr 500 mg31 DIVIGEL GEL 0.25MG ..................... 101 DIVIGEL GEL 0.5MG ....................... 101 DIVIGEL GEL 1MG/GM .................... 102 DOCEFREZ INJ 20MG ........................ 60 DOCEFREZ INJ 80MG ........................ 60 docetaxel for inj conc 20 mg/ml ......... 60 docetaxel for inj conc 80 mg/4ml (20 mg/ml) ........................................... 60 DOCETAXEL INJ 140/7ML .................. 60 DOCETAXEL INJ 160/16ML ................ 60 DOCETAXEL INJ 160/8ML .................. 60 DOCETAXEL INJ 20/0.5ML ................. 60 DOCETAXEL INJ 200MG/20 ................ 60 DOCETAXEL INJ 20MG/2ML ............... 60 DOCETAXEL INJ 80MG/2ML ............... 60 DOCETAXEL INJ 80MG/8ML ............... 60 DOCETAXEL INJ NON-ALCO ............... 60 dofetilide cap 125 mcg (0.125 mg) ..... 23 dofetilide cap 250 mcg (0.25 mg)....... 23 dofetilide cap 500 mcg (0.5 mg) ........ 23 donepezil hydrochloride orally disintegrating tab 10 mg ................. 129 donepezil hydrochloride orally disintegrating tab 5 mg ................... 129 donepezil hydrochloride tab 10 mg ... 129 donepezil hydrochloride tab 23 mg ... 129 donepezil hydrochloride tab 5 mg ..... 129 DORIBAX INJ 250MG ........................ 19 DORIBAX INJ 500MG ........................ 19 dorzolamide hcl ophth soln 2% ........ 124 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 121 doxazosin mesylate tab 1 mg ............ 47 doxazosin mesylate tab 2 mg ............ 47 doxazosin mesylate tab 4 mg ............ 47 doxazosin mesylate tab 8 mg ............ 47 doxepin hcl cap 10 mg ...................... 35 doxepin hcl cap 100 mg .................... 35 doxepin hcl cap 150 mg .................... 35 doxepin hcl cap 25 mg ...................... 35 doxepin hcl cap 50 mg ...................... 35 doxepin hcl cap 75 mg ...................... 35 doxepin hcl conc 10 mg/ml ................ 35 doxepin hcl cream 5% ...................... 90 doxercalciferol cap 0.5 mcg ............... 99 158

October 1, 2016

doxercalciferol cap 1 mcg...................99 doxercalciferol cap 2.5 mcg ................99 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) ......................................................99 doxorubicin hcl for inj 10 mg ..............56 doxorubicin hcl for inj 50 mg ..............56 doxorubicin hcl inj 2 mg/ml ................56 doxy 100 inj 100mg ........................ 132 doxycycline hyclate cap 100 mg ....... 133 doxycycline hyclate cap 50 mg ......... 132 doxycycline hyclate for inj 100 mg .... 133 doxycycline hyclate tab 100 mg ........ 133 doxycycline hyclate tab 20 mg .......... 133 doxycycline hyclate tab delayed release 100 mg ......................................... 133 doxycycline hyclate tab delayed release 150 mg ......................................... 133 doxycycline hyclate tab delayed release 75 mg ........................................... 133 doxycycline monohydrate cap 100 mg .................................................... 133 doxycycline monohydrate cap 150 mg .................................................... 133 doxycycline monohydrate cap 50 mg . 133 doxycycline monohydrate cap 75 mg . 133 doxycycline monohydrate for susp 25 mg/5ml ......................................... 133 doxycycline monohydrate tab 150 mg 133 doxycycline monohydrate tab 50 mg . 133 doxycycline monohydrate tab 75 mg . 133 dronabinol cap 10 mg ........................41 dronabinol cap 2.5 mg .......................41 dronabinol cap 5 mg .........................41 drospirenone-ethinyl estradiol tab 3-0.03 mg ..................................................80 DROXIA CAP 200MG ........................ 109 DROXIA CAP 300MG ........................ 109 DROXIA CAP 400MG ........................ 109 duloxetine hcl enteric coated pellets cap 20 mg .............................................33 duloxetine hcl enteric coated pellets cap 30 mg .............................................33 duloxetine hcl enteric coated pellets cap 60 mg .............................................33 DUREZOL EMU 0.05% ..................... 123 dutasteride cap 0.5 mg .................... 108 dutasteride-tamsulosin hcl cap 0.5-0.4

mg ............................................... 108 D-VI-SOL LIQ 400UNIT ................... 142 DYRENIUM CAP 100MG ..................... 96 DYRENIUM CAP 50MG ....................... 96 E e.e.s. 400 tab 400mg ..................... 112 E.E.S. GRAN SUS 200/5ML .............. 112 e.s.p. sus 200-600 ........................... 18 econazole nitrate cream 1% .............. 89 EDARBI TAB 40MG ........................... 47 EDARBI TAB 80MG ........................... 47 EDECRIN TAB 25MG ......................... 96 ed-spaz tab 0.125mg ...................... 136 EDURANT TAB 25MG ........................ 67 EFFIENT TAB 10MG ........................ 109 EFFIENT TAB 5MG .......................... 109 ELAPRASE INJ 6MG/3ML ................... 99 ELELYSO INJ 200UNIT .................... 109 ELESTRIN GEL 0.06% ..................... 102 ELIDEL CRE 1% ............................... 94 ELIGARD INJ 22.5MG ........................ 55 ELIGARD INJ 30MG .......................... 55 ELIGARD INJ 45MG .......................... 55 ELIGARD INJ 7.5MG ......................... 55 elinest tab ....................................... 80 ELIQUIS TAB 2.5MG ......................... 26 ELIQUIS TAB 5MG ............................ 26 ELIXOPHYLLIN ELX 80/15ML .............. 25 ELLA TAB 30MG ............................... 82 ELMIRON CAP 100MG ..................... 107 ELOXATIN INJ 200MG ....................... 53 EMADINE SOL 0.05% OP ................. 124 EMBEDA CAP 100-4MG ..................... 12 EMBEDA CAP 20-0.8MG .................... 12 EMBEDA CAP 30-1.2MG .................... 12 EMBEDA CAP 50-2MG ....................... 12 EMBEDA CAP 60-2.4MG .................... 12 EMBEDA CAP 80-3.2MG .................... 12 EMCYT CAP 140MG ........................... 55 EMEND CAP 125MG .......................... 41 EMEND CAP 40MG ............................ 41 EMEND CAP 80MG ............................ 41 EMEND PAK 80 & 125 ....................... 41 emoquette tab ................................. 80 EMSAM DIS 12MG/24H ..................... 32 EMSAM DIS 6MG/24HR ..................... 31 EMSAM DIS 9MG/24HR ..................... 32 159

October 1, 2016

EMTRIVA CAP 200MG ........................67 EMTRIVA SOL 10MG/ML .....................67 enalapril maleate & hydrochlorothiazide tab 10-25 mg ...................................49 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ..................................49 enalapril maleate tab 10 mg ...............46 enalapril maleate tab 2.5 mg ..............46 enalapril maleate tab 20 mg ...............46 enalapril maleate tab 5 mg ................46 ENBREL INJ 25/0.5ML........................10 ENBREL INJ 25MG .............................10 ENBREL INJ 50MG/ML........................10 ENBREL SRCLK INJ 50MG/ML .............10 ENCARE SUP 100MG ....................... 141 endocet tab 10-325mg ......................15 endocet tab 5-325mg ........................15 endocet tab 7.5-325 ..........................15 ENGERIX-B INJ 10/0.5ML................. 140 ENGERIX-B INJ 20MCG/ML ............... 140 ENJUVIA TAB 0.3MG........................ 102 ENJUVIA TAB 0.45MG ...................... 102 ENJUVIA TAB 0.625MG .................... 102 ENJUVIA TAB 0.9MG........................ 102 ENJUVIA TAB 1.25MG ...................... 102 enoxaparin sodium inj 100 mg/ml .......27 enoxaparin sodium inj 120 mg/0.8ml ..27 enoxaparin sodium inj 150 mg/ml .......27 enoxaparin sodium inj 30 mg/0.3ml ....26 enoxaparin sodium inj 300 mg/3ml .....27 enoxaparin sodium inj 40 mg/0.4ml ....27 enoxaparin sodium inj 60 mg/0.6ml ....27 enoxaparin sodium inj 80 mg/0.8ml ....27 enpresse-28 tab ...............................80 entacapone tab 200 mg .....................61 entecavir tab 0.5 mg .........................69 entecavir tab 1 mg ............................69 ENTRESTO TAB 24-26MG ...................76 ENTRESTO TAB 49-51MG ...................76 ENTRESTO TAB 97-103MG .................76 enulose sol 10gm/15 ....................... 107 EPIDUO FORTE GEL 0.3-2.5% ............87 EPIDUO GEL 0.1-2.5% ......................87 epinastine hcl ophth soln 0.05% ....... 124 epinephrine hcl inj 1 mg/ml.............. 141 epinephrine hcl soln prefilled syringe 0.1 mg/ml ........................................... 141

epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ...................... 141 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) ........................ 141 EPIPEN 2-PAK INJ 0.3MG ................ 141 EPIPEN-JR INJ 2-PAK ...................... 141 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ........................................... 56 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ........................................... 56 EPIRUBICIN INJ 50MG ...................... 56 epitol tab 200mg .............................. 28 EPIVIR HBV SOL 5MG/ML .................. 69 eplerenone tab 25 mg ....................... 51 eplerenone tab 50 mg ....................... 51 epoprostenol sodium for inj 0.5 mg .... 77 epoprostenol sodium for inj 1.5 mg .... 77 eprosartan mesylate tab 600 mg ........ 47 EPZICOM TAB 600-300 ..................... 67 ERAXIS INJ 100MG ........................... 42 ERAXIS INJ 50MG ............................ 41 ERBITUX INJ 100MG ......................... 55 ERBITUX INJ 200MG ......................... 55 ergocalciferol cap 50000 unit ........... 142 ergoloid mesylates tab 1 mg ............ 131 ERGOMAR SUB 2MG ....................... 114 ERIVEDGE CAP 150MG ...................... 55 errin tab 0.35mg .............................. 83 ERTACZO CRE 2% ............................ 90 ery pad 2% ..................................... 87 ERYPED SUS 200/5ML..................... 112 ERYPED SUS 400/5ML..................... 113 ERY-TAB TAB 250MG EC ................. 112 ERY-TAB TAB 333MG EC ................. 112 ERY-TAB TAB 500MG EC ................. 112 ERYTHROCIN INJ 1000MG ............... 113 ERYTHROCIN INJ 500MG ................. 113 erythrocin tab 250mg ..................... 113 erythromycin ethylsuccinate tab 400 mg .................................................... 113 erythromycin gel 2% ........................ 87 erythromycin ophth oint 5 mg/gm .... 122 erythromycin pads 2% ...................... 87 erythromycin soln 2% ....................... 87 erythromycin tab 250 mg ................ 113 erythromycin tab 500 mg ................ 113 erythromycin w/ delayed release particles 160

October 1, 2016

cap 250 mg .................................... 113 escitalopram oxalate soln 5 mg/5ml (base equiv) .............................................32 escitalopram oxalate tab 10 mg (base equiv) .............................................32 escitalopram oxalate tab 20 mg (base equiv) .............................................32 escitalopram oxalate tab 5 mg (base equiv) .............................................32 esomeprazole magnesium cap delayed release 20 mg (base eq) .................. 137 esomeprazole magnesium cap delayed release 40 mg (base eq) .................. 137 esomeprazole sodium for intravenous soln 20 mg (base equiv) ......................... 137 esomeprazole sodium for intravenous soln 40 mg (base equiv) ......................... 137 ESTRACE VAG CRE 0.1MG/GM .......... 141 estradiol & norethindrone acetate tab 0.5-0.1 mg .................................... 101 estradiol & norethindrone acetate tab 1-0.5 mg ....................................... 101 estradiol tab 0.5 mg ........................ 102 estradiol tab 1 mg ........................... 102 estradiol tab 2 mg ........................... 102 estradiol td patch twice weekly 0.025 mg/24hr ........................................ 103 estradiol td patch twice weekly 0.0375 mg/24hr ........................................ 103 estradiol td patch twice weekly 0.05 mg/24hr ........................................ 103 estradiol td patch twice weekly 0.075 mg/24hr ........................................ 103 estradiol td patch twice weekly 0.1 mg/24hr ........................................ 102 estradiol td patch weekly 0.025 mg/24hr .................................................... 103 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ............................. 103 estradiol td patch weekly 0.05 mg/24hr .................................................... 103 estradiol td patch weekly 0.06 mg/24hr .................................................... 103 estradiol td patch weekly 0.075 mg/24hr .................................................... 103 estradiol td patch weekly 0.1 mg/24hr .................................................... 103

estradiol valerate im in oil 10 mg/ml 103 estradiol valerate im in oil 20 mg/ml 103 estradiol valerate im in oil 40 mg/ml 103 ESTRING MIS 2MG ......................... 141 ESTROGEL GEL .............................. 104 estropipate tab 0.75 mg .................. 104 estropipate tab 1.5 mg ................... 104 estropipate tab 3 mg ...................... 104 eszopiclone tab 1 mg ...................... 111 eszopiclone tab 2 mg ...................... 111 eszopiclone tab 3 mg ...................... 111 ethacrynate sodium for inj 50 mg ....... 96 ethacrynic acid tab 25 mg ................. 96 ethambutol hcl tab 100 mg................ 52 ethambutol hcl tab 400 mg................ 52 ethosuximide cap 250 mg ................. 30 ethosuximide soln 250 mg/5ml .......... 30 etodolac cap 200 mg .......................... 9 etodolac cap 300 mg .......................... 9 etodolac tab 400 mg ........................... 9 etodolac tab 500 mg ........................... 9 etodolac tab sr 24hr 400 mg ................ 9 etodolac tab sr 24hr 500 mg ................ 9 etodolac tab sr 24hr 600 mg ................ 9 ETOPOPHOS INJ 100MG .................... 60 etoposide cap 50 mg ........................ 60 etoposide inj 100 mg/5ml (20 mg/ml) 60 EURAX CRE 10% .............................. 94 EURAX LOT 10% .............................. 94 EVAMIST SPR 1.53MG ..................... 104 EVOTAZ TAB 300-150 ....................... 67 EXELDERM CRE 1% .......................... 90 EXELDERM SOL 1% .......................... 90 EXELON SOL 2MG/ML ..................... 129 exemestane tab 25 mg ..................... 55 EXJADE TAB 125MG.......................... 40 EXJADE TAB 250MG.......................... 40 EXJADE TAB 500MG.......................... 40 F FABRAZYME INJ 35MG ...................... 99 FABRAZYME INJ 5MG ........................ 99 FACTIVE TAB 320MG ...................... 106 falmina tab ...................................... 80 famciclovir tab 125 mg ..................... 69 famciclovir tab 250 mg ..................... 70 famciclovir tab 500 mg ..................... 70 famotidine for susp 40 mg/5ml ........ 136 161

October 1, 2016

famotidine in nacl 0.9% iv soln 20 mg/50ml ....................................... 136 famotidine inj 20 mg/2ml................. 136 famotidine inj 200 mg/20ml ............. 136 famotidine inj 40 mg/4ml................. 136 famotidine inj 500 mg/50ml ............. 136 famotidine tab 20 mg ...................... 136 famotidine tab 40 mg ...................... 136 FANAPT PAK .....................................63 FANAPT TAB 10MG ............................63 FANAPT TAB 12MG ............................63 FANAPT TAB 1MG ..............................63 FANAPT TAB 2MG ..............................63 FANAPT TAB 4MG ..............................63 FANAPT TAB 6MG ..............................63 FANAPT TAB 8MG ..............................63 FARESTON TAB 60MG ........................55 FARXIGA TAB 10MG ..........................39 FARXIGA TAB 5MG ............................39 FARYDAK CAP 10MG ..........................57 FARYDAK CAP 15MG ..........................57 FARYDAK CAP 20MG ..........................57 FASLODEX INJ 250MG .......................55 FC2 FEMALE MIS CONDOM ............... 113 felbamate susp 600 mg/5ml ...............30 felbamate tab 400 mg .......................30 felbamate tab 600 mg .......................30 felodipine tab sr 24hr 10 mg ..............75 felodipine tab sr 24hr 2.5 mg .............74 felodipine tab sr 24hr 5 mg ................74 FEMCAP MIS 22MM ......................... 113 FEMCAP MIS 26MM ......................... 113 FEMCAP MIS 30MM ......................... 113 FEMRING MIS 0.05/24H................... 141 FEMRING MIS 0.1MG/24 .................. 141 fenofibrate cap 150 mg......................44 fenofibrate cap 50 mg .......................44 fenofibrate micronized cap 130 mg .....45 fenofibrate micronized cap 134 mg .....45 fenofibrate micronized cap 200 mg .....45 fenofibrate micronized cap 43 mg .......44 fenofibrate micronized cap 67 mg .......44 fenofibrate tab 145 mg ......................45 fenofibrate tab 160 mg ......................45 fenofibrate tab 48 mg ........................45 fenofibrate tab 54 mg ........................45 fenofibric acid tab 105 mg .................45

fenofibric acid tab 35 mg ................... 45 fenoprofen calcium cap 400 mg ........... 9 fenoprofen calcium tab 600 mg ............ 9 fentanyl citrate lozenge on a handle 1200 mcg ................................................ 12 fentanyl citrate lozenge on a handle 1600 mcg ................................................ 12 fentanyl citrate lozenge on a handle 200 mcg ................................................ 12 fentanyl citrate lozenge on a handle 400 mcg ................................................ 12 fentanyl citrate lozenge on a handle 600 mcg ................................................ 12 fentanyl citrate lozenge on a handle 800 mcg ................................................ 12 fentanyl td patch 72hr 100 mcg/hr ..... 12 fentanyl td patch 72hr 12 mcg/hr ....... 12 fentanyl td patch 72hr 25 mcg/hr ....... 12 fentanyl td patch 72hr 50 mcg/hr ....... 12 fentanyl td patch 72hr 75 mcg/hr ....... 12 FERRIPROX TAB 500MG .................... 40 FINACEA GEL 15% ........................... 94 finasteride tab 5 mg ....................... 108 FIRAZYR INJ 30MG/3ML .................. 108 FIRMAGON INJ 120MG ...................... 55 FIRMAGON INJ 80MG ........................ 55 FLAGYL ER TAB 750MG ..................... 18 FLAREX SUS 0.1% OP ..................... 123 flavoxate hcl tab 100 mg ................. 139 FLEBOGAMMA INJ 10/200ML ........... 125 FLEBOGAMMA INJ 20/400ML ........... 125 FLEBOGAMMA INJ DIF 10% ............. 125 FLEBOGAMMA INJ DIF 5% ............... 125 flecainide acetate tab 100 mg ............ 23 flecainide acetate tab 150 mg ............ 23 flecainide acetate tab 50 mg .............. 23 FLEXICHAMBER MIS MASK SM ......... 114 floxuridine for inj 0.5 gm ................... 54 FLUBLOK SOL 2015-16 ................... 140 FLUCELVAX INJ 2015-16 ................. 140 fluconazole for susp 10 mg/ml ........... 42 fluconazole for susp 40 mg/ml ........... 42 fluconazole in dextrose inj 200 mg/100ml ...................................................... 42 fluconazole in dextrose inj 400 mg/200ml ...................................................... 42 fluconazole in nacl 0.9% inj 200 162

October 1, 2016

mg/100ml ........................................42 fluconazole in nacl 0.9% inj 400 mg/200ml ........................................42 fluconazole tab 100 mg .....................42 fluconazole tab 150 mg .....................42 fluconazole tab 200 mg .....................42 fluconazole tab 50 mg .......................42 FLUCONAZOLE/ INJ NACL 100 ............42 fludarabine phosphate for inj 50 mg ....54 fludarabine phosphate inj 25 mg/ml ....54 fludrocortisone acetate tab 0.1 mg ......85 FLUMIST QUAD SUS 2014-15 ........... 140 flunisolide nasal soln 25 mcg/act (0.025%)....................................... 121 fluocin acet oil 0.01% sc ....................92 fluocin acet oil body ..........................92 fluocinolone acetonide (otic) oil 0.01% .................................................... 125 fluocinolone acetonide cream 0.01% ...92 fluocinolone acetonide cream 0.025% .92 fluocinolone acetonide oint 0.025% .....92 fluocinolone acetonide soln 0.01% ......92 fluocinonide cream 0.05%..................92 fluocinonide cream 0.1% ...................92 fluocinonide gel 0.05% ......................92 fluocinonide oint 0.05% .....................92 fluocinonide soln 0.05%.....................92 FLUORABON DRO............................ 116 fluor-a-day dro 0.125mg.................. 116 fluoritab chw 0.25mg f .................... 116 fluoritab chw 0.5mg f ...................... 116 fluoritab chw 2.2mg ........................ 116 fluorometholone ophth susp 0.1%..... 123 FLUOROPLEX CRE 1% .......................90 fluorouracil cream 0.5% ....................90 fluorouracil cream 5% .......................90 fluorouracil inj 1 gm/20ml (50 mg/ml).54 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ......................................................54 fluorouracil inj 5 gm/100ml (50 mg/ml) ......................................................54 fluorouracil inj 500 mg/10ml (50 mg/ml) ......................................................54 fluorouracil soln 2% ..........................90 fluorouracil soln 5% ..........................90 fluoxetine hcl cap 10 mg ....................32 fluoxetine hcl cap 20 mg ....................32

fluoxetine hcl cap 40 mg ................... 32 fluoxetine hcl cap delayed release 90 mg ...................................................... 32 fluoxetine hcl solution 20 mg/5ml ...... 32 fluoxetine hcl tab 10 mg ................... 32 fluoxetine hcl tab 20 mg ................... 32 FLUOXETINE TAB 60MG .................... 32 fluphenazine decanoate inj 25 mg/ml . 65 fluphenazine hcl elixir 2.5 mg/5ml ...... 65 fluphenazine hcl inj 2.5 mg/ml ........... 65 fluphenazine hcl oral conc 5 mg/ml .... 65 fluphenazine hcl tab 1 mg ................. 65 fluphenazine hcl tab 10 mg ............... 65 fluphenazine hcl tab 2.5 mg .............. 65 fluphenazine hcl tab 5 mg ................. 65 flura-drops dro 0.125mg ................. 116 flura-drops dro 0.25mg f ................. 116 flurandrenolide cream 0.05%............. 92 flurbiprofen sodium ophth soln 0.03% .................................................... 124 flurbiprofen tab 100 mg ...................... 9 flurbiprofen tab 50 mg ........................ 9 flutamide cap 125 mg ....................... 55 fluticasone propionate cream 0.05% ... 92 fluticasone propionate lotion 0.05% .... 93 fluticasone propionate nasal susp 50 mcg/act ........................................ 121 fluticasone propionate oint 0.005% .... 93 fluvastatin sodium cap 20 mg ............ 45 fluvastatin sodium cap 40 mg ............ 45 FLUVIRIN INJ 2015-16 .................... 140 fluvoxamine maleate cap sr 24hr 100 mg ...................................................... 32 fluvoxamine maleate cap sr 24hr 150 mg ...................................................... 32 fluvoxamine maleate tab 100 mg ....... 32 fluvoxamine maleate tab 25 mg ......... 32 fluvoxamine maleate tab 50 mg ......... 32 FLUZONE HD INJ PF 15-16 .............. 140 FLUZONE INJ INTRADRM ................. 140 FLUZONE QUAD INJ 15-16 .............. 140 FLUZONE SPLT INJ 2015-16 ............ 140 FML FORTE SUS 0.25% OP .............. 123 FML OIN 0.1% OP .......................... 123 folbic tab ......................................... 95 folic acid tab 1 mg .......................... 109 folic acid tab 400 mcg ..................... 109 163

October 1, 2016

folic acid tab 800 mcg ..................... 109 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ........................................27 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ...................................27 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ........................................27 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ...................................27 FORTAZ INJ 1GM ..............................79 FORTAZ INJ 2GM ..............................79 FORTAZ INJ 500MG ...........................79 FORTEO SOL 600/2.4 ........................97 FOSAMAX + D TAB 70-2800 ...............97 FOSAMAX + D TAB 70-5600 ...............97 foscarnet sodium inj 24 mg/ml ...........69 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................49 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ................................49 fosinopril sodium tab 10 mg ...............46 fosinopril sodium tab 20 mg ...............46 fosinopril sodium tab 40 mg ...............46 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) .............................30 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) .............................30 FOSRENOL CHW 1000MG ................. 107 FOSRENOL CHW 500MG .................. 107 FOSRENOL CHW 750MG .................. 107 FOSRENOL POW 1000MG ................. 107 FOSRENOL POW 750MG ................... 107 FRAGMIN INJ 10000/ML.....................27 FRAGMIN INJ 12500UNT ....................27 FRAGMIN INJ 15000UNT ....................27 FRAGMIN INJ 18000UNT ....................27 FRAGMIN INJ 2500/0.2 ......................27 FRAGMIN INJ 25000/ML.....................27 FRAGMIN INJ 5000/0.2 ......................27 FRAGMIN INJ 7500/0.3 ......................27 FRAGMIN INJ 95000UNT ....................27 frovatriptan succinate tab 2.5 mg (base equivalent) .................................... 114 furosemide inj 10 mg/ml....................96 furosemide oral soln 10 mg/ml ...........96 FUROSEMIDE ORAL SOLN 8 MG/ML .....96 furosemide tab 20 mg .......................96

furosemide tab 40 mg....................... 96 furosemide tab 80 mg....................... 96 FUZEON INJ 90MG ........................... 67 G gabapentin cap 100 mg .................... 28 gabapentin cap 300 mg .................... 28 gabapentin cap 400 mg .................... 28 gabapentin oral soln 250 mg/5ml ....... 28 gabapentin tab 600 mg ..................... 28 gabapentin tab 800 mg ..................... 28 GABITRIL TAB 12MG......................... 30 GABITRIL TAB 16MG......................... 30 galantamine hydrobromide cap sr 24hr 16 mg ............................................... 129 galantamine hydrobromide cap sr 24hr 24 mg ............................................... 129 galantamine hydrobromide cap sr 24hr 8 mg ............................................... 129 galantamine hydrobromide oral soln 4 mg/ml .......................................... 129 galantamine hydrobromide tab 12 mg129 galantamine hydrobromide tab 4 mg 129 galantamine hydrobromide tab 8 mg 129 GAMASTAN S/D INJ ........................ 125 GAMMAGARD INJ 10GM/100 ............ 125 GAMMAGARD INJ 1GM/10ML ........... 125 GAMMAGARD INJ 2.5GM/25 ............ 125 GAMMAGARD INJ 20GM/200 ............ 125 GAMMAGARD INJ 30GM/300 ............ 125 GAMMAGARD INJ 5GM/50ML ........... 125 GAMMAGARD SD INJ 10GM HU ........ 125 GAMMAGARD SD INJ 2.5GM HU ....... 125 GAMMAGARD SD INJ 5GM HU .......... 125 GAMMAKED INJ 10GM/100 .............. 125 GAMMAKED INJ 1GM/10ML .............. 125 GAMMAKED INJ 2.5GM/25 ............... 125 GAMMAKED INJ 20GM/200 .............. 125 GAMMAKED INJ 5GM/50ML .............. 125 GAMMAPLEX INJ 10GM.................... 126 GAMMAPLEX INJ 2.5GM................... 126 GAMMAPLEX INJ 20GM.................... 126 GAMMAPLEX INJ 5GM ..................... 126 GAMUNEX-C INJ 10GM/100 ............. 126 GAMUNEX-C INJ 1GM/10ML ............. 126 GAMUNEX-C INJ 2.5GM/25 .............. 126 GAMUNEX-C INJ 20GM/200 ............. 126 GAMUNEX-C INJ 40/400ML .............. 126 164

October 1, 2016

GAMUNEX-C INJ 5GM/50ML ............. 126 GARDASIL 9 INJ ............................. 140 GARDASIL INJ ................................ 140 gatifloxacin ophth soln 0.5% ............ 122 gavilyte-c sol .................................. 111 gavilyte-g sol ................................. 111 gavilyte-h kit .................................. 111 gavilyte-n sol flav pk ....................... 111 GAZYVA INJ 25MG/ML .......................55 GELNIQUE GEL 10%........................ 139 GELNIQUE GEL 3% ......................... 139 gemcitabine hcl for inj 1 gm ...............54 gemcitabine hcl for inj 2 gm ...............54 gemcitabine hcl for inj 200 mg ...........54 gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) .........................54 gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) .........................54 gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) .........................54 gemfibrozil tab 600 mg ......................45 generlac sol 10gm/15 ...................... 107 gengraf cap 100mg ...........................71 gengraf cap 25mg .............................71 gengraf sol 100mg/ml .......................71 GENOTROPIN INJ 0.2MG ....................98 GENOTROPIN INJ 0.4MG ....................98 GENOTROPIN INJ 0.6MG ....................98 GENOTROPIN INJ 0.8MG ....................98 GENOTROPIN INJ 1.2MG ....................98 GENOTROPIN INJ 1.4MG ....................98 GENOTROPIN INJ 1.6MG ....................98 GENOTROPIN INJ 1.8MG ....................98 GENOTROPIN INJ 12MG .....................98 GENOTROPIN INJ 1MG.......................98 GENOTROPIN INJ 2MG.......................98 GENOTROPIN INJ 5MG.......................98 gentak oin 0.3% op......................... 122 GENTAM/NACL INJ 0.9MG/ML .............. 7 GENTAM/NACL INJ 1.4MG/ML .............. 7 gentamicin in saline inj 0.8 mg/ml ....... 7 gentamicin in saline inj 1 mg/ml .......... 7 gentamicin in saline inj 1.2 mg/ml ....... 7 gentamicin in saline inj 1.6 mg/ml ....... 7 gentamicin in saline inj 2 mg/ml .......... 7 gentamicin sulfate cream 0.1% ..........89 gentamicin sulfate inj 10 mg/ml .......... 7

gentamicin sulfate inj 40 mg/ml ........... 7 gentamicin sulfate iv soln 10 mg/ml ..... 7 gentamicin sulfate oint 0.1% ............. 89 gentamicin sulfate ophth oint 0.3% .. 122 gentamicin sulfate ophth soln 0.3% .. 122 GENVOYA TAB ................................. 67 GEODON INJ 20MG........................... 63 gianvi tab 3-0.02mg ......................... 80 gildess fe tab 1.5/30......................... 80 gildess fe tab 1/20 ........................... 80 gildess tab 1.5/30 ............................ 80 gildess tab 1/20 ............................... 80 GILENYA CAP 0.5MG ....................... 131 GLASSIA INJ .................................. 132 glatopa inj 20mg/ml ....................... 131 GLEOSTINE CAP 100MG .................... 53 GLEOSTINE CAP 10MG ...................... 53 GLEOSTINE CAP 40MG ...................... 53 GLEOSTINE CAP 5MG........................ 53 GLIADEL WAF 7.7MG ........................ 53 glimepiride tab 1 mg ........................ 39 glimepiride tab 2 mg ........................ 39 glimepiride tab 4 mg ........................ 39 glipizide tab 10 mg ........................... 39 glipizide tab 5 mg............................. 39 glipizide tab sr 24hr 10 mg ................ 39 glipizide tab sr 24hr 2.5 mg ............... 39 glipizide tab sr 24hr 5 mg ................. 39 glipizide-metformin hcl tab 2.5-250 mg ...................................................... 37 glipizide-metformin hcl tab 2.5-500 mg ...................................................... 37 glipizide-metformin hcl tab 5-500 mg . 37 GLUCAGON KIT 1MG ........................ 38 glyburide micronized tab 1.5 mg ........ 39 glyburide micronized tab 3 mg ........... 39 glyburide micronized tab 6 mg ........... 39 glyburide tab 1.25 mg ...................... 39 glyburide tab 2.5 mg ........................ 40 glyburide tab 5 mg ........................... 40 glyburide-metformin tab 1.25-250 mg 37 glyburide-metformin tab 2.5-500 mg .. 37 glyburide-metformin tab 5-500 mg ..... 37 glycopyrrolate inj 0.2 mg/ml............ 136 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) ......................................... 136 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 165

October 1, 2016

.................................................... 136 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) .................................................... 136 glycopyrrolate tab 1 mg ................... 136 glycopyrrolate tab 2 mg ................... 136 GOLYTELY SOL ............................... 111 GRALISE STAR MIS 300/600 ............ 131 GRALISE TAB 300MG....................... 131 GRALISE TAB 600MG....................... 131 granisetron hcl inj 0.1 mg/ml .............40 granisetron hcl inj 1 mg/ml ................40 granisetron hcl inj 4 mg/4ml (1 mg/ml) ......................................................40 granisetron hcl tab 1 mg ....................40 griseofulvin microsize susp 125 mg/5ml ......................................................42 griseofulvin microsize tab 500 mg .......42 griseofulvin ultramicrosize tab 125 mg 42 griseofulvin ultramicrosize tab 250 mg 42 guanfacine hcl tab 1 mg ....................48 guanfacine hcl tab 2 mg ....................48 guanfacine hcl tab sr 24hr 1 mg (base equiv) .............................................. 6 guanfacine hcl tab sr 24hr 2 mg (base equiv) .............................................. 6 guanfacine hcl tab sr 24hr 3 mg (base equiv) .............................................. 6 guanfacine hcl tab sr 24hr 4 mg (base equiv) .............................................. 6 GUANIDINE TAB 125MG ....................51 GYNAZOLE-1 CRE 2%...................... 141 GYNOL II GEL 3% ........................... 141 H halobetasol propionate cream 0.05% ..93 halobetasol propionate oint 0.05% ......93 HALOG CRE 0.1% .............................93 HALOG OIN 0.1% .............................93 haloperidol decanoate im soln 100 mg/ml ......................................................64 haloperidol decanoate im soln 50 mg/ml ......................................................64 haloperidol lactate inj 5 mg/ml ...........64 haloperidol lactate oral conc 2 mg/ml ..64 haloperidol tab 0.5 mg ......................64 haloperidol tab 1 mg .........................64 haloperidol tab 10 mg .......................64 haloperidol tab 2 mg .........................64

haloperidol tab 20 mg ....................... 64 haloperidol tab 5 mg......................... 64 HARVONI TAB 90-400MG .................. 69 HAVRIX INJ 1440UNIT .................... 140 HAVRIX INJ 720UNIT ...................... 140 heather tab 0.35mg.......................... 83 heparin sodium (porcine) inj 1000 unit/ml ...................................................... 27 heparin sodium (porcine) inj 10000 unit/ml ........................................... 27 heparin sodium (porcine) inj 20000 unit/ml ........................................... 27 heparin sodium (porcine) inj 5000 unit/ml ...................................................... 27 heparin sodium (porcine) pf inj 5000 unit/0.5ml ....................................... 27 HEXALEN CAP 50MG ......................... 53 HIBERIX SOL 10MCG ...................... 139 HIZENTRA INJ 10/50ML .................. 126 HIZENTRA INJ 1GM/5ML ................. 126 HIZENTRA INJ 2GM/10ML ................ 126 HIZENTRA INJ 4GM/20ML................ 126 homatropaire sol 5% op .................. 122 homatropine hbr ophth soln 5% ....... 122 HUMALOG INJ 100/ML ...................... 38 HUMALOG KWIK INJ 100/ML .............. 38 HUMALOG KWIK INJ 200/ML .............. 38 HUMALOG MIX INJ 50/50 .................. 38 HUMALOG MIX INJ 50/50KWP ............ 38 HUMALOG MIX INJ 75/25KWP ............ 38 HUMALOG MIX SUS 75/25 ................. 38 HUMATROPE INJ 12MG ..................... 98 HUMATROPE INJ 24MG ..................... 98 HUMATROPE INJ 5MG ....................... 98 HUMATROPE INJ 6MG ....................... 98 HUMATROPEN MIS FOR 12MG .......... 114 HUMATROPEN MIS FOR 24MG .......... 114 HUMATROPEN MIS FOR 6MG............ 114 HUMIRA INJ 10MG/0.2 ........................ 8 HUMIRA KIT 20MG/0.4 ....................... 8 HUMIRA KIT 40MG/0.8 ....................... 8 HUMIRA PEN INJ CROHNS ................... 8 HUMULIN INJ 70/30 ......................... 38 HUMULIN INJ 70/30KWP ................... 38 HUMULIN N INJ U-100 ...................... 38 HUMULIN N INJ U-100KWP ................ 38 HUMULIN R INJ U-100 ...................... 38 166

October 1, 2016

HUMULIN R INJ U-500 .......................38 HYCAMTIN CAP 0.25MG .....................60 HYCAMTIN CAP 1MG..........................61 hydralazine hcl inj 20 mg/ml ..............51 hydralazine hcl tab 10 mg ..................51 hydralazine hcl tab 100 mg ................51 hydralazine hcl tab 25 mg ..................51 hydralazine hcl tab 50 mg ..................51 hydrochlorothiazide cap 12.5 mg ........97 hydrochlorothiazide tab 12.5 mg .........97 hydrochlorothiazide tab 25 mg ...........97 hydrochlorothiazide tab 50 mg ...........97 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml ...........................................85 hydrocodone w/ homatropine tab 5-1.5 mg ..................................................85 hydrocodone-acetaminophen soln 10-325 mg/15ml .........................................15 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .............................15 hydrocodone-acetaminophen tab 10-300 mg ..................................................16 hydrocodone-acetaminophen tab 10-325 mg ..................................................16 hydrocodone-acetaminophen tab 2.5-325 mg ..................................................15 hydrocodone-acetaminophen tab 5-300 mg ..................................................15 hydrocodone-acetaminophen tab 5-325 mg ..................................................15 hydrocodone-acetaminophen tab 7.5-300 mg ..................................................15 hydrocodone-acetaminophen tab 7.5-325 mg ..................................................15 hydrocortisone butyrate cream 0.1%...93 hydrocortisone butyrate hydrophilic lipo base cream 0.1%..............................93 hydrocortisone butyrate oint 0.1% ......93 hydrocortisone butyrate soln 0.1%......93 hydrocortisone cream 1% ..................93 hydrocortisone cream 2.5% ...............93 hydrocortisone lotion 2.5% ................93 hydrocortisone oint 1% .....................93 hydrocortisone oint 2.5% ...................93 hydrocortisone tab 10 mg ..................84 hydrocortisone tab 20 mg ..................84 hydrocortisone tab 5 mg ....................84

hydrocortisone valerate cream 0.2% .. 93 hydrocortisone valerate oint 0.2% ...... 93 hydrocortisone w/ acetic acid otic soln 1-2% ............................................ 125 hydromet syp 5-1.5/5 ....................... 85 HYDROMORPHON SUP 3MG ............... 12 hydromorphone hcl inj 1 mg/ml ......... 12 hydromorphone hcl inj 2 mg/ml ......... 12 hydromorphone hcl inj 4 mg/ml ......... 12 hydromorphone hcl liqd 1 mg/ml ........ 12 hydromorphone hcl preservative free (pf) inj 10 mg/ml ................................... 12 hydromorphone hcl tab 2 mg ............. 12 hydromorphone hcl tab 4 mg ............. 12 hydromorphone hcl tab 8 mg ............. 12 hydromorphone hcl tab er 24hr deter 12 mg ................................................. 13 hydromorphone hcl tab er 24hr deter 16 mg ................................................. 13 hydromorphone hcl tab er 24hr deter 32 mg ................................................. 13 hydromorphone hcl tab er 24hr deter 8 mg ................................................. 12 hydroxychloroquine sulfate tab 200 mg ...................................................... 51 hydroxyurea cap 500 mg .................. 59 hydroxyzine hcl im soln 25 mg/ml ...... 21 hydroxyzine hcl im soln 50 mg/ml ...... 21 hydroxyzine hcl syrup 10 mg/5ml....... 21 hydroxyzine hcl tab 10 mg ................ 21 hydroxyzine hcl tab 25 mg ................ 21 hydroxyzine hcl tab 50 mg ................ 21 hydroxyzine pamoate cap 100 mg ...... 22 hydroxyzine pamoate cap 25 mg ........ 22 hydroxyzine pamoate cap 50 mg ........ 22 hyomax-sl sub 0.125mg.................. 136 hyoscyamine sulfate tab 0.125 mg ... 136 hyoscyamine sulfate tab disp 0.125 mg .................................................... 136 hyoscyamine sulfate tab sl 0.125 mg 136 hyoscyamine sulfate tab sr 12hr 0.375 mg .................................................... 136 I ibandronate sodium iv soln 3 mg/3ml (base equivalent) ............................. 97 ibandronate sodium tab 150 mg (base equivalent) ...................................... 97 167

October 1, 2016

IBRANCE CAP 100MG ........................57 IBRANCE CAP 125MG ........................57 IBRANCE CAP 75MG ..........................57 ibuprofen susp 100 mg/5ml ................ 9 ibuprofen tab 400 mg ......................... 9 ibuprofen tab 600 mg ......................... 9 ibuprofen tab 800 mg ......................... 9 ICLUSIG TAB 15MG ...........................57 ICLUSIG TAB 45MG ...........................57 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ......................................................56 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) ......................................................56 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) ......................................................56 ifosfamide & mesna inj kit 1000-1000 mg ......................................................57 ifosfamide for inj 1 gm ......................53 ifosfamide iv inj 1 gm/20ml (50 mg/ml) ......................................................53 ifosfamide iv inj 3 gm/60ml (50 mg/ml) ......................................................53 ilotycin oin op ................................. 122 imatinib mesylate tab 100 mg (base equivalent) ......................................57 imatinib mesylate tab 400 mg (base equivalent) ......................................57 IMBRUVICA CAP 140MG .....................57 imipenem-cilastatin intravenous for soln 250 mg ...........................................19 imipenem-cilastatin intravenous for soln 500 mg ...........................................19 imipramine hcl tab 10 mg ..................35 imipramine hcl tab 25 mg ..................35 imipramine hcl tab 50 mg ..................35 imipramine pamoate cap 100 mg ........36 imipramine pamoate cap 125 mg ........36 imipramine pamoate cap 150 mg ........36 imipramine pamoate cap 75 mg..........35 imiquimod cream 5% ........................94 IMPLANON IMP 68MG ........................83 INCRELEX INJ 40MG/4ML ...................99 indapamide tab 1.25 mg ....................97 indapamide tab 2.5 mg ......................97 INDOCIN SUS 25MG/5ML .................... 9 indomethacin cap 25 mg ..................... 9 indomethacin cap 50 mg ..................... 9

indomethacin cap cr 75 mg ................. 9 INFANRIX INJ ................................ 135 INFLUENZA A SPR 09 H1N1 ............. 140 INLYTA TAB 1MG .............................. 57 INLYTA TAB 5MG .............................. 58 INSULIN SYRG MIS 1ML/31G ........... 114 INTELENCE TAB 100MG .................... 67 INTELENCE TAB 200MG .................... 67 INTELENCE TAB 25MG ...................... 67 INTRON A INJ 10MU ......................... 59 INTRON A INJ 18MU ......................... 59 INTRON A INJ 25MU ......................... 59 INTRON A INJ 50MU ......................... 59 introvale tab .................................... 80 INVANZ INJ 1GM .............................. 19 INVEGA SUST INJ 117/0.75 ............... 63 INVEGA SUST INJ 156MG/ML ............. 63 INVEGA SUST INJ 234/1.5 ................ 63 INVEGA SUST INJ 39/0.25 ................ 63 INVEGA SUST INJ 78/0.5ML .............. 63 INVIRASE CAP 200MG ...................... 67 INVIRASE TAB 500MG ...................... 67 IOPIDINE SOL 1% OP ..................... 122 IPOL INJ INACTIVE ......................... 140 ipratropium bromide inhal soln 0.02% 23 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ................................... 121 ipratropium bromide nasal soln 0.06% (42 mcg/spray) ................................... 121 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ........................... 25 irbesartan tab 150 mg ...................... 47 irbesartan tab 300 mg ...................... 47 irbesartan tab 75 mg ........................ 47 irbesartan-hydrochlorothiazide tab 150-12.5 mg ................................... 49 irbesartan-hydrochlorothiazide tab 300-12.5 mg ................................... 49 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ...................................................... 61 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ...................................................... 61 irinotecan hcl inj 500 mg/25ml (20 mg/ml) ........................................... 61 ISENTRESS CHW 100MG ................... 67 ISENTRESS CHW 25MG ..................... 67 ISENTRESS POW 100MG ................... 67 168

October 1, 2016

ISENTRESS TAB 400MG .....................67 ISO HOMATROP SOL 2% OP ............. 122 isoditrate tab 40mg er .......................20 ISOLYTE-S INJ................................ 115 isoniazid inj 100 mg/ml .....................52 isoniazid syrup 50 mg/5ml .................52 isoniazid tab 100 mg .........................52 isoniazid tab 300 mg .........................52 ISORDIL TAB 40MG ...........................20 isosorbide dinitrate sl tab 2.5 mg ........20 isosorbide dinitrate tab 10 mg ............20 isosorbide dinitrate tab 20 mg ............20 isosorbide dinitrate tab 30 mg ............20 isosorbide dinitrate tab 5 mg ..............20 isosorbide dinitrate tab cr 40 mg ........20 isosorbide mononitrate tab 10 mg .......20 isosorbide mononitrate tab 20 mg .......20 isosorbide mononitrate tab sr 24hr 120 mg ..................................................20 isosorbide mononitrate tab sr 24hr 30 mg ......................................................20 isosorbide mononitrate tab sr 24hr 60 mg ......................................................20 isradipine cap 2.5 mg ........................75 isradipine cap 5 mg ...........................75 ISTALOL SOL 0.5% OP .................... 121 itraconazole cap 100 mg ....................42 IV PREP WIPE PAD ............................66 ivermectin tab 3 mg ..........................18 J JAKAFI TAB 10MG .............................58 JAKAFI TAB 15MG .............................58 JAKAFI TAB 20MG .............................58 JAKAFI TAB 25MG .............................58 JAKAFI TAB 5MG ...............................58 jantoven tab 10mg............................26 jantoven tab 1mg .............................26 jantoven tab 2.5mg...........................26 jantoven tab 2mg .............................26 jantoven tab 3mg .............................26 jantoven tab 4mg .............................26 jantoven tab 5mg .............................26 jantoven tab 6mg .............................26 jantoven tab 7.5mg...........................26 JANUMET TAB 50-1000 ......................37 JANUMET TAB 50-500MG ...................37 JANUMET XR TAB 100-1000 ...............37

JANUMET XR TAB 50-1000 ................ 37 JANUMET XR TAB 50-500MG.............. 37 JANUVIA TAB 100MG ........................ 38 JANUVIA TAB 25MG .......................... 38 JANUVIA TAB 50MG .......................... 38 JARDIANCE TAB 10MG ...................... 39 JARDIANCE TAB 25MG ...................... 39 JENTADUETO TAB 2.5-1000 ............... 37 JENTADUETO TAB 2.5-500 ................ 37 JENTADUETO TAB 2.5-850 ................ 37 jinteli tab 1mg-5mcg ...................... 101 jolessa tab ...................................... 80 jolivette tab 0.35mg ......................... 83 junel 1.5/30 tab ............................... 81 junel 1/20 tab .................................. 81 junel fe tab 1.5/30 ........................... 81 junel fe tab 1/20 .............................. 81 K KADCYLA INJ 100MG ........................ 55 KADCYLA INJ 160MG ........................ 55 KALETRA SOL .................................. 67 KALETRA TAB 100-25MG ................... 67 KALETRA TAB 200-50MG ................... 67 KALYDECO PAK 50MG ..................... 132 KALYDECO PAK 75MG ..................... 132 KALYDECO TAB 150MG ................... 132 kanamycin sulfate inj 333 mg/ml ......... 8 kariva tab 28 day ............................. 81 kcl 20 meq/l (0.15%) in nacl 0.45% inj .................................................... 115 kcl 20 meq/l (0.15%) in nacl 0.9% inj .................................................... 115 kcl 40 meq/l (0.3%) in nacl 0.9% inj 116 kelnor tab 1/35 ................................ 81 KEPIVANCE INJ 6.25MG .................... 59 KETEK TAB 300MG ........................... 19 KETEK TAB 400MG ........................... 19 ketoconazole cream 2% .................... 90 ketoconazole shampoo 2% ................ 90 ketodan aer 2% ............................... 90 ketoprofen cap 50 mg ......................... 9 ketoprofen cap 75 mg ......................... 9 ketoprofen cap sr 24hr 200 mg ............ 9 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) ....................................... 9 ketorolac tromethamine inj 15 mg/ml ... 9 ketorolac tromethamine inj 30 mg/ml ... 9 169

October 1, 2016

ketorolac tromethamine inj 300 mg/10ml (30 mg/ml) ......................................10 ketorolac tromethamine inj 60 mg/2ml (30 mg/ml) ....................................... 9 ketorolac tromethamine ophth soln 0.4% .................................................... 124 ketorolac tromethamine ophth soln 0.5% .................................................... 124 ketorolac tromethamine tab 10 mg .....10 KEYTRUDA INJ 100MG/4M .................55 KEYTRUDA SOL 50MG .......................55 KINERET INJ ..................................... 8 KINRIX INJ..................................... 135 kionex sus 15gm/60 ..........................71 klor-con 10 tab 10meq er ................ 117 klor-con 8 tab 8meq er .................... 117 KLOR-CON M15 TAB 15MEQ ER ........ 117 klor-con m20 tab 20meq er .............. 117 KRISTALOSE PAK 10GM ................... 111 KRISTALOSE PAK 20GM ................... 111 kurvelo tab 0.15/30 ..........................81 KUVAN POW 100MG ..........................99 KUVAN POW 500MG ..........................99 KUVAN TAB 100MG ...........................99 L labetalol hcl iv soln 5 mg/ml ...............72 labetalol hcl tab 100 mg ....................72 labetalol hcl tab 200 mg ....................72 labetalol hcl tab 300 mg ....................72 laclotion lot 12%...............................94 LACRISERT MIS 5MG OP .................. 121 lactic acid (ammonium lactate) cream 12% ................................................94 lactic acid (ammonium lactate) lotion 10% ......................................................94 lactic acid (ammonium lactate) lotion 12% ......................................................94 lactulose solution 10 gm/15ml .......... 111 LAMICTAL CHW 2MG .........................28 LAMICTAL KIT START 35 ....................28 LAMICTAL KIT START 49 ....................28 LAMICTAL KIT START 98 ....................28 LAMICTAL XR KIT..............................28 LAMISIL GRA 125MG .........................42 LAMISIL GRA 187.5MG ......................42 lamivudine oral soln 10 mg/ml ...........67 lamivudine tab 100 mg (hbv) .............69

lamivudine tab 150 mg ..................... 67 lamivudine tab 300 mg ..................... 67 lamivudine-zidovudine tab 150-300 mg ...................................................... 67 lamotrigine orally disintegrating tab 100 mg ................................................. 28 lamotrigine orally disintegrating tab 200 mg ................................................. 28 lamotrigine orally disintegrating tab 25 mg ................................................. 28 lamotrigine orally disintegrating tab 50 mg ................................................. 28 lamotrigine tab 100 mg ..................... 28 lamotrigine tab 150 mg ..................... 28 lamotrigine tab 200 mg ..................... 28 lamotrigine tab 25 mg ...................... 28 lamotrigine tab chewable dispersible 25 mg ................................................. 28 lamotrigine tab chewable dispersible 5 mg ...................................................... 28 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit .............................. 28 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit ................................. 28 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit ............................... 29 lamotrigine tab sr 24hr 100 mg.......... 29 lamotrigine tab sr 24hr 200 mg.......... 29 lamotrigine tab sr 24hr 25 mg ........... 29 lamotrigine tab sr 24hr 250 mg.......... 29 lamotrigine tab sr 24hr 300 mg.......... 29 lamotrigine tab sr 24hr 50 mg ........... 29 LANOXIN PED INJ 0.1MG/ML ............. 76 LANOXIN TAB 0.0625MG ................... 76 LANOXIN TAB 0.1875MG ................... 76 lansoprazole cap delayed release 15 mg .................................................... 137 lansoprazole cap delayed release 30 mg .................................................... 137 LANTUS INJ 100/ML ......................... 38 LANTUS INJ SOLOSTAR ..................... 38 LASTACAFT SOL 0.25%................... 124 latanoprost ophth soln 0.005% ........ 124 LATUDA TAB 120MG ......................... 63 LATUDA TAB 20MG ........................... 63 LATUDA TAB 40MG ........................... 63 LATUDA TAB 60MG ........................... 63 170

October 1, 2016

LATUDA TAB 80MG ...........................63 leena tab .........................................81 leflunomide tab 10 mg .......................10 leflunomide tab 20 mg .......................10 LENVIMA CAP 10 MG .........................58 LENVIMA CAP 14 MG .........................58 LENVIMA CAP 18 MG .........................58 LENVIMA CAP 20 MG .........................58 LENVIMA CAP 24 MG .........................58 LENVIMA CAP 8 MG ...........................58 lessina tab .......................................81 LETAIRIS TAB 10MG ..........................77 LETAIRIS TAB 5MG ...........................77 letrozole tab 2.5 mg ..........................55 leucovorin calcium for inj 100 mg .......59 leucovorin calcium for inj 200 mg .......59 leucovorin calcium for inj 350 mg .......59 leucovorin calcium for inj 50 mg .........59 LEUCOVORIN CALCIUM FOR INJ 500 MG ......................................................59 leucovorin calcium tab 10 mg .............60 leucovorin calcium tab 15 mg .............60 leucovorin calcium tab 25 mg .............60 leucovorin calcium tab 5 mg ...............59 LEUKERAN TAB 2MG..........................53 LEUKINE INJ 250MCG ...................... 110 LEUKINE INJ 500 MCG ..................... 110 leuprolide acetate inj kit 5 mg/ml .......55 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .....................................25 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .....................................25 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) .....................................25 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) ......................25 LEVATOL TAB 20MG ..........................72 LEVEMIR INJ ....................................38 LEVEMIR INJ FLEXTOUC .....................38 LEVETIRACETA INJ 10MG/ML..............29 LEVETIRACETA INJ 15MG/ML..............29 LEVETIRACETA INJ 5MG/ML ...............29 levetiracetam inj 500 mg/5ml (100 mg/ml) ............................................29 levetiracetam oral soln 100 mg/ml ......29 levetiracetam tab 1000 mg ................29 levetiracetam tab 250 mg ..................29

levetiracetam tab 500 mg ................. 29 levetiracetam tab 750 mg ................. 29 levetiracetam tab sr 24hr 500 mg ...... 29 levetiracetam tab sr 24hr 750 mg ...... 29 levobunolol hcl ophth soln 0.25% ..... 122 levobunolol hcl ophth soln 0.5%....... 121 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ........................ 43 levocetirizine dihydrochloride tab 5 mg 43 levofloxacin in d5w iv soln 250 mg/50ml .................................................... 106 levofloxacin in d5w iv soln 500 mg/100ml .................................................... 106 levofloxacin in d5w iv soln 750 mg/150ml .................................................... 106 levofloxacin iv soln 25 mg/ml .......... 106 levofloxacin ophth soln 0.5% ........... 122 levofloxacin oral soln 25 mg/ml........ 106 levofloxacin tab 250 mg .................. 106 levofloxacin tab 500 mg .................. 106 levofloxacin tab 750 mg .................. 106 levonest tab .................................... 81 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ............... 81 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 81 levonorgestrel tab 0.75 mg ............... 82 levonorgestrel tab 1.5 mg ................. 82 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ...................... 81 levora-28 tab 0.15/30....................... 81 levorphanol tartrate tab 2 mg ............ 13 levothyroxine sodium tab 100 mcg ... 134 levothyroxine sodium tab 112 mcg ... 134 levothyroxine sodium tab 125 mcg ... 134 levothyroxine sodium tab 137 mcg ... 134 levothyroxine sodium tab 150 mcg ... 134 levothyroxine sodium tab 175 mcg ... 134 levothyroxine sodium tab 200 mcg ... 134 levothyroxine sodium tab 25 mcg ..... 133 levothyroxine sodium tab 300 mcg ... 134 levothyroxine sodium tab 50 mcg ..... 133 levothyroxine sodium tab 75 mcg ..... 133 levothyroxine sodium tab 88 mcg ..... 133 levoxyl tab 100mcg ........................ 134 levoxyl tab 112mcg ........................ 134 levoxyl tab 125mcg ........................ 134 171

October 1, 2016

levoxyl tab 137mcg ......................... 134 levoxyl tab 150mcg ......................... 134 levoxyl tab 175mcg ......................... 134 levoxyl tab 200mcg ......................... 134 levoxyl tab 25mcg........................... 134 levoxyl tab 50mcg........................... 134 levoxyl tab 75mcg........................... 134 levoxyl tab 88mcg........................... 134 LEXIVA SUS 50MG/ML .......................67 LEXIVA TAB 700MG ...........................67 LIDO/DEXTROS INJ 5-7.5% ............. 112 lidocaine hcl cream 3% ......................94 lidocaine hcl gel 2% ..........................94 lidocaine hcl iv inj 10 mg/ml...............23 lidocaine hcl iv inj 20 mg/ml...............23 lidocaine hcl laryngotracheal soln 4% 118 lidocaine hcl local inj 0.5% ............... 112 lidocaine hcl local inj 1%.................. 112 lidocaine hcl local inj 1.5% ............... 112 lidocaine hcl local inj 2%.................. 112 lidocaine hcl local preservative free (pf) inj 0.5% ............................................. 112 lidocaine hcl local preservative free (pf) inj 1% ............................................... 112 lidocaine hcl local preservative free (pf) inj 2% ............................................... 112 lidocaine hcl local preservative free (pf) inj 4% ............................................... 112 lidocaine hcl lotion 3%.......................94 lidocaine hcl soln 4% .........................94 lidocaine hcl viscous soln 2% ........... 118 lidocaine iv infusion in d5w inj 4 mg/ml ......................................................23 lidocaine iv infusion in d5w inj 8 mg/ml ......................................................23 lidocaine oint 5% ..............................94 lidocaine patch 5%............................94 lidocaine-prilocaine cream 2.5-2.5% ...94 lidocaine-prilocaine cream kit 2.5-2.5% ......................................................94 LILETTA IUD 52MG............................82 lincomycin hcl inj 300 mg/ml ..............20 lindane lotion 1% ..............................94 lindane shampoo 1% .........................95 linezolid for susp 100 mg/5ml ............20 linezolid in sodium chloride iv soln 600 mg/300ml-0.9% ...............................20

linezolid iv soln 600 mg/300ml (2 mg/ml) ...................................................... 20 linezolid tab 600 mg ......................... 20 LINZESS CAP 145MCG .................... 107 LINZESS CAP 290MCG .................... 107 liothyronine sodium iv soln 10 mcg/ml .................................................... 134 liothyronine sodium tab 25 mcg ....... 134 liothyronine sodium tab 5 mcg ......... 134 liothyronine sodium tab 50 mcg ....... 134 lipodox 50 inj 2mg/ml ....................... 57 lipodox inj 2mg/ml ........................... 57 lisinopril & hydrochlorothiazide tab 10-12.5 mg ..................................... 49 lisinopril & hydrochlorothiazide tab 20-12.5 mg ..................................... 49 lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 50 lisinopril tab 10 mg........................... 46 lisinopril tab 2.5 mg ......................... 46 lisinopril tab 20 mg........................... 46 lisinopril tab 30 mg........................... 46 lisinopril tab 40 mg........................... 46 lisinopril tab 5 mg ............................ 46 lithium carbonate cap 150 mg............ 63 lithium carbonate cap 300 mg............ 63 lithium carbonate cap 600 mg............ 63 lithium carbonate tab 300 mg ............ 63 lithium carbonate tab cr 300 mg ........ 63 lithium carbonate tab cr 450 mg ........ 63 LITHIUM SOL 8MEQ/5ML ................... 63 LIVALO TAB 1MG.............................. 45 LIVALO TAB 2MG.............................. 45 LIVALO TAB 4MG.............................. 45 LO LOESTRIN TAB ............................ 81 lokara lot 0.05% .............................. 93 lomedia 24 tab fe ............................. 81 loperamide hcl cap 2 mg ................... 40 lorazepam conc 2 mg/ml ................... 22 lorazepam tab 0.5 mg ....................... 22 lorazepam tab 1 mg ......................... 22 lorazepam tab 2 mg ......................... 22 loryna tab 3-0.02mg ......................... 81 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 50 losartan potassium & hydrochlorothiazide tab 100-25 mg................................. 50 172

October 1, 2016

losartan potassium & hydrochlorothiazide tab 50-12.5 mg ................................50 losartan potassium tab 100 mg ..........47 losartan potassium tab 25 mg ............47 losartan potassium tab 50 mg ............47 LOTEMAX GEL 0.5% ........................ 123 LOTEMAX OIN 0.5% ........................ 123 LOTEMAX SUS 0.5%........................ 123 lovastatin tab 10 mg .........................45 lovastatin tab 20 mg .........................45 lovastatin tab 40 mg .........................45 low-ogestrel tab................................81 loxapine succinate cap 10 mg .............64 loxapine succinate cap 25 mg .............64 loxapine succinate cap 5 mg...............64 loxapine succinate cap 50 mg .............64 ludent chw 0.25mg f ....................... 116 ludent chw 0.5mg f ......................... 116 ludent chw 1mg f ............................ 116 LUFYLLIN TAB 200MG ........................25 LUFYLLIN TAB 400MG ........................26 LUMIGAN SOL 0.01% ...................... 124 LUPR DEP-PED INJ 11.25MG...............99 LUPR DEP-PED INJ 15MG ...................99 LUPR DEP-PED INJ 30MG ...................99 LUPR DEP-PED INJ 7.5MG ..................99 LUPRON DEPOT INJ 11.25MG .............56 LUPRON DEPOT INJ 22.5MG ...............56 LUPRON DEPOT INJ 3.75MG ...............56 LUPRON DEPOT INJ 30MG ..................56 LUPRON DEPOT INJ 45MG ..................56 LUPRON DEPOT INJ 7.5MG .................56 LURIDE CHW 0.25MG F.................... 116 LURIDE CHW 0.5MG F ..................... 116 LURIDE DRO 0.5MG/ML ................... 116 lutera tab .........................................81 LYNPARZA CAP 50MG ........................58 LYRICA CAP 100MG ...........................29 LYRICA CAP 150MG ...........................29 LYRICA CAP 200MG ...........................29 LYRICA CAP 225MG ...........................29 LYRICA CAP 25MG ............................29 LYRICA CAP 300MG ...........................29 LYRICA CAP 50MG ............................29 LYRICA CAP 75MG ............................29 LYRICA SOL 20MG/ML .......................29 LYSODREN TAB 500MG ......................56

M MAGNESIUM SU INJ 20/500ML......... 117 MAGNESIUM SU INJ 2GM/50ML........ 116 MAGNESIUM SU INJ 40G/1000 ........ 117 MAGNESIUM SU INJ 4G/100ML ........ 117 MAGNESIUM SU INJ 80MG/ML ......... 117 magnesium sulfate 1% in d5w ......... 117 magnesium sulfate inj 50% ............. 117 magnesium sulfate iv soln 2 gm/50ml (40 mg/ml) ......................................... 117 magnesium sulfate iv soln 20 gm/500ml (40 mg/ml) ................................... 117 magnesium sulfate iv soln 4 gm/100ml (40 mg/ml) ................................... 117 magnesium sulfate iv soln 4 gm/50ml (80 mg/ml) ......................................... 117 magnesium sulfate iv soln 40 gm/1000ml (40 mg/ml) ................................... 117 malathion lotion 0.5% ...................... 95 maprotiline hcl tab 25 mg ................. 31 maprotiline hcl tab 50 mg ................. 31 maprotiline hcl tab 75 mg ................. 31 marlissa tab 0.15/30 ........................ 81 MARPLAN TAB 10MG ......................... 32 MATULANE CAP 50MG ....................... 59 matzim la tab 180mg/24 ................... 75 matzim la tab 240mg/24 ................... 75 matzim la tab 300mg/24 ................... 75 matzim la tab 360mg/24 ................... 75 matzim la tab 420mg/24 ................... 75 MAXIDEX SUS 0.1% OP .................. 123 MAXIPIME INJ 1GM........................... 80 MAXIPIME INJ 2GM........................... 80 meclizine hcl tab 12.5 mg ................. 41 meclizine hcl tab 25 mg .................... 41 meclofenamate sodium cap 100 mg.... 10 meclofenamate sodium cap 50 mg ..... 10 MEDROL TAB 2MG ............................ 84 medroxyprogesterone acetate im susp 150 mg/ml ...................................... 83 medroxyprogesterone acetate tab 10 mg .................................................... 129 medroxyprogesterone acetate tab 2.5 mg .................................................... 129 medroxyprogesterone acetate tab 5 mg .................................................... 129 mefenamic acid cap 250 mg .............. 10 173

October 1, 2016

mefloquine hcl tab 250 mg .................51 MEFOXIN INJ 1GM/50ML ....................78 MEFOXIN INJ 2GM/50ML ....................78 megestrol acetate susp 40 mg/ml .......56 megestrol acetate susp 625 mg/5ml . 129 megestrol acetate tab 20 mg ..............56 megestrol acetate tab 40 mg ..............56 MEKINIST TAB 0.5MG ........................58 MEKINIST TAB 2MG ..........................58 meloxicam susp 7.5 mg/5ml ..............10 meloxicam tab 15 mg ........................10 meloxicam tab 7.5 mg .......................10 melphalan hcl for inj 50 mg (base equiv) ......................................................53 memantine hcl oral solution 2 mg/ml 129 memantine hcl tab 10 mg ................ 130 memantine hcl tab 5 mg .................. 129 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................ 130 MENACTRA INJ ............................... 139 MENEST TAB 0.3MG ........................ 104 MENEST TAB 0.625MG ..................... 104 MENEST TAB 1.25MG ...................... 104 MENEST TAB 2.5MG ........................ 104 MENHIBRIX INJ .............................. 139 MENOMUNE INJ A/C/Y/W ................. 139 MENOSTAR DIS 14MCG ................... 104 MENTAX CRE 1% ..............................90 MENVEO INJ ................................... 139 meperidine hcl inj 10 mg/ml...............13 meperidine hcl inj 100 mg/ml .............13 meperidine hcl inj 25 mg/ml...............13 meperidine hcl inj 50 mg/ml...............13 meperidine hcl oral soln 50 mg/5ml ....13 meperidine hcl tab 100 mg ................13 meperidine hcl tab 50 mg ..................13 MEPHYTON TAB 5MG ....................... 142 meprobamate tab 200 mg..................22 meprobamate tab 400 mg..................22 mercaptopurine tab 50 mg .................54 meropenem iv for soln 1 gm ..............19 meropenem iv for soln 500 mg ...........19 mesalamine enema 4 gm ................. 106 mesalamine rectal enema 4 gm & cleanser wipe kit ......................................... 106 mesna inj 100 mg/ml ........................60 MESNEX TAB 400MG .........................60

MESTINON SYP 60MG/5ML ................ 51 metaproterenol sulfate syrup 10 mg/5ml ...................................................... 25 metaproterenol sulfate tab 10 mg ...... 25 metaproterenol sulfate tab 20 mg ...... 25 metaxalone tab 400 mg .................. 120 metaxalone tab 800 mg .................. 120 metformin hcl tab 1000 mg ............... 37 metformin hcl tab 500 mg ................. 37 metformin hcl tab 850 mg ................. 37 metformin hcl tab sr 24hr 500 mg ...... 37 metformin hcl tab sr 24hr 750 mg ...... 37 metformin hcl tab sr 24hr osmotic 1000 mg ................................................. 37 metformin hcl tab sr 24hr osmotic 500 mg ...................................................... 37 methadone hcl conc 10 mg/ml ........... 13 methadone hcl soln 10 mg/5ml .......... 13 methadone hcl soln 5 mg/5ml ............ 13 methadone hcl tab 10 mg ................. 13 methadone hcl tab 5 mg ................... 13 methadone hcl tab for oral susp 40 mg 13 METHADONE INJ 10MG/ML ................ 13 methadose tab 40mg ........................ 13 methamphetamine hcl tab 5 mg ........... 5 methazolamide tab 25 mg ................. 95 methazolamide tab 50 mg ................. 95 methenamine hippurate tab 1 gm .... 138 methimazole tab 10 mg .................. 133 methimazole tab 5 mg .................... 133 methocarbamol tab 500 mg ............. 120 methocarbamol tab 750 mg ............. 120 methotrexate sodium for inj 1 gm ...... 54 methotrexate sodium inj 250 mg/10ml (25 mg/ml) ..................................... 54 methotrexate sodium inj 50 mg/2ml (25 mg/ml) ........................................... 54 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) ..................................... 54 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ........................ 54 methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) ..................................... 54 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ..................................... 54 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ..................................... 54 174

October 1, 2016

methotrexate sodium tab 2.5 mg (base equiv) .............................................54 methoxsalen rapid cap 10 mg.............91 methscopolamine bromide tab 2.5 mg .................................................... 136 methscopolamine bromide tab 5 mg .. 136 methyclothiazide tab 5 mg .................97 methyldopa tab 250 mg .....................48 methyldopa tab 500 mg .....................48 methyldopate hcl inj 250 mg/5ml .......48 methylphenidate hcl cap cr 10 mg (cd) . 6 methylphenidate hcl cap cr 20 mg (cd) . 6 methylphenidate hcl cap cr 30 mg (cd) . 6 methylphenidate hcl cap cr 40 mg (cd) . 6 methylphenidate hcl cap cr 50 mg (cd) . 6 methylphenidate hcl cap cr 60 mg (cd) . 7 methylphenidate hcl cap sr 24hr 20 mg (la) .................................................. 7 methylphenidate hcl cap sr 24hr 30 mg (la) .................................................. 7 methylphenidate hcl cap sr 24hr 40 mg (la) .................................................. 7 methylphenidate hcl chew tab 10 mg ... 7 methylphenidate hcl chew tab 2.5 mg .. 7 methylphenidate hcl chew tab 5 mg ..... 7 methylphenidate hcl soln 10 mg/5ml .... 7 methylphenidate hcl soln 5 mg/5ml...... 7 methylphenidate hcl tab 10 mg ........... 7 methylphenidate hcl tab 20 mg ........... 7 methylphenidate hcl tab 5 mg ............. 7 methylphenidate hcl tab cr 10 mg ........ 7 methylphenidate hcl tab cr 20 mg ........ 7 methylphenidate hcl tab sa osm 18 mg. 7 methylphenidate hcl tab sa osm 27 mg. 7 methylphenidate hcl tab sa osm 36 mg. 7 methylphenidate hcl tab sa osm 54 mg. 7 methylphenidate hcl tab sr 24hr 18 mg 7 methylphenidate hcl tab sr 24hr 27 mg 7 methylphenidate hcl tab sr 24hr 36 mg 7 methylphenidate hcl tab sr 24hr 54 mg 7 methylprednisolone acetate inj susp 40 mg/ml .............................................84 methylprednisolone acetate inj susp 80 mg/ml .............................................84 methylprednisolone sodium succinate for inj 1000 mg .....................................84 methylprednisolone sodium succinate for

inj 125 mg ...................................... 84 methylprednisolone sodium succinate for inj 40 mg ........................................ 84 methylprednisolone sodium succinate for inj 500 mg ...................................... 84 methylprednisolone tab 16 mg ........... 84 methylprednisolone tab 32 mg ........... 84 methylprednisolone tab 4 mg ............ 84 methylprednisolone tab 8 mg ............ 84 methylprednisolone tab therapy pack 4 mg (21) .......................................... 84 methyltestosterone cap 10 mg ........... 17 metipranolol ophth soln 0.3% .......... 122 metoclopramide hcl inj 5 mg/ml ....... 106 metoclopramide hcl orally disintegrating tab 5 mg ....................................... 106 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)...................................... 106 metoclopramide hcl tab 10 mg ......... 106 metoclopramide hcl tab 5 mg .......... 106 metolazone tab 10 mg ...................... 97 metolazone tab 2.5 mg ..................... 97 metolazone tab 5 mg ........................ 97 metoprolol & hydrochlorothiazide tab 100-25 mg ...................................... 50 metoprolol & hydrochlorothiazide tab 100-50 mg ...................................... 50 metoprolol & hydrochlorothiazide tab 50-25 mg ........................................ 50 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) ................................ 72 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) ................................ 72 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) ................................ 72 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) ................................ 72 metoprolol tartrate inj 1 mg/ml .......... 72 metoprolol tartrate tab 100 mg .......... 72 metoprolol tartrate tab 25 mg............ 72 metoprolol tartrate tab 50 mg............ 72 metronidazole cap 375 mg ................ 18 metronidazole cream 0.75% .............. 94 metronidazole gel 0.75% .................. 94 metronidazole gel 1% ....................... 94 metronidazole in nacl 0.79% iv soln 500 mg/100ml ....................................... 18 175

October 1, 2016

metronidazole lotion 0.75% ...............94 metronidazole tab 250 mg .................18 metronidazole tab 500 mg .................18 metronidazole vaginal gel 0.75% ...... 141 mexiletine hcl cap 150 mg .................23 mexiletine hcl cap 200 mg .................23 mexiletine hcl cap 250 mg .................23 MG SO4/D5W INJ 10MG/ML ............. 117 MG SO4/D5W INJ 20MG/ML ............. 117 MIACALCIN INJ 200/ML .....................97 miconazole 3 kit combo pk ............... 141 miconazole 3 sup 200mg ................. 141 midodrine hcl tab 10 mg .................. 142 midodrine hcl tab 2.5 mg ................. 142 midodrine hcl tab 5 mg .................... 142 miglitol tab 100 mg ...........................36 miglitol tab 25 mg.............................36 miglitol tab 50 mg.............................36 MILLIPRED DP PAK 5MG ....................84 MILLIPRED SOL 10MG/5ML ................84 MILLIPRED TAB 5MG .........................84 mimvey tab 1-0.5mg ....................... 101 MINASTRIN 24 CHW FE .....................81 minitran dis 0.1mg/hr .......................20 minitran dis 0.2mg/hr .......................20 minitran dis 0.4mg/hr .......................20 minitran dis 0.6mg/hr .......................20 minocycline hcl cap 100 mg ............. 133 minocycline hcl cap 50 mg ............... 133 minocycline hcl cap 75 mg ............... 133 minocycline hcl tab 100 mg .............. 133 minocycline hcl tab 50 mg ............... 133 minocycline hcl tab 75 mg ............... 133 minocycline hcl tab sr 24hr 135 mg ... 133 minocycline hcl tab sr 24hr 45 mg .... 133 minocycline hcl tab sr 24hr 90 mg .... 133 minoxidil tab 10 mg ..........................51 minoxidil tab 2.5 mg .........................51 MIRAPEX ER TAB 3.75MG...................62 MIRENA IUD SYSTEM ........................83 mirtazapine orally disintegrating tab 15 mg ..................................................31 mirtazapine orally disintegrating tab 30 mg ..................................................31 mirtazapine orally disintegrating tab 45 mg ..................................................31 mirtazapine tab 15 mg ......................31

mirtazapine tab 30 mg ...................... 31 mirtazapine tab 45 mg ...................... 31 mirtazapine tab 7.5 mg ..................... 31 misoprostol tab 100 mcg ................. 137 misoprostol tab 200 mcg ................. 137 mitomycin for iv soln 20 mg .............. 57 mitomycin for iv soln 40 mg .............. 57 mitomycin for iv soln 5 mg ................ 57 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) ........................................... 57 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ....................................... 57 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) ........................................... 57 M-M-R II INJ.................................. 140 modafinil tab 100 mg.......................... 7 modafinil tab 200 mg.......................... 7 moexipril hcl tab 15 mg .................... 46 moexipril hcl tab 7.5 mg ................... 46 moexipril-hydrochlorothiazide tab 15-12.5 mg ..................................... 50 moexipril-hydrochlorothiazide tab 15-25 mg ................................................. 50 moexipril-hydrochlorothiazide tab 7.5-12.5 mg .................................... 50 mometasone furoate cream 0.1% ...... 93 mometasone furoate oint 0.1% .......... 93 mometasone furoate solution 0.1% (lotion) ........................................... 93 mono-linyah tab 0.25-35................... 81 mononessa tab ................................ 81 montelukast sodium chew tab 4 mg (base equiv) ............................................. 24 montelukast sodium chew tab 5 mg (base equiv) ............................................. 24 montelukast sodium oral granules packet 4 mg (base equiv) ............................ 24 montelukast sodium tab 10 mg (base equiv) ............................................. 24 MONUROL PAK GRANULES .............. 138 morgidox cap 1x100mg .................. 133 MORPHINE SUL INJ 150/30ML ........... 13 MORPHINE SUL INJ 2MG/ML .............. 13 MORPHINE SUL INJ 4MG/ML .............. 13 MORPHINE SUL INJ 5MG/ML .............. 13 MORPHINE SUL SUP 30MG ................ 13 morphine sulfate beads cap sr 24hr 120 176

October 1, 2016

mg ..................................................13 morphine sulfate beads cap sr 24hr 30 mg ......................................................13 morphine sulfate beads cap sr 24hr 45 mg ......................................................13 morphine sulfate beads cap sr 24hr 60 mg ......................................................13 morphine sulfate beads cap sr 24hr 75 mg ......................................................13 morphine sulfate beads cap sr 24hr 90 mg ......................................................13 morphine sulfate cap sr 24hr 10 mg ....13 morphine sulfate cap sr 24hr 100 mg ..13 morphine sulfate cap sr 24hr 20 mg ....13 morphine sulfate cap sr 24hr 30 mg ....13 morphine sulfate cap sr 24hr 50 mg ....13 morphine sulfate cap sr 24hr 60 mg ....13 morphine sulfate cap sr 24hr 80 mg ....13 morphine sulfate inj 10 mg/ml............13 morphine sulfate inj 15 mg/ml............14 morphine sulfate inj 8 mg/ml .............13 morphine sulfate inj pf 1 mg/ml ..........14 morphine sulfate iv soln 1 mg/ml ........14 morphine sulfate iv soln 25 mg/ml ......14 morphine sulfate iv soln 50 mg/ml ......14 morphine sulfate iv soln pf 10 mg/ml ..14 morphine sulfate iv soln pf 15 mg/ml ..14 morphine sulfate iv soln pf 4 mg/ml ....14 morphine sulfate iv soln pf 8 mg/ml ....14 morphine sulfate oral soln 10 mg/5ml .14 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ......................................14 morphine sulfate oral soln 20 mg/5ml .14 morphine sulfate suppos 10 mg ..........14 morphine sulfate suppos 20 mg ..........14 morphine sulfate suppos 5 mg ............14 morphine sulfate tab 15 mg ...............14 morphine sulfate tab 30 mg ...............14 morphine sulfate tab cr 100 mg ..........14 morphine sulfate tab cr 15 mg ............14 morphine sulfate tab cr 200 mg ..........14 morphine sulfate tab cr 30 mg ............14 morphine sulfate tab cr 60 mg ............14 MOTOFEN TAB ..................................40 MOVANTIK TAB 12.5MG ................... 107 MOVANTIK TAB 25MG ..................... 107 MOVIPREP SOL ............................... 111

MOXEZA SOL 0.5% ........................ 122 moxifloxacin hcl tab 400 mg (base equiv) .................................................... 106 MOZOBIL INJ ................................. 110 MULTAQ TAB 400MG......................... 23 multi-vit/fe dro /fl 0.25 ................... 119 multivit/fl chw 0.25mg .................... 118 multivit/fl chw 0.5mg...................... 118 multivit/fl chw 1mg ........................ 118 multi-vit/fl dro /fe 0.25 ................... 119 multi-vit/fl dro 0.25mg ................... 118 multi-vit/fl dro 0.5mg/ml ................ 118 mupirocin oint 2% ............................ 89 mvc-fluoride chw 0.5mg.................. 118 mvc-fluoride chw 1mg .................... 118 MYCAMINE INJ 100MG ...................... 42 MYCAMINE INJ 50MG ........................ 42 mycophenolate mofetil cap 250 mg .... 71 mycophenolate mofetil for oral susp 200 mg/ml ............................................ 71 mycophenolate mofetil tab 500 mg..... 71 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) ................. 71 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ................. 71 MYLERAN TAB 2MG........................... 53 myorisan cap 10mg .......................... 87 myorisan cap 20mg .......................... 87 myorisan cap 40mg .......................... 87 MYOZYME INJ 50MG ......................... 99 MYRBETRIQ TAB 25MG ................... 138 MYRBETRIQ TAB 50MG ................... 138 myzilra tab ...................................... 81 N nabumetone tab 500 mg ................... 10 nabumetone tab 750 mg ................... 10 nadolol & bendroflumethiazide tab 40-5 mg ................................................. 50 nadolol & bendroflumethiazide tab 80-5 mg ................................................. 50 nadolol tab 20 mg ............................ 72 nadolol tab 40 mg ............................ 72 nadolol tab 80 mg ............................ 73 NAFCILLIN INJ 1GM/50ML ............... 128 NAFCILLIN INJ 2GM/100 ................. 128 nafcillin sodium for inj 1 gm ............ 128 nafcillin sodium for inj 10 gm ........... 128 177

October 1, 2016

nafcillin sodium for inj 2 gm ............. 128 nafcillin sodium for iv soln 1 gm ....... 128 nafcillin sodium for iv soln 2 gm ....... 128 nafrinse chw 1mg f ......................... 116 naftifine hcl cream 1% ......................90 naftifine hcl cream 2% ......................90 NAFTIN GEL 1% ...............................90 NAFTIN GEL 2% ...............................90 NAGLAZYME INJ 1MG/ML ...................99 nalbuphine hcl inj 10 mg/ml ...............17 nalbuphine hcl inj 20 mg/ml ...............17 naloxone hcl inj 0.4 mg/ml.................40 naloxone hcl inj 1 mg/ml ...................40 naltrexone hcl tab 50 mg ...................40 NAMENDA XR CAP 14MG .................. 130 NAMENDA XR CAP 21MG .................. 130 NAMENDA XR CAP 28MG .................. 130 NAMENDA XR CAP 7MG ................... 130 NAMENDA XR CAP TITRATIO ............ 130 naphazoline hcl ophth soln 0.1% ...... 123 naproxen dr tab 375mg .....................10 naproxen dr tab 500mg .....................10 naproxen sodium tab 275 mg .............10 naproxen sodium tab 550 mg .............10 naproxen susp 125 mg/5ml................10 naproxen tab 250 mg ........................10 naproxen tab 375 mg ........................10 naproxen tab 500 mg ........................10 naratriptan hcl tab 1 mg (base equiv) 114 naratriptan hcl tab 2.5 mg (base equiv) .................................................... 115 NARCAN SPR ....................................40 NATACYN SUS 5% OP ..................... 122 NATAZIA TAB ...................................81 nateglinide tab 120 mg ......................39 nateglinide tab 60 mg .......................39 NEBUPENT INH 300MG ......................18 necon tab 0.5/35 ..............................81 necon tab 1/35 .................................81 necon tab 1/50-28 ............................81 NECON TAB 10/11-28........................81 necon tab 7/7/7 ................................81 nefazodone hcl tab 100 mg ................33 nefazodone hcl tab 150 mg ................33 nefazodone hcl tab 200 mg ................33 nefazodone hcl tab 250 mg ................33 nefazodone hcl tab 50 mg ..................33

NEO-FRADIN SOL 125/5ML .................. 8 neomycin sulfate tab 500 mg ............... 8 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ..... 123 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 123 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 124 neomycin-polymyxin-hc ophth susp .. 124 neomycin-polymyxin-hc otic soln 1% 125 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 125 NEULASTA INJ 6MG/0.6M ................ 110 NEULASTA KIT 6MG/0.6M................ 110 NEUPOGEN INJ 300/0.5 .................. 110 NEUPOGEN INJ 300MCG .................. 110 NEUPOGEN INJ 480/0.8 .................. 110 NEUPOGEN INJ 480MCG .................. 110 NEVANAC SUS 0.1% ....................... 124 nevirapine susp 50 mg/5ml ............... 67 nevirapine tab 200 mg ...................... 67 nevirapine tab sr 24hr 100 mg ........... 67 nevirapine tab sr 24hr 400 mg ........... 67 NEXAVAR TAB 200MG ....................... 58 NEXIUM GRA 10MG DR ................... 137 NEXIUM GRA 2.5MG DR .................. 137 NEXIUM GRA 20MG DR ................... 137 NEXIUM GRA 40MG DR ................... 137 NEXIUM GRA 5MG DR ..................... 137 NEXPLANON IMP 68MG ..................... 83 NEXTERONE INJ ............................... 23 niacin tab cr 1000 mg (antihyperlipidemic) ......................... 46 niacin tab cr 500 mg (antihyperlipidemic) ...................................................... 46 niacin tab cr 750 mg (antihyperlipidemic) ...................................................... 46 nicardipine hcl cap 20 mg .................. 75 nicardipine hcl cap 30 mg .................. 75 nicardipine hcl iv soln 2.5 mg/ml ........ 75 nicotine polacrilex gum 2 mg ........... 131 nicotine polacrilex gum 4 mg ........... 131 nicotine polacrilex lozenge 2 mg ...... 131 nicotine polacrilex lozenge 4 mg ...... 131 nicotine td patch 24hr 14 mg/24hr ... 132 nicotine td patch 24hr 21 mg/24hr ... 132 nicotine td patch 24hr 7 mg/24hr ..... 131 178

October 1, 2016

NICOTROL INH ............................... 132 NICOTROL NS SPR 10MG/ML ............ 132 nifedical xl tab 30mg .........................75 nifedical xl tab 60mg .........................75 nifedipine tab sr 24hr 30 mg ..............75 nifedipine tab sr 24hr 60 mg ..............75 nifedipine tab sr 24hr 90 mg ..............75 nifedipine tab sr 24hr osmotic release 30 mg ..................................................75 nifedipine tab sr 24hr osmotic release 60 mg ..................................................75 nifedipine tab sr 24hr osmotic release 90 mg ..................................................75 NILANDRON TAB 150MG ....................56 nilutamide tab 150 mg ......................56 nimodipine cap 30 mg .......................75 NIPENT INJ 10MG .............................59 nisoldipine tab sr 24hr 17 mg .............75 nisoldipine tab sr 24hr 20 mg .............75 nisoldipine tab sr 24hr 25.5 mg ..........75 nisoldipine tab sr 24hr 30 mg .............75 nisoldipine tab sr 24hr 34 mg .............75 nisoldipine tab sr 24hr 40 mg .............75 nisoldipine tab sr 24hr 8.5 mg ............75 NITRO-BID OIN 2% ..........................20 NITRO-DUR DIS 0.3MG/HR ................20 NITRO-DUR DIS 0.8MG/HR ................20 nitrofurantoin macrocrystalline cap 100 mg ................................................ 138 nitrofurantoin macrocrystalline cap 25 mg .................................................... 138 nitrofurantoin macrocrystalline cap 50 mg .................................................... 138 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............ 138 nitrofurantoin susp 25 mg/5ml ......... 138 NITROGLYCER INJ 5MG/ML ................20 nitroglycerin cap cr 2.5 mg ................20 nitroglycerin cap cr 6.5 mg ................20 nitroglycerin cap cr 9 mg ...................20 nitroglycerin iv soln 100 mcg/ml in d5w ......................................................20 nitroglycerin iv soln 200 mcg/ml in d5w ......................................................20 nitroglycerin iv soln 400 mcg/ml in d5w ......................................................21 nitroglycerin lingual aerosol 400

mcg/spray ....................................... 21 nitroglycerin td patch 24hr 0.1 mg/hr . 21 nitroglycerin td patch 24hr 0.2 mg/hr . 21 nitroglycerin td patch 24hr 0.4 mg/hr . 21 nitroglycerin td patch 24hr 0.6 mg/hr . 21 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ..................................... 21 NITROSTAT SUB 0.3MG .................... 21 NITROSTAT SUB 0.4MG .................... 21 NITROSTAT SUB 0.6MG .................... 21 nizatidine cap 150 mg ..................... 136 nizatidine cap 300 mg ..................... 136 nizatidine oral soln 15 mg/ml........... 136 nora-be tab 0.35mg ......................... 83 NORDITROPIN INJ 10/1.5ML.............. 98 NORDITROPIN INJ 15/1.5ML.............. 98 NORDITROPIN INJ 30/3ML ................ 98 NORDITROPIN INJ 5/1.5ML ............... 98 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg .......................... 81 norethindrone acetate tab 5 mg ....... 129 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg ....................... 101 norethindrone tab 0.35 mg ................ 83 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ..................................... 81 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg ... 81 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ... 81 NORMOSOL -R INJ.......................... 116 NORPACE CAP 100MG CR .................. 23 NORPACE CAP 150MG CR .................. 23 nortrel tab 0.5/35 ............................ 81 nortrel tab 1/35 ............................... 81 nortrel tab 7/7/7 .............................. 82 nortriptyline hcl cap 10 mg ................ 36 nortriptyline hcl cap 25 mg ................ 36 nortriptyline hcl cap 50 mg ................ 36 nortriptyline hcl cap 75 mg ................ 36 nortriptyline hcl soln 10 mg/5ml ........ 36 NORTUSS-EX LIQ 200-20/5 ............... 85 NORVIR CAP 100MG ......................... 67 NORVIR SOL 80MG/ML...................... 67 NORVIR TAB 100MG ......................... 67 novarel inj 10000unt ........................ 98 NOVOLIN INJ 70/30.......................... 38 179

October 1, 2016

NOVOLIN N INJ U-100 .......................38 NOVOLIN R INJ U-100 .......................38 NOVOLOG INJ 100/ML .......................38 NOVOLOG INJ FLEXPEN .....................38 NOVOLOG INJ PENFILL ......................38 NOVOLOG MIX INJ 70/30 ...................38 NOVOLOG MIX INJ FLEXPEN ...............39 NOXAFIL SUS 40MG/ML .....................42 NOXAFIL TAB 100MG.........................42 NUCYNTA ER TAB 100MG ...................14 NUCYNTA ER TAB 150MG ...................14 NUCYNTA ER TAB 200MG ...................14 NUCYNTA ER TAB 250MG ...................14 NUCYNTA ER TAB 50MG.....................14 NUCYNTA TAB 100MG .......................14 NUCYNTA TAB 50MG .........................14 NUCYNTA TAB 75MG .........................14 NUEDEXTA CAP 20-10MG ................. 131 nulev tab 0.125mg .......................... 136 NULOJIX INJ 250MG ..........................71 NUPLAZID TAB 17MG ........................63 NUTROPIN AQ INJ 10MG/2ML .............98 NUTROPIN AQ INJ 20MG/2ML .............98 NUTROPIN AQ INJ NUSPIN 5 ..............98 NUTROPIN INJ 10MG .........................98 NUVARING MIS.................................82 nyamyc pow 100000 .........................90 nystatin cream 100000 unit/gm ..........90 nystatin oint 100000 unit/gm .............90 nystatin oral powder .........................42 nystatin susp 100000 unit/ml ........... 118 nystatin tab 500000 unit....................42 nystatin topical powder......................90 nystatin-triamcinolone cream 100000-0.1 unit/gm-% .......................................90 nystatin-triamcinolone oint 100000-0.1 unit/gm-% .......................................90 nystop pow 100000...........................90 O ocella tab 3-0.03mg ..........................82 OCTAGAM INJ 10/100ML .................. 126 OCTAGAM INJ 10GM........................ 126 OCTAGAM INJ 1GM ......................... 126 OCTAGAM INJ 2.5GM....................... 126 OCTAGAM INJ 20/200ML.................. 126 OCTAGAM INJ 25GM........................ 126 OCTAGAM INJ 2GM/20ML ................. 126

OCTAGAM INJ 5GM ......................... 126 OCTAGAM INJ 5GM/50ML ................ 126 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ......................................... 100 octreotide acetate inj 1000 mcg/ml (1 mg/ml) ......................................... 100 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ......................................... 100 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ......................................... 100 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ......................................... 100 ofloxacin ophth soln 0.3% ............... 123 ofloxacin otic soln 0.3% .................. 125 ofloxacin tab 200 mg ...................... 106 ofloxacin tab 300 mg ...................... 106 ofloxacin tab 400 mg ...................... 106 ogestrel tab ..................................... 82 olanzapine for im inj 10 mg ............... 64 olanzapine orally disintegrating tab 10 mg ...................................................... 64 olanzapine orally disintegrating tab 15 mg ...................................................... 65 olanzapine orally disintegrating tab 20 mg ...................................................... 65 olanzapine orally disintegrating tab 5 mg ...................................................... 64 olanzapine tab 10 mg ....................... 65 olanzapine tab 15 mg ....................... 65 olanzapine tab 2.5 mg ...................... 65 olanzapine tab 20 mg ....................... 65 olanzapine tab 5 mg ......................... 65 olanzapine tab 7.5 mg ...................... 65 olopatadine hcl nasal soln 0.6% ....... 121 olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 124 omega-3-acid ethyl esters cap 1 gm ... 44 omeprazole cap delayed release 10 mg .................................................... 137 omeprazole cap delayed release 20 mg .................................................... 137 omeprazole cap delayed release 40 mg .................................................... 137 OMNIFLEX DPR .............................. 113 OMNITROPE INJ 10/1.5ML ................. 99 OMNITROPE INJ 5.8MG ..................... 98 OMNITROPE INJ 5/1.5ML................... 99 180

October 1, 2016

OMONTYS INJ 10MG/ML .................. 110 OMONTYS INJ 20MG/2ML ................. 110 ONCASPAR INJ 750/ML ......................59 ondansetron hcl inj 4 mg/2ml (2 mg/ml) ......................................................41 ondansetron hcl inj 40 mg/20ml (2 mg/ml) ............................................41 ondansetron hcl oral soln 4 mg/5ml ....41 ondansetron hcl tab 24 mg ................41 ondansetron hcl tab 4 mg ..................41 ondansetron hcl tab 8 mg ..................41 ondansetron orally disintegrating tab 4 mg ..................................................41 ondansetron orally disintegrating tab 8 mg ..................................................41 ONETOUCH KIT ULTRA 2.................. 114 ONETOUCH KIT VERIO .................... 114 ONETOUCH MIS LANC DEV ............... 114 ONETOUCH MIS REMOTE ................. 114 ONETOUCH SOL VERIO .................... 114 ONETOUCH TES ULTRA BL ............... 114 ONETOUCH US MIS LANCETS ........... 114 ONFI SUS 2.5MG/ML .........................27 ONFI TAB 10MG ................................28 ONFI TAB 20MG ................................28 ONFI TAB 5MG .................................27 OPTICHAMBER MIS FACE MAS .......... 114 oralone pst 0.1% ............................ 118 ORAVIG TAB 50MG ......................... 118 ORENCIA CLCK INJ 125MG/ML ...........10 ORENCIA INJ 125MG/ML ....................10 ORENCIA INJ 250MG .........................10 ORFADIN CAP 10MG ........................ 100 ORFADIN CAP 2MG ......................... 100 ORFADIN CAP 5MG ......................... 100 ORFADIN SUS 4MG/ML .................... 100 ORKAMBI TAB 200-125 ................... 132 orphenadrine citrate inj 30 mg/ml ..... 120 orphenadrine citrate tab sr 12hr 100 mg .................................................... 120 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg ................................ 120 orsythia tab .....................................82 ORTHO COIL DPR KIT 100 ............... 113 ORTHO COIL DPR KIT 105 ............... 113 ORTHO COIL DPR KIT 50 ................. 113 ORTHO FLAT DPR KIT 55 ................. 113

ORTHO FLAT DPR KIT 60 ................. 113 ORTHO FLAT DPR KIT 65 ................. 113 ORTHO FLAT DPR KIT 70 ................. 113 ORTHO FLAT DPR KIT 75 ................. 113 ORTHO FLAT DPR KIT 80 ................. 113 ORTHO FLAT DPR KIT 85 ................. 113 ORTHO FLAT DPR KIT 90 ................. 113 ORTHO FLAT DPR KIT 95 ................. 113 ORTHO FLEX DPR 65MM .................. 113 ORTHO FLEX DPR 70MM .................. 113 ORTHO FLEX DPR 75MM .................. 113 ORTHO FLEX DPR 80MM .................. 113 ortho-est tab 0.625 ........................ 104 ortho-est tab 1.25 .......................... 105 oscimin sr tab 0.375mg .................. 136 oscimin sub 0.125mg...................... 136 oscimin tab 0.125mg ...................... 136 oscion clnsr lot 6% ........................... 87 OSMOPREP TAB 1.5GM ................... 112 oxacillin sodium for inj 1 gm ............ 128 oxacillin sodium for inj 10 gm .......... 128 oxacillin sodium for inj 2 gm ............ 128 oxaliplatin for iv inj 100 mg ............... 53 oxaliplatin for iv inj 50 mg ................. 53 oxaliplatin iv soln 100 mg/20ml ......... 53 oxaliplatin iv soln 50 mg/10ml ........... 53 oxandrolone tab 10 mg ..................... 17 oxandrolone tab 2.5 mg .................... 17 oxaprozin tab 600 mg ....................... 10 oxazepam cap 10 mg........................ 22 oxazepam cap 15 mg........................ 22 oxazepam cap 30 mg........................ 22 oxcarbazepine susp 300 mg/5ml (60 mg/ml) ........................................... 29 oxcarbazepine tab 150 mg ................ 29 oxcarbazepine tab 300 mg ................ 29 oxcarbazepine tab 600 mg ................ 29 oxiconazole nitrate cream 1% ............ 90 OXISTAT LOT 1% ............................. 90 oxybutynin chloride syrup 5 mg/5ml . 139 oxybutynin chloride tab 5 mg .......... 139 oxybutynin chloride tab sr 24hr 10 mg .................................................... 139 oxybutynin chloride tab sr 24hr 15 mg .................................................... 139 oxybutynin chloride tab sr 24hr 5 mg 139 oxycodone hcl cap 5 mg .................... 14 181

October 1, 2016

oxycodone hcl conc 100 mg/5ml (20 mg/ml) ............................................14 oxycodone hcl soln 5 mg/5ml .............14 oxycodone hcl tab 10 mg ...................14 oxycodone hcl tab 15 mg ...................14 oxycodone hcl tab 20 mg ...................14 oxycodone hcl tab 30 mg ...................14 oxycodone hcl tab 5 mg .....................14 oxycodone hcl tab er 12hr deter 10 mg ......................................................14 oxycodone hcl tab er 12hr deter 20 mg ......................................................14 oxycodone hcl tab er 12hr deter 40 mg ......................................................14 oxycodone hcl tab er 12hr deter 80 mg ......................................................15 oxycodone w/ acetaminophen soln 5-325 mg/5ml ...........................................16 oxycodone w/ acetaminophen tab 10-325 mg ..................................................16 oxycodone w/ acetaminophen tab 2.5-325 mg ..................................................16 oxycodone w/ acetaminophen tab 5-325 mg ..................................................16 oxycodone w/ acetaminophen tab 7.5-325 mg ..................................................16 oxycodone-aspirin tab 4.8355-325 mg 16 oxycodone-ibuprofen tab 5-400 mg.....16 OXYCONTIN TAB 10MG CR .................15 OXYCONTIN TAB 15MG CR .................15 OXYCONTIN TAB 20MG CR .................15 OXYCONTIN TAB 30MG CR .................15 OXYCONTIN TAB 40MG CR .................15 OXYCONTIN TAB 60MG CR .................15 OXYCONTIN TAB 80MG CR .................15 oxymorphone hcl tab 10 mg ...............15 oxymorphone hcl tab 5 mg ................15 oxymorphone hcl tab sr 12hr 10 mg ....15 oxymorphone hcl tab sr 12hr 15 mg ....15 oxymorphone hcl tab sr 12hr 20 mg ....15 oxymorphone hcl tab sr 12hr 30 mg ....15 oxymorphone hcl tab sr 12hr 40 mg ....15 oxymorphone hcl tab sr 12hr 5 mg .....15 oxymorphone hcl tab sr 12hr 7.5 mg ...15 OXYTROL DIS 3.9MG/24 .................. 139 P pacerone tab 100mg .........................23

pacerone tab 200mg......................... 23 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) ........................................... 60 paclitaxel iv conc 150 mg/25ml (6 mg/ml) ...................................................... 60 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ...................................................... 60 paclitaxel iv conc 300 mg/50ml (6 mg/ml) ...................................................... 60 paliperidone tab sr 24hr 1.5 mg ......... 63 paliperidone tab sr 24hr 3 mg ............ 63 paliperidone tab sr 24hr 6 mg ............ 63 paliperidone tab sr 24hr 9 mg ............ 63 pamidronate disodium for inj 30 mg ... 97 pamidronate disodium for inj 90 mg ... 97 pamidronate disodium iv soln 3 mg/ml 97 pamidronate disodium iv soln 9 mg/ml 97 PAMIDRONATE INJ 6MG/ML ............... 97 PANDA MASK MIS PEDIATRI ............ 114 PANRETIN GEL 0.1% ........................ 90 pantoprazole sodium ec tab 20 mg (base equiv) ........................................... 137 pantoprazole sodium ec tab 40 mg (base equiv) ........................................... 137 PARAGARD IUD T380A ...................... 82 parcaine sol 0.5% op ...................... 123 paricalcitol cap 1 mcg ..................... 100 paricalcitol cap 2 mcg ..................... 100 paricalcitol cap 4 mcg ..................... 100 paricalcitol iv soln 2 mcg/ml ............ 100 paricalcitol iv soln 5 mcg/ml ............ 100 paromomycin sulfate cap 250 mg ......... 8 paroxetine hcl tab 10 mg .................. 32 paroxetine hcl tab 20 mg .................. 32 paroxetine hcl tab 30 mg .................. 32 paroxetine hcl tab 40 mg .................. 32 paroxetine hcl tab sr 24hr 12.5 mg..... 32 paroxetine hcl tab sr 24hr 25 mg ....... 32 paroxetine hcl tab sr 24hr 37.5 mg..... 32 PASER GRA 4GM .............................. 52 PATADAY SOL 0.2% ....................... 124 PCE TAB 333MG EC ........................ 113 PCE TAB 500MG EC ........................ 113 pedia d-vite dro 400unit .................. 142 PEDIADERM HC KIT .......................... 93 PEDIADERM TA KIT .......................... 93 PEDIARIX INJ 0.5ML ....................... 135 182

October 1, 2016

PEDVAX HIB INJ ............................. 139 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ................................... 111 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ................................... 111 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ................................................ 111 PEGANONE TAB 250MG .....................30 PEGASYS INJ ....................................69 PEGASYS INJ 180MCG/M ...................69 PEGASYS INJ PROCLICK ....................69 PEGASYS KIT ...................................69 PEN G PROC INJ 600000 .................. 127 PENICILL GK/ INJ DEX 1MU .............. 127 PENICILL GK/ INJ DEX 2MU .............. 127 PENICILL GK/ INJ DEX 3MU .............. 127 penicillin g potassium for inj 20000000 unit ............................................... 127 penicillin g potassium for inj 5000000 unit .................................................... 127 penicillin g sodium for inj 5000000 unit .................................................... 127 penicillin v potassium for soln 125 mg/5ml .................................................... 127 penicillin v potassium for soln 250 mg/5ml .................................................... 127 penicillin v potassium tab 250 mg ..... 127 penicillin v potassium tab 500 mg ..... 127 PENTACEL INJ ................................ 135 PENTAM 300 INJ 300MG ....................18 pentoxifylline tab cr 400 mg ............. 108 PERFOROMIST NEB 20MCG ................25 perindopril erbumine tab 2 mg ...........46 perindopril erbumine tab 4 mg ...........46 perindopril erbumine tab 8 mg ...........46 periogard sol 0.12% ........................ 118 permethrin cream 5% .......................95 perphenazine tab 16 mg ....................66 perphenazine tab 2 mg ......................65 perphenazine tab 4 mg ......................65 perphenazine tab 8 mg ......................65 pfizerpen-g inj 20mu ....................... 127 phenadoz sup 25mg ..........................43 phenazopyridine hcl tab 100 mg ....... 108 phenazopyridine hcl tab 200 mg ....... 108 phenelzine sulfate tab 15 mg..............32 phenobarbital elixir 20 mg/5ml ......... 110

phenobarbital tab 100 mg ............... 111 phenobarbital tab 15 mg ................. 110 phenobarbital tab 16.2 mg .............. 110 phenobarbital tab 30 mg ................. 110 phenobarbital tab 32.4 mg .............. 110 phenobarbital tab 60 mg ................. 110 phenobarbital tab 64.8 mg .............. 110 phenobarbital tab 97.2 mg .............. 110 phenoxybenzamine hcl cap 10 mg ...... 47 phenylephrine hcl ophth soln 10% .... 123 phenylephrine hcl ophth soln 2.5% ... 123 phenytoin chew tab 50 mg ................ 30 phenytoin sodium extended cap 100 mg ...................................................... 30 phenytoin sodium extended cap 200 mg ...................................................... 30 phenytoin sodium extended cap 300 mg ...................................................... 30 phenytoin sodium inj 50 mg/ml ......... 30 phenytoin susp 125 mg/5ml .............. 30 PHISOHEX LIQ 3% ........................... 66 PHOSLYRA SOL .............................. 107 PHOSPHOLINE SOL 0.125%OP ......... 122 PHOTOFRIN INJ 75MG ...................... 59 physiolyte sol .................................. 71 physiosol sol irrigat .......................... 71 PICATO GEL 0.015% ........................ 90 PICATO GEL 0.05% .......................... 90 pilocarpine hcl tab 5 mg .................. 118 pilocarpine hcl tab 7.5 mg ............... 118 PILOPINE HS GEL 4% OP ................ 122 pimozide tab 1 mg ......................... 131 pimozide tab 2 mg ......................... 131 pindolol tab 10 mg ........................... 73 pindolol tab 5 mg ............................. 73 pioglitazone hcl tab 15 mg (base equiv) ...................................................... 39 pioglitazone hcl tab 30 mg (base equiv) ...................................................... 39 pioglitazone hcl tab 45 mg (base equiv) ...................................................... 39 pioglitazone hcl-glimepiride tab 30-2 mg ...................................................... 37 pioglitazone hcl-glimepiride tab 30-4 mg ...................................................... 37 pioglitazone hcl-metformin hcl tab 15-500 mg ................................................. 37 183

October 1, 2016

pioglitazone hcl-metformin hcl tab 15-850 mg ..................................................37 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) ................... 128 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ...................... 128 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) ............................... 128 piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) ...................... 128 piroxicam cap 10 mg .........................10 piroxicam cap 20 mg .........................10 PLASMA-LYTE INJ -148 .................... 116 PLASMA-LYTE INJ -A ....................... 116 PNEUMOVAX 23 INJ 25/0.5 .............. 139 podofilox soln 0.5% ..........................94 polycin oin op ................................. 123 poly-dex oin 0.1% op ...................... 124 polyethylene glycol 3350 oral packet . 112 polyethylene glycol 3350 oral powder 112 polymyxin b sulfate for inj 500000 unit 20 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 123 POMALYST CAP 1MG .........................59 POMALYST CAP 2MG .........................59 POMALYST CAP 3MG .........................59 POMALYST CAP 4MG .........................59 portia-28 tab ....................................82 potassium chloride cap cr 10 meq ..... 117 potassium chloride cap cr 8 meq ....... 117 potassium chloride inj 10 meq/100ml 117 potassium chloride inj 10 meq/50ml .. 117 potassium chloride inj 2 meq/ml ....... 117 potassium chloride inj 20 meq/100ml 117 potassium chloride inj 20 meq/50ml .. 117 potassium chloride inj 40 meq/100ml 117 potassium chloride microencapsulated crys cr tab 10 meq .......................... 117 potassium chloride microencapsulated crys cr tab 20 meq .......................... 117 potassium chloride oral soln 10% (20 meq/15ml)..................................... 117 potassium chloride oral soln 20% (40 meq/15ml)..................................... 117 potassium chloride tab cr 10 meq ..... 117 potassium chloride tab cr 20 meq (1500 mg) .............................................. 117

potassium chloride tab cr 8 meq (600 mg) .................................................... 117 potassium citrate tab cr 10 meq (1080 mg) .............................................. 107 potassium citrate tab cr 15 meq (1620 mg) .............................................. 107 potassium citrate tab cr 5 meq (540 mg) .................................................... 107 POTIGA TAB 200MG ......................... 29 POTIGA TAB 300MG ......................... 29 POTIGA TAB 400MG ......................... 29 POTIGA TAB 50MG ........................... 29 pr benzoyl liq 7% wash ..................... 87 pramipexole dihydrochloride tab 0.125 mg ................................................. 62 pramipexole dihydrochloride tab 0.25 mg ...................................................... 62 pramipexole dihydrochloride tab 0.5 mg ...................................................... 62 pramipexole dihydrochloride tab 0.75 mg ...................................................... 62 pramipexole dihydrochloride tab 1 mg 62 pramipexole dihydrochloride tab 1.5 mg ...................................................... 62 pramipexole dihydrochloride tab sr 24hr 0.375 mg ........................................ 62 pramipexole dihydrochloride tab sr 24hr 0.75 mg .......................................... 62 pramipexole dihydrochloride tab sr 24hr 1.5 mg............................................ 62 pramipexole dihydrochloride tab sr 24hr 2.25 mg .......................................... 62 pramipexole dihydrochloride tab sr 24hr 3 mg ................................................. 62 pramipexole dihydrochloride tab sr 24hr 3.75 mg .......................................... 62 pramipexole dihydrochloride tab sr 24hr 4.5 mg............................................ 62 pramox gel 1% ................................ 94 pravastatin sodium tab 10 mg ........... 45 pravastatin sodium tab 20 mg ........... 45 pravastatin sodium tab 40 mg ........... 45 pravastatin sodium tab 80 mg ........... 45 prazosin hcl cap 1 mg ....................... 48 prazosin hcl cap 2 mg ....................... 48 prazosin hcl cap 5 mg ....................... 48 PRED MILD SUS 0.12% OP .............. 124 184

October 1, 2016

PRED SOD PHO SOL 1% OP ............. 124 prednicarbate cream 0.1% .................93 prednicarbate oint 0.1% ....................93 prednisolone acetate ophth susp 1% . 124 prednisolone sod phos orally disintegr tab 10 mg (base eq) ...............................84 prednisolone sod phos orally disintegr tab 15 mg (base eq) ...............................84 prednisolone sod phos orally disintegr tab 30 mg (base eq) ...............................84 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ...................84 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) .........................84 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ........................85 prednisolone syrup 15 mg/5ml (usp solution equivalent)...........................85 PREDNISONE CON 5MG/ML ................85 prednisone oral soln 5 mg/5ml ...........85 prednisone tab 1 mg .........................85 prednisone tab 10 mg .......................85 prednisone tab 2.5 mg ......................85 prednisone tab 20 mg .......................85 prednisone tab 5 mg .........................85 prednisone tab 50 mg .......................85 prednisone tab therapy pack 10 mg (21) ......................................................85 prednisone tab therapy pack 10 mg (48) ......................................................85 prednisone tab therapy pack 5 mg (21) ......................................................85 prednisone tab therapy pack 5 mg (48) ......................................................85 pregnyl inj 10000unt .........................98 PREMARIN INJ 25MG ....................... 105 PREMARIN TAB 0.3MG ..................... 105 PREMARIN TAB 0.45MG ................... 105 PREMARIN TAB 0.625MG ................. 105 PREMARIN TAB 0.9MG ..................... 105 PREMARIN TAB 1.25MG ................... 105 PREMARIN VAG CRE 0.625MG .......... 141 prenatabs rx tab ............................. 119 PRENTIF MIS 22MM ......................... 113 PRENTIF MIS 25MM ......................... 113 PRENTIF MIS 28MM ......................... 113 PRENTIF MIS 31MM ......................... 113

PRENTIF MIS FITTING ..................... 113 PREPOPIK PAK ............................... 111 prevalite pow 4gm............................ 44 previfem tab .................................... 82 PREVNAR 13 INJ ............................ 139 PREZCOBIX TAB 800-150 .................. 67 PREZISTA SUS 100MG/ML ................. 67 PREZISTA TAB 150MG ...................... 68 PREZISTA TAB 400MG ...................... 68 PREZISTA TAB 600MG ...................... 68 PREZISTA TAB 75MG ........................ 68 PREZISTA TAB 800MG ...................... 68 PRIFTIN TAB 150MG ......................... 52 PRIMAQUINE TAB 26.3MG ................. 51 primidone tab 250 mg ...................... 29 primidone tab 50 mg ........................ 29 PRIMLEV TAB 10-300MG ................... 16 PRIMLEV TAB 5-300MG ..................... 16 PRIMLEV TAB 7.5-300 ....................... 16 PRIMSOL SOL 50MG/5ML .................. 18 PRIVIGEN INJ 10GRAMS ................. 126 PRIVIGEN INJ 20GRAMS ................. 126 PRIVIGEN INJ 40GRAMS ................. 126 PRIVIGEN INJ 5 GRAMS .................. 126 PROAIR HFA AER .............................. 25 probenecid tab 500 mg ................... 108 procainamide hcl inj 100 mg/ml ......... 23 PROCAINAMIDE INJ 500MG/ML .......... 23 prochlorperazine edisylate inj 5 mg/ml 66 prochlorperazine maleate tab 10 mg (base equivalent) ...................................... 66 prochlorperazine maleate tab 5 mg (base equivalent) ...................................... 66 prochlorperazine suppos 25 mg.......... 66 PROCRIT INJ 10000/ML................... 110 PROCRIT INJ 2000/ML .................... 110 PROCRIT INJ 20000/ML................... 110 PROCRIT INJ 3000/ML .................... 110 PROCRIT INJ 4000/ML .................... 110 PROCRIT INJ 40000/ML................... 110 procto-pak cre 1% ........................... 17 proctosol hc cre 2.5% ....................... 17 proctozone cre -hc 2.5% ................... 17 progesterone micronized cap 100 mg 129 progesterone micronized cap 200 mg 129 PROGLYCEM SUS 50MG/ML ............... 38 PROGRAF INJ 5MG/ML ...................... 71 185

October 1, 2016

PROLASTIN-C INJ 1000MG ............... 132 PROLIA SOL 60MG/ML .......................97 PROMACTA TAB 12.5MG .................. 110 PROMACTA TAB 25MG ..................... 110 PROMACTA TAB 50MG ..................... 110 PROMACTA TAB 75MG ..................... 110 prometh vc syp plain .........................85 prometh vc/ syp codeine....................85 promethazine hcl inj 25 mg/ml ...........43 promethazine hcl inj 50 mg/ml ...........43 promethazine hcl suppos 12.5 mg .......43 promethazine hcl suppos 25 mg .........43 promethazine hcl syrup 6.25 mg/5ml ..43 promethazine hcl tab 12.5 mg ............43 promethazine hcl tab 25 mg ...............44 promethazine hcl tab 50 mg ...............44 promethazine w/ codeine syrup 6.25-10 mg/5ml ...........................................85 promethazine-dm syrup 6.25-15 mg/5ml ......................................................85 promethegan sup 12.5mg ..................44 promethegan sup 25mg .....................44 promethegan sup 50mg .....................44 propafenone hcl cap sr 12hr 225 mg ...23 propafenone hcl cap sr 12hr 325 mg ...23 propafenone hcl cap sr 12hr 425 mg ...23 propafenone hcl tab 150 mg...............23 propafenone hcl tab 225 mg...............23 propafenone hcl tab 300 mg...............23 proparacaine hcl ophth soln 0.5% ..... 123 propranolol & hydrochlorothiazide tab 40-25 mg ........................................50 propranolol & hydrochlorothiazide tab 80-25 mg ........................................50 propranolol hcl cap sr 24hr 120 mg .....73 propranolol hcl cap sr 24hr 160 mg .....73 propranolol hcl cap sr 24hr 60 mg .......73 propranolol hcl cap sr 24hr 80 mg .......73 propranolol hcl inj 1 mg/ml ................73 propranolol hcl oral soln 20 mg/5ml ....73 propranolol hcl oral soln 40 mg/5ml ....73 propranolol hcl tab 10 mg ..................73 propranolol hcl tab 20 mg ..................73 propranolol hcl tab 40 mg ..................73 propranolol hcl tab 60 mg ..................73 propranolol hcl tab 80 mg ..................73 propylthiouracil tab 50 mg ............... 133

PROQUAD INJ ................................ 140 protriptyline hcl tab 10 mg ................ 36 protriptyline hcl tab 5 mg .................. 36 PROVENTIL AER HFA ........................ 25 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml .............................. 86 pyrazinamide tab 500 mg .................. 52 pyridostigmine bromide tab 60 mg ..... 52 pyridostigmine bromide tab cr 180 mg 52 Q QUADRAMET INJ .............................. 59 QUARTETTE TAB .............................. 82 quasense tab ................................... 82 quetiapine fumarate tab 100 mg ........ 65 quetiapine fumarate tab 200 mg ........ 65 quetiapine fumarate tab 25 mg .......... 65 quetiapine fumarate tab 300 mg ........ 65 quetiapine fumarate tab 400 mg ........ 65 quetiapine fumarate tab 50 mg .......... 65 QUFLORA PED CHW 0.25MG ............ 118 QUFLORA PED CHW 0.5MG .............. 118 QUFLORA PED CHW 1MG ................. 118 quflora ped dro 0.25mg .................. 118 quflora ped dro 0.5mg/ml ............... 118 quinapril hcl tab 10 mg ..................... 46 quinapril hcl tab 20 mg ..................... 46 quinapril hcl tab 40 mg ..................... 46 quinapril hcl tab 5 mg ....................... 46 quinapril-hydrochlorothiazide tab 10-12.5 mg ................................................. 50 quinapril-hydrochlorothiazide tab 20-12.5 mg ................................................. 50 quinapril-hydrochlorothiazide tab 20-25 mg ................................................. 50 quinine sulfate cap 324 mg ............... 51 quinine sulfate tab 260 mg ................ 51 QVAR AER 40MCG ............................ 24 QVAR AER 80MCG ............................ 24 R rabeprazole sodium ec tab 20 mg ..... 137 raloxifene hcl tab 60 mg ................... 99 ramipril cap 1.25 mg ........................ 46 ramipril cap 10 mg ........................... 47 ramipril cap 2.5 mg .......................... 46 ramipril cap 5 mg ............................. 47 RANEXA TAB 1000MG ....................... 20 RANEXA TAB 500MG ......................... 20 186

October 1, 2016

ranitidine hcl cap 150 mg ................. 137 ranitidine hcl cap 300 mg ................. 137 ranitidine hcl inj 1000 mg/40ml (25 mg/ml) .......................................... 137 ranitidine hcl inj 150 mg/6ml (25 mg/ml) .................................................... 137 ranitidine hcl inj 50 mg/2ml (25 mg/ml) .................................................... 137 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ........................................ 137 ranitidine hcl tab 150 mg ................. 137 ranitidine hcl tab 300 mg ................. 137 RAPAFLO CAP 4MG .......................... 108 RAPAFLO CAP 8MG .......................... 108 RAPAMUNE SOL 1MG/ML....................71 REBETOL SOL 40MG/ML .....................69 REBIF INJ 22/0.5 ............................ 131 REBIF INJ 44/0.5 ............................ 131 REBIF REBIDO INJ 22/0.5 ................ 131 REBIF REBIDO INJ 44/0.5 ................ 131 REBIF REBIDO INJ TITRATN ............. 131 REBIF TITRTN INJ PACK ................... 131 reclipsen tab ....................................82 RECOMBIVA HB INJ 10MCG/ML ......... 140 RECOMBIVA HB INJ 5MCG/0.5 .......... 140 RECOMBIVA-HB INJ 40MCG/ML ........ 140 RECTIV OIN 0.4% .............................17 REGONOL INJ 5MG/ML ......................52 REGRANEX GEL 0.01% ......................95 RELENZA MIS DISKHALE....................70 RELPAX TAB 20MG .......................... 115 RELPAX TAB 40MG .......................... 115 REMICADE INJ 100MG ..................... 106 REMODULIN INJ 10MG/ML .................77 REMODULIN INJ 1MG/ML ...................77 REMODULIN INJ 2.5MG/ML ................77 REMODULIN INJ 5MG/ML ...................77 RENVELA PAK 0.8GM ....................... 107 RENVELA PAK 2.4GM ....................... 107 RENVELA TAB 800MG ...................... 107 repaglinide tab 0.5 mg ......................39 repaglinide tab 1 mg .........................39 repaglinide tab 2 mg .........................39 repaglinide-metformin hcl tab 1-500 mg ......................................................37 repaglinide-metformin hcl tab 2-500 mg ......................................................37

REPATHA INJ 140MG/ML ................... 46 REPATHA PUSH INJ 420/3.5 .............. 46 REPATHA SURE INJ 140MG/ML........... 46 RESCRIPTOR TAB 100 MG ................. 68 RESCRIPTOR TAB 200MG .................. 68 RESTASIS EMU 0.05% .................... 123 RETROVIR INJ 10MG/ML ................... 68 REVLIMID CAP 10MG ........................ 70 REVLIMID CAP 15MG ........................ 70 REVLIMID CAP 2.5MG ....................... 70 REVLIMID CAP 20MG ........................ 70 REVLIMID CAP 25MG ........................ 70 REVLIMID CAP 5MG .......................... 70 REYATAZ CAP 100MG ....................... 68 REYATAZ CAP 150MG ....................... 68 REYATAZ CAP 200MG ....................... 68 REYATAZ CAP 300MG ....................... 68 REYATAZ POW 50MG ........................ 68 RHEUMATREX TAB 2.5MG .................... 8 ribasphere cap 200mg ...................... 69 ribasphere tab 200mg....................... 69 ribasphere tab 400mg....................... 69 ribasphere tab 600mg....................... 69 ribavirin cap 200 mg......................... 69 ribavirin tab 200 mg ......................... 69 rifabutin cap 150 mg ........................ 52 RIFAMATE CAP ................................. 52 rifampin cap 150 mg ........................ 52 rifampin cap 300 mg ........................ 52 rifampin for inj 600 mg ..................... 52 RIFATER TAB ................................... 52 riluzole tab 50 mg .......................... 121 rimantadine hydrochloride tab 100 mg 70 risedronate sodium tab 150 mg ......... 97 risedronate sodium tab 30 mg ........... 97 risedronate sodium tab 35 mg ........... 97 risedronate sodium tab 5 mg ............. 97 risedronate sodium tab delayed release 35 mg ................................................. 97 RISPERDAL INJ 12.5MG .................... 63 RISPERDAL INJ 25MG ....................... 63 RISPERDAL INJ 37.5MG .................... 63 RISPERDAL INJ 50MG ....................... 63 risperidone orally disintegrating tab 0.25 mg ................................................. 64 risperidone orally disintegrating tab 0.5 mg ................................................. 64 187

October 1, 2016

risperidone orally disintegrating tab 1 mg ......................................................64 risperidone orally disintegrating tab 2 mg ......................................................64 risperidone orally disintegrating tab 3 mg ......................................................64 risperidone orally disintegrating tab 4 mg ......................................................64 risperidone soln 1 mg/ml ...................64 risperidone tab 0.25 mg ....................64 risperidone tab 0.5 mg ......................64 risperidone tab 1 mg .........................64 risperidone tab 2 mg .........................64 risperidone tab 3 mg .........................64 risperidone tab 4 mg .........................64 RITUXAN INJ 100MG .........................55 RITUXAN INJ 500MG .........................55 rivastigmine tartrate cap 1.5 mg ....... 130 rivastigmine tartrate cap 3 mg ......... 130 rivastigmine tartrate cap 4.5 mg ....... 130 rivastigmine tartrate cap 6 mg ......... 130 rivastigmine td patch 24hr 13.3 mg/24hr .................................................... 130 rivastigmine td patch 24hr 4.6 mg/24hr .................................................... 130 rivastigmine td patch 24hr 9.5 mg/24hr .................................................... 130 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ....................... 115 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) ......................... 115 rizatriptan benzoate tab 10 mg (base equivalent) .................................... 115 rizatriptan benzoate tab 5 mg (base equivalent) .................................... 115 romycin oin op ............................... 123 ropinirole hydrochloride tab 0.25 mg ...62 ropinirole hydrochloride tab 0.5 mg .....62 ropinirole hydrochloride tab 1 mg .......62 ropinirole hydrochloride tab 2 mg .......62 ropinirole hydrochloride tab 3 mg .......62 ropinirole hydrochloride tab 4 mg .......62 ropinirole hydrochloride tab 5 mg .......62 rosadan cre 0.75% ...........................94 rosuvastatin calcium tab 10 mg ..........45 rosuvastatin calcium tab 20 mg ..........45 rosuvastatin calcium tab 40 mg ..........45

rosuvastatin calcium tab 5 mg ........... 45 ROTARIX SUS ................................ 140 ROTATEQ SOL................................ 140 roxicet tab 5-325mg ......................... 16 ROZEREM TAB 8MG ........................ 111 S SABRIL POW 500MG ......................... 30 SABRIL TAB 500MG .......................... 30 SAFYRAL TAB................................... 82 SAIZEN INJ 5MG .............................. 99 SAIZEN INJ 8.8MG ........................... 99 SAMSCA TAB 15MG ........................ 101 SAMSCA TAB 30MG ........................ 101 SANCUSO DIS 3.1MG ....................... 41 SANDIMMUNE SOL 100MG/ML ........... 71 SANDOSTATIN KIT LAR 10MG .......... 100 SANDOSTATIN KIT LAR 20MG .......... 100 SANDOSTATIN KIT LAR 30MG .......... 100 SANTYL OIN 250/GM ........................ 94 SAPHRIS SUB 10MG ......................... 65 SAPHRIS SUB 2.5MG ........................ 65 SAPHRIS SUB 5MG ........................... 65 SAVELLA MIS TITR PAK ................... 130 SAVELLA TAB 100MG ...................... 130 SAVELLA TAB 12.5MG ..................... 130 SAVELLA TAB 25MG........................ 130 SAVELLA TAB 50MG........................ 130 scalacort lot 2% ............................... 93 selegiline hcl cap 5 mg ...................... 62 selegiline hcl tab 5 mg ...................... 62 selenium sulfide lotion 2.5% .............. 91 selenium sulfide-pyrithione zinc in urea shampoo 2.25%............................... 91 SELZENTRY TAB 150MG .................... 68 SELZENTRY TAB 300MG .................... 68 SENSIPAR TAB 30MG ...................... 100 SENSIPAR TAB 60MG ...................... 100 SENSIPAR TAB 90MG ...................... 100 SEREVENT DIS AER 50MCG ............... 25 SEROQUEL XR TAB 150MG ................ 65 SEROQUEL XR TAB 200MG ................ 65 SEROQUEL XR TAB 300MG ................ 65 SEROQUEL XR TAB 400MG ................ 65 SEROQUEL XR TAB 50MG .................. 65 SEROSTIM INJ 4MG .......................... 99 SEROSTIM INJ 5MG .......................... 99 SEROSTIM INJ 6MG .......................... 99 188

October 1, 2016

sertraline hcl oral conc 20 mg/ml ........32 sertraline hcl tab 100 mg ...................33 sertraline hcl tab 25 mg .....................32 sertraline hcl tab 50 mg .....................33 SHUR-SEAL GEL 2% ........................ 141 sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) ..............................77 sildenafil citrate tab 20 mg .................77 silver sulfadiazine cream 1% ..............91 SIMPONI ARIA SOL 50MG/4ML ............ 8 SIMPONI INJ 100MG/ML ..................... 8 SIMPONI INJ 50/0.5ML ....................... 8 SIMULECT INJ 10MG .........................71 SIMULECT INJ 20MG .........................71 simvastatin tab 10 mg .......................45 simvastatin tab 20 mg .......................45 simvastatin tab 40 mg .......................45 simvastatin tab 5 mg.........................45 simvastatin tab 80 mg .......................45 sirolimus tab 0.5 mg .........................71 sirolimus tab 1 mg ............................71 sirolimus tab 2 mg ............................71 SKLICE LOT 0.5% .............................95 SKYLA IUD 13.5MG ...........................83 sm nicotine dis 14mg/24h ................ 132 sm nicotine dis 21mg ...................... 132 sm nicotine dis 7mg/24hr ................ 132 sm vitamin d tab 400unit ................. 142 sodium chloride flush iv soln 0.9% .... 118 sodium chloride inj 0.45% ............... 118 sodium chloride inj 0.9% ................. 118 sodium chloride inj 2.5 meq/ml (14.6%) .................................................... 118 sodium chloride inj 3% .................... 118 sodium chloride inj 4 meq/ml (23.4%) .................................................... 118 sodium chloride inj 5% .................... 118 sodium chloride irrigation soln 0.9% . 107 sodium chloride iv soln 0.9% ............ 118 sodium chloride soln nebu 0.9% .........86 sodium chloride soln nebu 10% ..........86 sodium chloride soln nebu 3% ............86 sodium chloride soln nebu 7% ............86 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) .................................. 116 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) .................................... 116

sodium fluoride chew tab 1 mg f (from 2.2 mg naf) ........................................ 116 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) .................................... 116 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) .............................................. 116 sodium fluoride tab 1 mg f (from 2.2 mg naf) .............................................. 116 sodium phenylbutyrate oral powder 3 gm/teaspoonful .............................. 100 sodium polystyrene sulfonate oral susp 15 gm/60ml ......................................... 71 sodium polystyrene sulfonate rectal susp 30 gm/120ml................................... 71 solia tab .......................................... 82 SOLU-CORTEF INJ 1000MG ............... 85 SOLU-CORTEF INJ 100MG ................. 85 SOLU-CORTEF INJ 250MG ................. 85 SOLU-CORTEF INJ 500MG ................. 85 SOLU-MEDROL INJ 2GM .................... 85 SOMATULINE INJ 120/.5ML ............. 100 SOMATULINE INJ 60/0.2ML ............. 100 SOMATULINE INJ 90/0.3ML ............. 100 SOMAVERT INJ 10MG ....................... 98 SOMAVERT INJ 15MG ....................... 98 SOMAVERT INJ 20MG ....................... 98 SOMAVERT INJ 25MG ....................... 98 SOMAVERT INJ 30MG ....................... 98 sorine tab 120mg ............................. 73 sorine tab 160mg ............................. 73 sorine tab 240mg ............................. 73 sorine tab 80mg ............................... 73 sotalol hcl (afib/afl) tab 120 mg ......... 73 sotalol hcl (afib/afl) tab 160 mg ......... 73 sotalol hcl (afib/afl) tab 80 mg ........... 73 SOTALOL HCL INJ 150/10ML.............. 73 sotalol hcl tab 120 mg ...................... 73 sotalol hcl tab 160 mg ...................... 73 sotalol hcl tab 240 mg ...................... 73 sotalol hcl tab 80 mg ........................ 73 SOVALDI TAB 400MG ....................... 69 spinosad susp 0.9% ......................... 95 SPIRIVA AER 1.25MCG ...................... 24 SPIRIVA CAP HANDIHLR ................... 24 SPIRIVA SPR RESPIMAT .................... 24 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................ 96 189

October 1, 2016

spironolactone tab 100 mg .................96 spironolactone tab 25 mg ..................96 spironolactone tab 50 mg ..................96 SPORANOX SOL 10MG/ML ..................42 sprintec 28 tab 28 day .......................82 SPRYCEL TAB 100MG ........................58 SPRYCEL TAB 140MG ........................58 SPRYCEL TAB 20MG ..........................58 SPRYCEL TAB 50MG ..........................58 SPRYCEL TAB 70MG ..........................58 SPRYCEL TAB 80MG ..........................58 sronyx tab .......................................82 ssd cre 1%.......................................91 sss 10-5 aer 10-5% ..........................87 stavudine cap 15 mg .........................68 stavudine cap 20 mg .........................68 stavudine cap 30 mg .........................68 stavudine cap 40 mg .........................68 stavudine for oral soln 1 mg/ml ..........68 STAVZOR CAP 125MG .......................31 STAVZOR CAP 250MG .......................31 STAVZOR CAP 500MG .......................31 STELARA INJ 45MG/0.5 .....................91 STELARA INJ 90MG/ML ......................91 STIVARGA TAB 40MG ........................58 STRATTERA CAP 100MG ..................... 6 STRATTERA CAP 10MG ....................... 6 STRATTERA CAP 18MG ....................... 6 STRATTERA CAP 25MG ....................... 6 STRATTERA CAP 40MG ....................... 6 STRATTERA CAP 60MG ....................... 6 STRATTERA CAP 80MG ....................... 6 streptomycin sulfate for inj 1 gm ......... 8 STRIBILD TAB ..................................68 SUBOXONE MIS 12-3MG ....................17 SUBOXONE MIS 2-0.5MG ...................17 SUBOXONE MIS 4-1MG......................17 SUBOXONE MIS 8-2MG......................17 SUCRAID SOL 8500/ML .....................95 sucralfate tab 1 gm ......................... 137 sulfacetamide sodium lotion 10% (acne) ......................................................87 sulfacetamide sodium ophth oint 10% .................................................... 123 sulfacetamide sodium ophth soln 10% .................................................... 123 sulfacetamide sodium w/ sulfur cleanser

10-2% ............................................ 88 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% ........................................ 88 sulfacetamide sodium w/ sulfur cleansing cloth 10-5% .................................... 88 sulfacetamide sodium w/ sulfur cleansing pad 10-4% ...................................... 88 sulfacetamide sodium w/ sulfur cream 10-2% ............................................ 88 sulfacetamide sodium w/ sulfur cream 10-5% ............................................ 88 sulfacetamide sodium w/ sulfur cream 9.8-4.8% ........................................ 88 sulfacetamide sodium w/ sulfur lotion 10-5% ............................................ 88 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% ........................................ 88 sulfacetamide sodium w/ sulfur wash 9-4% .............................................. 88 sulfacetamide sodium w/ sulfur wash 9-4.5% ........................................... 88 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ...................... 124 sulfacleanse sus 8-4% ...................... 88 SULFADIAZINE TAB 500MG ............. 132 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml................................ 18 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml................................ 18 sulfamethoxazole-trimethoprim tab 400-80 mg ...................................... 18 sulfamethoxazole-trimethoprim tab 800-160 mg .................................... 19 SULFAMYLON CRE 85MG/GM ............. 91 sulfasalazine tab 500 mg................. 106 sulfasalazine tab delayed release 500 mg .................................................... 106 sulindac tab 150 mg ......................... 10 sulindac tab 200 mg ......................... 10 sumatriptan nasal spray 20 mg/act .. 115 sumatriptan nasal spray 5 mg/act .... 115 sumatriptan succinate inj 4 mg/0.5ml 115 sumatriptan succinate inj 6 mg/0.5ml 115 sumatriptan succinate solution auto-injector 4 mg/0.5ml ................ 115 sumatriptan succinate solution auto-injector 6 mg/0.5ml ................ 115 190

October 1, 2016

sumatriptan succinate solution cartridge 4 mg/0.5ml ...................................... 115 sumatriptan succinate solution cartridge 6 mg/0.5ml ...................................... 115 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ......................... 115 sumatriptan succinate tab 100 mg .... 115 sumatriptan succinate tab 25 mg ...... 115 sumatriptan succinate tab 50 mg ...... 115 SUPRAX CAP 400MG ..........................79 SUPRAX CHW 100MG ........................79 SUPRAX CHW 200MG ........................79 SUPRAX SUS 500/5ML .......................79 SUPRAX TAB 400MG ..........................79 SUPREP BOWEL SOL PREP ............... 111 SUSTIVA CAP 200MG ........................68 SUSTIVA CAP 50MG ..........................68 SUSTIVA TAB 600MG ........................68 SUTENT CAP 12.5MG .........................58 SUTENT CAP 25MG ...........................58 SUTENT CAP 37.5MG .........................58 SUTENT CAP 50MG ...........................58 syeda tab 3-0.03mg ..........................82 symax fastab tab 0.125mg............... 136 symax-sl sub 0.125mg .................... 136 SYMLINPEN 60 INJ 1000MCG .............37 SYMLNPEN 120 INJ 1000MCG .............37 SYNAREL SOL 2MG/ML ......................99 SYNERA DIS 70-70MG .......................94 SYNRIBO INJ 3.5MG ..........................59 SYNTHROID TAB 100MCG ................ 134 SYNTHROID TAB 112MCG ................ 134 SYNTHROID TAB 125MCG ................ 134 SYNTHROID TAB 137MCG ................ 134 SYNTHROID TAB 150MCG ................ 134 SYNTHROID TAB 175MCG ................ 134 SYNTHROID TAB 200MCG ................ 134 SYNTHROID TAB 25MCG .................. 134 SYNTHROID TAB 300MCG ................ 134 SYNTHROID TAB 50MCG .................. 134 SYNTHROID TAB 75MCG .................. 134 SYNTHROID TAB 88MCG .................. 134 SYPRINE CAP 250MG .........................70 T TABLOID TAB 40MG ..........................54 TACLONEX SUS ................................93 tacrolimus cap 0.5 mg .......................71

tacrolimus cap 1 mg ......................... 71 tacrolimus cap 5 mg ......................... 71 tacrolimus oint 0.03% ...................... 94 tacrolimus oint 0.1% ........................ 94 TAFINLAR CAP 50MG ........................ 58 TAFINLAR CAP 75MG ........................ 58 TAMIFLU CAP 30MG .......................... 70 TAMIFLU CAP 45MG .......................... 70 TAMIFLU CAP 75MG .......................... 70 TAMIFLU SUS 6MG/ML ...................... 70 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 56 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 56 tamsulosin hcl cap 0.4 mg ............... 108 TARCEVA TAB 100MG ....................... 58 TARCEVA TAB 150MG ....................... 58 TARCEVA TAB 25MG ......................... 58 TARGRETIN GEL 1% ......................... 90 tazicef inj 1gm ................................. 79 tazicef inj 2gm ................................. 79 tazicef inj 6gm ................................. 79 TAZORAC CRE 0.05% ....................... 91 TAZORAC CRE 0.1% ......................... 91 TAZORAC GEL 0.05% ....................... 91 TAZORAC GEL 0.1% ......................... 91 taztia xt cap 120mg/24 ..................... 75 taztia xt cap 180mg/24 ..................... 75 taztia xt cap 240mg/24 ..................... 75 taztia xt cap 300mg/24 ..................... 75 taztia xt cap 360mg/24 ..................... 75 TEFLARO INJ 400MG ......................... 80 TEFLARO INJ 600MG ......................... 80 TEKTURNA TAB 150MG ..................... 51 TEKTURNA TAB 300MG ..................... 51 telmisartan tab 20 mg ...................... 47 telmisartan tab 40 mg ...................... 47 telmisartan tab 80 mg ...................... 47 telmisartan-amlodipine tab 40-10 mg . 50 telmisartan-amlodipine tab 40-5 mg ... 50 telmisartan-amlodipine tab 80-10 mg . 50 telmisartan-amlodipine tab 80-5 mg ... 50 telmisartan-hydrochlorothiazide tab 40-12.5 mg ..................................... 50 telmisartan-hydrochlorothiazide tab 80-12.5 mg ..................................... 50 telmisartan-hydrochlorothiazide tab 191

October 1, 2016

80-25 mg ........................................50 temazepam cap 15 mg .................... 111 temazepam cap 22.5 mg ................. 111 temazepam cap 30 mg .................... 111 temazepam cap 7.5 mg ................... 111 TEMODAR INJ 100MG ........................53 temozolomide cap 100 mg .................53 temozolomide cap 140 mg .................53 temozolomide cap 180 mg .................53 temozolomide cap 20 mg ...................53 temozolomide cap 250 mg .................53 temozolomide cap 5 mg .....................53 TENIPOSIDE INJ 50MG/5ML ...............60 TENIVAC INJ 5-2LF ......................... 135 terazosin hcl cap 1 mg.......................48 terazosin hcl cap 10 mg .....................48 terazosin hcl cap 2 mg.......................48 terazosin hcl cap 5 mg.......................48 terbinafine hcl tab 250 mg .................42 terbutaline sulfate inj 1 mg/ml ...........25 terbutaline sulfate tab 2.5 mg ............25 terbutaline sulfate tab 5 mg ...............25 terconazole vaginal cream 0.4% ....... 141 terconazole vaginal suppos 80 mg .... 141 testosterone cypionate im inj in oil 100 mg/ml .............................................17 testosterone cypionate im inj in oil 200 mg/ml .............................................17 testosterone enanthate im inj in oil 200 mg/ml .............................................17 testosterone td gel 10mg/act (2%) .....17 testosterone td gel 25 mg/2.5gm (1%)17 TET/DIP TOX INJ 2-2 LF................... 135 tetrabenazine tab 12.5 mg ............... 130 tetrabenazine tab 25 mg .................. 130 tetracycline hcl cap 250 mg.............. 133 tetracycline hcl cap 500 mg.............. 133 TEXACORT SOL 2.5% ........................93 tgq 50pse/3 syp brm/30dm ................86 THALOMID CAP 100MG ......................70 THALOMID CAP 150MG ......................70 THALOMID CAP 200MG ......................70 THALOMID CAP 50MG ........................70 THEO-24 CAP 100MG CR....................26 THEO-24 CAP 200MG CR....................26 THEO-24 CAP 300MG CR....................26 THEO-24 CAP 400MG ER ....................26

theochron tab 100mg cr .................... 26 theochron tab 200mg cr .................... 26 theochron tab 300mg cr .................... 26 theophylline soln 80 mg/15ml ............ 26 theophylline tab sr 12hr 450 mg ........ 26 theophylline tab sr 24hr 400 mg ........ 26 theophylline tab sr 24hr 600 mg ........ 26 THERACYS INJ ................................. 59 thioridazine hcl tab 10 mg ................. 66 thioridazine hcl tab 100 mg ............... 66 thioridazine hcl tab 25 mg ................. 66 thioridazine hcl tab 50 mg ................. 66 thiothixene cap 1 mg ........................ 66 thiothixene cap 10 mg ...................... 66 thiothixene cap 2 mg ........................ 66 thiothixene cap 5 mg ........................ 66 thrive gum 4mg mint ...................... 132 THYMOGLOBULN INJ 25MG................ 71 THYROLAR-1 TAB 60MG .................. 134 THYROLAR-1/2 TAB 30MG ............... 134 THYROLAR-1/4 TAB 15MG ............... 134 THYROLAR-2 TAB 120MG ................ 134 THYROLAR-3 TAB 180MG ................ 134 tiagabine hcl tab 2 mg ...................... 30 tiagabine hcl tab 4 mg ...................... 30 TICE BCG INJ .................................. 59 ticlopidine hcl tab 250 mg ............... 109 tilia fe tab ....................................... 82 timolol maleate ophth gel forming soln 0.25% .......................................... 122 timolol maleate ophth gel forming soln 0.5% ............................................ 122 timolol maleate ophth soln 0.25% .... 122 timolol maleate ophth soln 0.5% ...... 122 timolol maleate tab 10 mg ................ 73 timolol maleate tab 20 mg ................ 73 timolol maleate tab 5 mg .................. 73 TIMOPTIC OCU SOL 0.25% OP ......... 122 TIMOPTIC OCU SOL 0.5% OP........... 122 tinidazole tab 250 mg ....................... 18 tinidazole tab 500 mg ....................... 18 tis-u-sol sol ..................................... 71 TIVICAY TAB 10MG........................... 68 TIVICAY TAB 25MG........................... 68 TIVICAY TAB 50MG........................... 68 tizanidine hcl cap 2 mg (base equivalent) .................................................... 120 192

October 1, 2016

tizanidine hcl cap 4 mg (base equivalent) .................................................... 120 tizanidine hcl cap 6 mg (base equivalent) .................................................... 120 tizanidine hcl tab 2 mg (base equivalent) .................................................... 120 tizanidine hcl tab 4 mg (base equivalent) .................................................... 120 TOBRA/NACL INJ 80/0.9 ..................... 8 TOBRADEX OIN 0.3-0.1% ................ 124 tobramycin nebu soln 300 mg/5ml ....... 8 tobramycin ophth soln 0.3% ............ 123 tobramycin sulfate for inj 1.2 gm ......... 8 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) .......................... 8 tobramycin sulfate inj 10 mg/ml (base equivalent) ....................................... 8 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) .......................... 8 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) .......................... 8 tobramycin-dexamethasone ophth susp 0.3-0.1% ....................................... 124 TOBREX OIN 0.3% OP ..................... 123 TODAY SPONGE MIS ....................... 141 tolazamide tab 250 mg ......................40 tolazamide tab 500 mg ......................40 tolbutamide tab 500 mg ....................40 tolcapone tab 100 mg........................61 tolmetin sodium cap 400 mg ..............10 tolmetin sodium tab 200 mg ..............10 tolmetin sodium tab 600 mg ..............10 tolterodine tartrate cap sr 24hr 2 mg 139 tolterodine tartrate cap sr 24hr 4 mg 139 tolterodine tartrate tab 1 mg ............ 139 tolterodine tartrate tab 2 mg ............ 139 topiramate sprinkle cap 15 mg ...........29 topiramate sprinkle cap 25 mg ...........29 topiramate tab 100 mg ......................30 topiramate tab 200 mg ......................30 topiramate tab 25 mg........................29 topiramate tab 50 mg........................30 toposar inj 100/5ml ..........................60 toposar inj 20mg/ml..........................60 topotecan hcl for inj 4 mg ..................61 TOPOTECAN INJ 4MG/4ML .................61 TORISEL SOL 25MG/ML .....................58

TORSEMIDE INJ 20MG/2ML ............... 96 TORSEMIDE INJ 50MG/5ML ............... 96 torsemide tab 10 mg ........................ 96 torsemide tab 100 mg ...................... 96 torsemide tab 20 mg ........................ 96 torsemide tab 5 mg .......................... 96 TOVIAZ TAB 4MG ........................... 139 TOVIAZ TAB 8MG ........................... 139 TRACLEER TAB 125MG ...................... 77 TRACLEER TAB 62.5MG ..................... 77 TRADJENTA TAB 5MG ....................... 38 tramadol hcl tab 50 mg ..................... 15 tramadol hcl tab sr 24hr 100 mg ........ 15 tramadol hcl tab sr 24hr 200 mg ........ 15 tramadol hcl tab sr 24hr 300 mg ........ 15 trandolapril tab 1 mg ........................ 47 trandolapril tab 2 mg ........................ 47 trandolapril tab 4 mg ........................ 47 trandolapril-verapamil hcl tab cr 1-240 mg ................................................. 50 trandolapril-verapamil hcl tab cr 2-180 mg ................................................. 50 trandolapril-verapamil hcl tab cr 2-240 mg ................................................. 50 trandolapril-verapamil hcl tab cr 4-240 mg ................................................. 50 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) .................................. 110 tranexamic acid tab 650 mg ............ 110 TRANSDERM-SC DIS 1MG ................. 41 tranylcypromine sulfate tab 10 mg ..... 32 TRAVATAN Z DRO 0.004% .............. 124 trazodone hcl tab 100 mg ................. 33 trazodone hcl tab 150 mg ................. 33 trazodone hcl tab 300 mg ................. 33 trazodone hcl tab 50 mg ................... 33 TRECATOR TAB 250MG ..................... 52 TRELSTAR INJ 11.25MG .................... 56 TRELSTAR MIX INJ 22.5MG ............... 56 TRELSTAR MIX INJ 3.75MG ............... 56 tretinoin cap 10 mg .......................... 59 tretinoin cream 0.025% .................... 88 tretinoin cream 0.05% ...................... 88 tretinoin cream 0.1% ........................ 88 tretinoin gel 0.01% .......................... 88 tretinoin gel 0.025% ......................... 89 tretinoin gel 0.05% .......................... 88 193

October 1, 2016

tretinoin microsphere gel 0.04% .........89 tretinoin microsphere gel 0.1% ...........89 TRETIN-X CRE 0.0375% ....................88 TRETIN-X CRE 0.075% ......................88 TREXALL TAB 10MG ..........................54 TREXALL TAB 15MG ..........................54 TREXALL TAB 5MG ............................54 TREXALL TAB 7.5MG .........................54 triamcinolone acetonide aerosol soln 0.147 mg/gm ...................................93 triamcinolone acetonide cream 0.025% ......................................................93 triamcinolone acetonide cream 0.1% ...93 triamcinolone acetonide cream 0.5% ...93 triamcinolone acetonide dental paste 0.1% ............................................. 118 triamcinolone acetonide lotion 0.025% 93 triamcinolone acetonide lotion 0.1% ....93 triamcinolone acetonide nasal aerosol suspension 55 mcg/act .................... 121 triamcinolone acetonide oint 0.025%...93 triamcinolone acetonide oint 0.1% ......93 triamcinolone acetonide oint 0.5% ......93 triamterene & hydrochlorothiazide cap 37.5-25 mg ......................................96 triamterene & hydrochlorothiazide cap 50-25 mg ........................................96 triamterene & hydrochlorothiazide tab 37.5-25 mg ......................................96 triamterene & hydrochlorothiazide tab 75-50 mg ........................................96 TRIANEX OIN 0.05% .........................93 triderm cre 0.1% ..............................93 trifluoperazine hcl tab 1 mg................66 trifluoperazine hcl tab 10 mg ..............66 trifluoperazine hcl tab 2 mg................66 trifluoperazine hcl tab 5 mg................66 trifluridine ophth soln 1% ................ 123 trihexyphenidyl hcl elixir 0.4 mg/ml ....61 trihexyphenidyl hcl tab 2 mg ..............61 trihexyphenidyl hcl tab 5 mg ..............61 tri-linyah tab ....................................82 trimethobenzamide hcl cap 300 mg .....41 trimethobenzamide hcl inj 100 mg/ml .41 trimethoprim tab 100 mg ...................18 trimipramine maleate cap 100 mg.......36 trimipramine maleate cap 25 mg ........36

trimipramine maleate cap 50 mg ........ 36 trinessa tab ..................................... 82 TRIPEDIA SUS P/F .......................... 135 tri-previfem tab ............................... 82 TRISENOX SOL 10MG/10M ................ 59 tri-sprintec tab ................................. 82 TRIUMEQ TAB .................................. 68 tri-vit/fe dro /fl 0.25 ....................... 119 tri-vit/fl dro 0.25mg ....................... 119 tri-vit/fl dro 0.5mg ......................... 118 tri-vit/fluo dro 0.25mg .................... 119 tri-vita/fl dro 0.25mg ...................... 119 trivora-28 tab .................................. 82 tropicamide ophth soln 0.5% ........... 122 tropicamide ophth soln 1% .............. 122 trospium chloride cap sr 24hr 60 mg 139 trospium chloride tab 20 mg ............ 139 TRULICITY INJ 0.75/0.5 .................... 38 TRULICITY INJ 1.5/0.5 ...................... 38 TRUMENBA INJ .............................. 140 TRUVADA TAB 100-150 ..................... 68 TRUVADA TAB 133-200 ..................... 68 TRUVADA TAB 167-250 ..................... 68 TRUVADA TAB 200-300 ..................... 68 tussigon tab 5-1.5mg ....................... 85 TWINRIX INJ ................................. 140 TYBOST TAB 150MG ......................... 68 TYGACIL INJ 50MG ........................... 19 TYKERB TAB 250MG ......................... 58 TYSABRI INJ 300/15ML ................... 131 TYVASO START SOL 0.6MG/ML .......... 77 TYZEKA TAB 600MG ......................... 69 TYZINE PED DRO 0.05% ................. 121 TYZINE SOL 0.1% .......................... 121 U ULESFIA LOT 5% ............................. 95 ULORIC TAB 40MG ......................... 108 ULORIC TAB 80MG ......................... 108 unithroid tab 100mcg ..................... 135 unithroid tab 112mcg ..................... 135 unithroid tab 125mcg ..................... 135 unithroid tab 200mcg ..................... 135 unithroid tab 25mcg ....................... 134 unithroid tab 300mcg ..................... 135 unithroid tab 50mcg ....................... 134 unithroid tab 75mcg ....................... 135 unithroid tab 88mcg ....................... 135 194

October 1, 2016

univert tab 32mg ..............................41 ursodiol cap 300 mg ........................ 106 ursodiol tab 250 mg ........................ 106 ursodiol tab 500 mg ........................ 106 UVADEX INJ 20MCG/ML .....................59 V VAGIFEM TAB 10MCG ...................... 141 valacyclovir hcl tab 1 gm ...................70 valacyclovir hcl tab 500 mg ................70 VALCYTE SOL 50MG/ML .....................69 valganciclovir hcl tab 450 mg (base equivalent) ......................................69 valproate sodium inj 100 mg/ml .........31 valproate sodium syrup 250 mg/5ml (base equiv) .....................................31 valproic acid cap 250 mg ...................31 valsartan tab 160 mg ........................47 valsartan tab 320 mg ........................47 valsartan tab 40 mg ..........................47 valsartan tab 80 mg ..........................47 valsartan-hydrochlorothiazide tab 160-12.5 mg ....................................51 valsartan-hydrochlorothiazide tab 160-25 mg ..................................................51 valsartan-hydrochlorothiazide tab 320-12.5 mg ....................................51 valsartan-hydrochlorothiazide tab 320-25 mg ..................................................51 valsartan-hydrochlorothiazide tab 80-12.5 mg ......................................51 vancomycin hcl cap 125 mg ...............18 vancomycin hcl cap 250 mg ...............18 vancomycin hcl for inj 10 gm..............18 vancomycin hcl for inj 1000 mg ..........18 vancomycin hcl for inj 500 mg ............18 vancomycin hcl for inj 5000 mg ..........18 vandazole gel 0.75% ....................... 141 VAQTA INJ 25/0.5ML ....................... 140 VAQTA INJ 50UNT/ML ...................... 140 VARIVAX INJ .................................. 140 VCF VAGINAL AER CONTRACP .......... 141 VCF VAGINAL MIS CONTRACP .......... 141 velivet pak .......................................82 VELTIN GEL......................................89 VENCLEXTA TAB 100MG ....................55 VENCLEXTA TAB 10MG ......................55 VENCLEXTA TAB 50MG ......................55

VENCLEXTA TAB START PK ................ 55 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ...................................... 33 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ...................................... 33 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) ...................................... 33 venlafaxine hcl tab 100 mg ............... 33 venlafaxine hcl tab 25 mg ................. 33 venlafaxine hcl tab 37.5 mg .............. 33 venlafaxine hcl tab 50 mg ................. 33 venlafaxine hcl tab 75 mg ................. 33 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) ...................................... 33 venlafaxine hcl tab sr 24hr 225 mg (base equivalent) ...................................... 33 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) ...................................... 33 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) ...................................... 33 VENTAVIS SOL 10MCG/ML ................ 77 VENTAVIS SOL 20MCG/ML ................ 77 VENTOLIN HFA AER .......................... 25 verapamil hcl cap sr 24hr 100 mg ...... 75 verapamil hcl cap sr 24hr 120 mg ...... 75 verapamil hcl cap sr 24hr 180 mg ...... 75 verapamil hcl cap sr 24hr 200 mg ...... 75 verapamil hcl cap sr 24hr 240 mg ...... 75 verapamil hcl cap sr 24hr 300 mg ...... 75 verapamil hcl cap sr 24hr 360 mg ...... 75 verapamil hcl iv soln 2.5 mg/ml ......... 75 verapamil hcl tab 120 mg .................. 76 verapamil hcl tab 40 mg ................... 75 verapamil hcl tab 80 mg ................... 75 verapamil hcl tab cr 120 mg .............. 76 verapamil hcl tab cr 180 mg .............. 76 verapamil hcl tab cr 240 mg .............. 76 VERDESO AER 0.05% ....................... 93 VEREGEN OIN 15% .......................... 89 VERIPRED 20 SOL 20MG/5ML ............ 85 VESICARE TAB 10MG ...................... 139 VESICARE TAB 5MG........................ 139 vestura tab 3-0.02mg ....................... 82 VEXOL SUS 1% OP ......................... 124 VIBATIV INJ 250MG .......................... 18 VIBATIV INJ 750MG .......................... 18 VIBRAMYCIN SYP 50MG/5ML ........... 133 195

October 1, 2016

vicodin es tab 7.5-300 .......................16 vicodin hp tab 10-300mg ...................16 vicodin tab 5-300mg .........................16 VICTOZA INJ 18MG/3ML ....................38 VIDEX SOL 2GM ...............................68 VIDEX SOL 4GM ...............................68 VIGAMOX DRO 0.5% ....................... 123 VIIBRYD KIT ....................................33 VIIBRYD KIT STARTER .......................33 VIIBRYD TAB 10MG ...........................33 VIIBRYD TAB 20MG ...........................33 VIIBRYD TAB 40MG ...........................33 VIMPAT INJ 200MG/20 ......................30 VIMPAT SOL 10MG/ML .......................30 VIMPAT TAB 100MG ..........................30 VIMPAT TAB 150MG ..........................30 VIMPAT TAB 200MG ..........................30 VIMPAT TAB 50MG ............................30 VINBLASTINE INJ 10MG .....................60 vinblastine sulfate inj 1 mg/ml ...........60 vincasar pfs inj 1mg/ml .....................60 vincristine sulfate iv soln 1 mg/ml .......60 vinorelbine tartrate inj 10 mg/ml (base equiv) .............................................60 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) .........................60 VIOKACE TAB ...................................95 VIOKACE TAB 20880 .........................95 viorele tab .......................................82 VIRACEPT TAB 250MG .......................68 VIRACEPT TAB 625MG .......................68 VIRAZOLE INH 6GM ..........................70 VIREAD POW 40MG/GM .....................68 VIREAD TAB 150MG ..........................68 VIREAD TAB 200MG ..........................68 VIREAD TAB 250MG ..........................68 VIREAD TAB 300MG ..........................68 VISTOGARD PAK 10GM ......................40 vit a/c/d/fl dro 0.25mg .................... 119 VITAMIN D2 TAB 400UNIT ............... 142 VITAMIN D3 LIQ 1000UNIT .............. 142 VITAMIN D3 LIQ 1200UNIT .............. 142 VITEKTA TAB 150MG .........................69 VITEKTA TAB 85MG ...........................69 VIVITROL INJ 380MG ........................40 VOLTAREN GEL 1% ...........................89 voriconazole for susp 40 mg/ml ..........42

voriconazole tab 200 mg ................... 42 voriconazole tab 50 mg ..................... 42 VOTRIENT TAB 200MG ...................... 58 VPRIV INJ 400UNIT ........................ 109 VYTORIN TAB 10-10MG..................... 44 VYTORIN TAB 10-20MG..................... 44 VYTORIN TAB 10-40MG..................... 44 VYTORIN TAB 10-80MG..................... 44 VYVANSE CAP 10MG ........................... 5 VYVANSE CAP 20MG ........................... 5 VYVANSE CAP 30MG ........................... 5 VYVANSE CAP 40MG ........................... 5 VYVANSE CAP 50MG ........................... 5 VYVANSE CAP 60MG ........................... 6 VYVANSE CAP 70MG ........................... 6 W warfarin sodium tab 1 mg ................. 26 warfarin sodium tab 10 mg ................ 26 warfarin sodium tab 2 mg ................. 26 warfarin sodium tab 2.5 mg ............... 26 warfarin sodium tab 3 mg ................. 26 warfarin sodium tab 4 mg ................. 26 warfarin sodium tab 5 mg ................. 26 warfarin sodium tab 6 mg ................. 26 warfarin sodium tab 7.5 mg ............... 26 WELCHOL PAK 3.75GM ..................... 44 WELCHOL TAB 625MG ...................... 44 wera tab 0.5/35 ............................... 82 WIDE-SEAL DPR KIT 60 .................. 114 WIDE-SEAL DPR KIT 65 .................. 114 WIDE-SEAL DPR KIT 70 .................. 114 WIDE-SEAL DPR KIT 75 .................. 114 WIDE-SEAL DPR KIT 80 .................. 114 WIDE-SEAL DPR KIT 85 .................. 114 WIDE-SEAL DPR KIT 90 .................. 114 WIDE-SEAL DPR KIT 95 .................. 114 X XALKORI CAP 200MG ........................ 58 XALKORI CAP 250MG ........................ 58 XARELTO STAR TAB 15/20MG ............ 26 XARELTO TAB 10MG ......................... 26 XARELTO TAB 15MG ......................... 26 XARELTO TAB 20MG ......................... 26 XELJANZ TAB 5MG ............................. 8 XEOMIN INJ 100UNIT ..................... 121 XEOMIN INJ 200UNIT ..................... 121 XEOMIN INJ 50 UNIT ...................... 121 196

October 1, 2016

XGEVA INJ .......................................98 XIFAXAN TAB 200MG ........................18 XIFAXAN TAB 550MG ........................18 XOLEGEL GEL 2% .............................90 XOPENEX HFA AER ............................25 xulane dis 150-35 .............................82 XYREM SOL 500MG/ML .................... 129 Y YERVOY INJ 200MG ...........................55 YERVOY INJ 50MG ............................55 Z zafirlukast tab 10 mg ........................24 zafirlukast tab 20 mg ........................24 zaleplon cap 10 mg ......................... 111 zaleplon cap 5 mg ........................... 111 ZALTRAP INJ 100/4ML .......................55 ZALTRAP INJ 200/8ML .......................55 ZANOSAR INJ 1GM ............................53 ZANTAC INJ 50/50ML ...................... 137 ZANTAC TAB 25MG EF ..................... 137 zarah tab 3-0.03mg ..........................82 ZAVESCA CAP 100MG ...................... 109 zazole cre 0.4% .............................. 141 zazole cre 0.8% .............................. 141 zazole sup 80mg ............................. 141 ZELAPAR TAB 1.25MG .......................62 ZELBORAF TAB 240MG ......................58 ZEMAIRA INJ 1000MG ..................... 132 zenchent fe chw 0.4mg-35 .................82 zenchent tab ....................................82 ZENPEP CAP 10000UNT .....................95 ZENPEP CAP 15000UNT .....................95 ZENPEP CAP 20000UNT .....................95 ZENPEP CAP 25000UNT .....................95 ZENPEP CAP 3000UNIT ......................95 ZENPEP CAP 40000UNT .....................95 ZENPEP CAP 5000UNIT ......................95 zenzedi tab 15mg .............................. 6 zenzedi tab 2.5mg ............................. 6 zenzedi tab 20mg .............................. 6 zenzedi tab 30mg .............................. 6 zenzedi tab 7.5mg ............................. 6 ZETIA TAB 10MG ..............................45 ZIAGEN SOL 20MG/ML ......................69 ZIANA GEL .......................................89 zidovudine cap 100 mg ......................69 zidovudine syrup 10 mg/ml ................69

zidovudine tab 300 mg ..................... 69 ZINACEF INJ 750MG ......................... 78 ZINACEF/H20 INJ 1.5GM PB .............. 78 ZIOPTAN DRO 0.0015% .................. 124 ziprasidone hcl cap 20 mg ................. 63 ziprasidone hcl cap 40 mg ................. 63 ziprasidone hcl cap 60 mg ................. 63 ziprasidone hcl cap 80 mg ................. 63 ZIRGAN GEL 0.15% ........................ 123 ZMAX SUS 2GM ............................. 112 zoledronic acid inj conc for iv infusion 4 mg/5ml ........................................... 98 zoledronic acid iv soln 5 mg/100ml ..... 98 ZOLEDRONIC INJ 4MG/100 ............... 98 ZOLINZA CAP 100MG........................ 58 zolmitriptan orally disintegrating tab 2.5 mg ............................................... 115 zolmitriptan orally disintegrating tab 5 mg .................................................... 115 zolmitriptan tab 2.5 mg .................. 115 zolmitriptan tab 5 mg ..................... 115 zolpidem tartrate tab 10 mg ............ 111 zolpidem tartrate tab 5 mg .............. 111 zolpidem tartrate tab cr 12.5 mg ...... 111 zolpidem tartrate tab cr 6.25 mg ...... 111 ZOMETA INJ 4MG/100 ...................... 98 ZOMIG NASAL SPR 5MG .................. 115 ZOMIG SPR 2.5MG ......................... 115 zonisamide cap 100 mg .................... 30 zonisamide cap 25 mg ...................... 30 zonisamide cap 50 mg ...................... 30 ZONTIVITY TAB 2.08MG .................. 109 ZORBTIVE INJ 8.8MG........................ 99 ZORTRESS TAB 0.25MG .................... 71 ZORTRESS TAB 0.5MG ...................... 71 ZORTRESS TAB 0.75MG .................... 71 ZOSTAVAX INJ ............................... 140 ZOSYN SOL 2-0.25GM .................... 128 ZOSYN SOL 3-0.375G ..................... 128 ZOSYN SOL 4-0.50GM .................... 128 zovia 1/35e tab ................................ 82 zovia 1/50e tab ................................ 82 ZUPLENZ MIS 4MG ........................... 41 ZUPLENZ MIS 8MG ........................... 41 ZYCLARA CRE 3.75% ........................ 94 ZYCLARA PUMP CRE 2.5% ................. 94 ZYDELIG TAB 100MG ........................ 58 197

October 1, 2016

ZYDELIG TAB 150MG.........................58 ZYFLO CR TAB 600MG .......................24

ZYKADIA CAP 150MG ........................ 58 ZYTIGA TAB 250MG .......................... 56

198

NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE NOTICE: Our Company complies with applicable federal and state civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, disability, or sex. We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in various formats (large print, audio, accessible electronic formats, other formats), and language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator 601 Gaines Street, Little Rock, AR 72201 Phone: 1-844-662-2276; TDD: 1-844-662-2275 You can file a grievance in person, by mail, or by email. If you need help filing a grievance our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201 Phone: 1-800-368-1019; TDD: 1-800-537-7697 Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: Language assistance services, free of charge, are available to you. Call 1- 844-662-2276. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-662-2276 . 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-844-662-2276. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-844-662-2276 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844662-2276 번으로 전화해 주십시오.

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PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-844-662-2276. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-844-662-2276. .‫ العدد‬1-844-662-2276 ‫ دعوة‬.‫ تتوفر لك خدمات المساعدة اللغوية مجانا‬،‫ إذا كنت تتحدث العربية‬:‫مالحظة‬ ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-844-662-2276. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-844-662-2276. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-844-662-2276. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-844-662-2276. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-844-662-2276. 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-662-2276 まで、お電話にてご連絡ください。 ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-844-662-2276. 1-488-227-7722 ‫ يرجى االتصال‬.‫ والخدمات اللغوية المقدمة مجانا بالنسبة لك‬،‫ إذا كنت تتحدث باللغة الفارسية‬:‫مالحظة‬. ુ ના: જો તમે ગજ ુ રાતી બોલતા હો, તો નન:શલ્ુ ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે . ફોન કરો સચ 1-844-662-2276. ध्यान दें: यदद आप ह िं दी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-844-662-2276 पर कॉल करें । LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-844-662-2276. 1-488-227-7722 ‫ کال کريں‬.‫ زبان کی مدد کی خدمات بال معاوضہ دستياب مفت ہيں‬،‫ آپ اردو بولتے ہيں تو‬:‫انتباہ‬ ້ າພາສາ ລາວ, ການບ ່ໍ ເສ ໂປດຊາບ: ຖ ້ າວ ່ າທ ່ ານເວ ໍ ິ ລການຊ ່ ວຍເຫ ້ ານພາສາ, ໂດຍບ ່ າ, ຼື ອດ ັ ຽຄ ແມ ່ ນມ ້ ອມໃຫ ້ ທ ່ ານ. ໂທຣ 1-844-662-2276. ີ ພ LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-844-662-2276

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