2013 Comprehensive Formulary

List of Covered drugs

MedBlueRxSM (PDP) Please Read This documenT conTains infoRmaTion

abouT The dRugs we coveR in This Plan

BlueCross BlueShield of South Carolina contracts with the Federal Government Contract S5953

S5953_RX2013CF CMS Accepted 12783M-2013

MedBlue RxSM (PDP)

2013 Formulary (List of Covered Drugs)

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2014

MedBlue Rx is a stand-alone prescription drug plan with a Medicare contract

This document is available in alternate formats To get this information in other formats please call 1-888-645-6025 TTYTDD users should call 1-888-645-6023

Last Updated July 24 2013 S5953_RX2013CF CMS Accepted 12783M-2013

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association

1

What is the MedBlue Rx Formulary

A formulary is a list of covered drugs selected by MedBlue Rx in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MedBlue Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a MedBlue Rx network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary change

Generally if you are taking a drug on our 2013 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of formulary changes such as removing a drug from our formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we can ensure your safety

If we remove drugs from our formulary or add prior authorization quantity limits andor step therapy restrictions on a drug or move a drug to a higher cost-sharing tier we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug The enclosed formulary is current as of August 1 2013 To get updated information about the drugs covered by MedBlue Rx please visit our Web site at wwwscbluesmedadvantagecomrx13 or call Customer Service at 1-888-645- 6025 8 am to 8 pm Eastern Time Monday through Friday from October 1 2012 to February 14 2013 8 am to 8 pm seven days a week Beginning February 15 2013 our automated telephone system handles calls received after 8 pm and on Saturdays Sundays and holidays TTYTDD users should call 1-888-645-6023

In the event of mid-year non-maintenance formulary changes all impacted printed formularies published by the plan will reflect the changes from the date of the change In addition members are notified of formulary changes in their monthly Explanation of Benefits (EOB) and the plan website is updated with the current formularies

2

MedBlue RxSM (PDP)

2013 Formulary (List of Covered Drugs)

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take

Beneficiaries must use network pharmacies to access their prescription drug benefit Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2014

MedBlue Rx is a stand-alone prescription drug plan with a Medicare contract

This document is available in alternate formats To get this information in other formats please call 1-888-645-6025 TTYTDD users should call 1-888-645-6023

Last Updated July 24 2013 S5953_RX2013CF CMS Accepted 12783M-2013

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association

1

What is the MedBlue Rx Formulary

A formulary is a list of covered drugs selected by MedBlue Rx in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MedBlue Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a MedBlue Rx network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary change

Generally if you are taking a drug on our 2013 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of formulary changes such as removing a drug from our formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we can ensure your safety

If we remove drugs from our formulary or add prior authorization quantity limits andor step therapy restrictions on a drug or move a drug to a higher cost-sharing tier we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug The enclosed formulary is current as of August 1 2013 To get updated information about the drugs covered by MedBlue Rx please visit our Web site at wwwscbluesmedadvantagecomrx13 or call Customer Service at 1-888-645- 6025 8 am to 8 pm Eastern Time Monday through Friday from October 1 2012 to February 14 2013 8 am to 8 pm seven days a week Beginning February 15 2013 our automated telephone system handles calls received after 8 pm and on Saturdays Sundays and holidays TTYTDD users should call 1-888-645-6023

In the event of mid-year non-maintenance formulary changes all impacted printed formularies published by the plan will reflect the changes from the date of the change In addition members are notified of formulary changes in their monthly Explanation of Benefits (EOB) and the plan website is updated with the current formularies

2

What is the MedBlue Rx Formulary

A formulary is a list of covered drugs selected by MedBlue Rx in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program MedBlue Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a MedBlue Rx network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary change

Generally if you are taking a drug on our 2013 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released Other types of formulary changes such as removing a drug from our formulary will not affect members who are currently taking the drug It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan except for cases in which you can save additional money or we can ensure your safety

If we remove drugs from our formulary or add prior authorization quantity limits andor step therapy restrictions on a drug or move a drug to a higher cost-sharing tier we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 60-day supply of the drug If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug The enclosed formulary is current as of August 1 2013 To get updated information about the drugs covered by MedBlue Rx please visit our Web site at wwwscbluesmedadvantagecomrx13 or call Customer Service at 1-888-645- 6025 8 am to 8 pm Eastern Time Monday through Friday from October 1 2012 to February 14 2013 8 am to 8 pm seven days a week Beginning February 15 2013 our automated telephone system handles calls received after 8 pm and on Saturdays Sundays and holidays TTYTDD users should call 1-888-645-6023

In the event of mid-year non-maintenance formulary changes all impacted printed formularies published by the plan will reflect the changes from the date of the change In addition members are notified of formulary changes in their monthly Explanation of Benefits (EOB) and the plan website is updated with the current formularies

2

How do I use the Formulary

There are two ways to find your drug within the formulary

Medical Condition The formulary begins on page 7 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascularrdquo If you know what your drug is used for look for the category name in the list that begins on page 7 Then look under the category name for your drug

Alphabetical Listing If you are not sure what category to look under you should look for your drug in the Index that begins on page 53 The Index provides an alphabetical list of all of the drugs included in this document Both brand-name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will 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

What are generic drugs

MedBlue Rx covers both brand-name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug Generally generic drugs cost less than brand-name drugs

Are there any restrictions on my coverage

Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include

bull Prior Authorization MedBlue Rx requires you or your physician to get prior authorization for certain drugs This means that you will need to get approval from MedBlue Rx before you fill your prescriptions If you donrsquot get approval MedBlue Rx may not cover the drug

bull Quantity Limits For certain drugs MedBlue Rx limits the amount of the drug that MedBlue Rx will cover For example MedBlue Rx provides 30 tablets per prescription for LUNESTA This may be in addition to a standard one-month or three-month supply

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7 You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at wwwscbluesmedadvantagecomrx13

3

You can ask MedBlue Rx to make an exception to these restrictions or limits See the section ldquoHow do I request an exception to the MedBlue Rx formularyrdquo below for information about how to request an exception

What if my drug is not in the Formulary

If your drug is not included in this formulary you should first contact Customer Service and confirm that your drug is not covered If you learn that MedBlue Rx does not cover your drug you have two options

bull You can ask Customer Service for a list of similar drugs that are covered by MedBlue Rx When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by MedBlue Rx

bull You can ask MedBlue Rx to make an exception and cover your drug See below for information about how to request an exception

How do I request an exception to the MedBlue Rx Formulary

You can ask MedBlue Rx to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

bull You can ask us to cover your drug even if it is not on our formulary

bull You can ask us to waive coverage restrictions or limits on your drug For example for certain drugs MedBlue Rx limits the amount of the drug that we will cover If your drug has a quantity limit you can ask us to waive the limit and cover more

bull You can ask us to provide a higher level of coverage for your drug If your drug is contained in one of the higher tiers subject to the tiering exceptions process you can ask us to cover it at the cost-sharing amount that applies to drugs in a preferred tier instead This would lower the amount you must pay for your drug Please note if we grant your request to cover a drug that is not on our formulary you may not ask us to provide a higher level of coverage for the drug Also you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier

Generally MedBlue Rx will only approve your request for an exception if the alternative drugs included on the planrsquos formulary the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects

You should contact us to ask us for an initial coverage decision for a formulary tiering or utilization- restriction exception When you are requesting a formulary tiering or utilization-restriction exception you should submit a statement from your physician supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos or prescribing physicianrsquos supporting statement You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get your prescriberrsquos or prescribing physicianrsquos supporting statement

4

What do I do before I can talk to my doctor about changing my drugs or requesting an exception

As a new or continuing member in our plan you may be taking drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your doctor to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy After your first 31-day supply we will not pay for these drugs even if you have been a member of the plan less than 90 days

If you are a resident of a long-term care facility we will allow you to refill your prescription until we have provided you with a 91-day transition supply consistent with the dispensing increment (unless you have a prescription written for fewer days) We will cover more than one refill of these drugs for the first 90 days you are a member of our plan If you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception

For members experiencing a level-of-care change in which the member changes from one treatment setting to another the plan waives early refill edits for 90 days after the level-of-care change The plan also provides a transition fill of at least a 31-day supply of non-formulary drugs or medications subject to utilization-management edits

For more information

For more detailed information about your MedBlue Rx prescription drug coverage please review your Evidence of Coverage and other plan materials

If you have questions about MedBlue Rx please call Customer Service at 1-888-645-6025 8 am to 8 pm Eastern Time Monday through Friday from October 1 2012 to February 14 2013 8 am to 8 pm seven days a week Beginning February 15 2013 our automated telephone system handles calls received after 8 pm and on Saturdays Sundays and holidays TTYTDD users should call 1-888-645- 6023 Or visit wwwscbluesmedadvantagecomrx13

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTYTDD users should call 1-877-486-2048 Or visit wwwmedicaregov

5

What do I do before I can talk to my doctor about changing my drugs or requesting an exception

As a new or continuing member in our plan you may be taking drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your doctor to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy After your first 31-day supply we will not pay for these drugs even if you have been a member of the plan less than 90 days

If you are a resident of a long-term care facility we will allow you to refill your prescription until we have provided you with a 91-day transition supply consistent with the dispensing increment (unless you have a prescription written for fewer days) We will cover more than one refill of these drugs for the first 90 days you are a member of our plan If you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception

For members experiencing a level-of-care change in which the member changes from one treatment setting to another the plan waives early refill edits for 90 days after the level-of-care change The plan also provides a transition fill of at least a 31-day supply of non-formulary drugs or medications subject to utilization-management edits

For more information

For more detailed information about your MedBlue Rx prescription drug coverage please review your Evidence of Coverage and other plan materials

If you have questions about MedBlue Rx please call Customer Service at 1-888-645-6025 8 am to 8 pm Eastern Time Monday through Friday from October 1 2012 to February 14 2013 8 am to 8 pm seven days a week Beginning February 15 2013 our automated telephone system handles calls received after 8 pm and on Saturdays Sundays and holidays TTYTDD users should call 1-888-645- 6023 Or visit wwwscbluesmedadvantagecomrx13

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTYTDD users should call 1-877-486-2048 Or visit wwwmedicaregov

5

MedBlue Rxrsquos Formulary

The formulary that begins on the next page provides coverage information about some of the drugs covered by MedBlue Rx If you have trouble finding your drug in the list turn to the Index that begins on page 53

The first column of the chart lists the drug name Brand-name drugs are capitalized (eg LIPITOR) and generic drugs are listed in lower-case italics (eg furosemide)

The information in the RequirementsLimits column tells you if MedBlue Rx has any special requirements for coverage of your drug

bull ldquoPArdquo means prior authorization is required bull ldquoQLrdquo means quantity limits bull ldquoSTrdquo means step therapy applies bull ldquoBDrdquo means Medicare Part B versus Medicare Part D determination bull ldquoLArdquo means limited-access drug available only at certain pharmacies

6

Drug Name Copayment Coinsurance

RequirementsLimits

ANALGESICS GOUT allopurinol sodium $5 allopurinol tab $5 colchicine w probenecid $5 COLCRYS $40 QL (60 tabs 30 days) probenecid $5 ULORIC $40 ST NARCOTIC ANALGESICS acetaminophen w codeine SOLN $5 QL (5000 mL 30 days) acetaminophen w codeine TABS $5 QL (400 tabs 30 days) butorphanol tartrate SOLN 1mgml

2mgml $5

co-gesic $5 QL (240 tabs 30 days) hydrocoapap sol 75-500 $5 QL (3600 mL 30 days) hydrocoapap tab 25-500 $5 QL (240 tabs 30 days) hydrocoapap tab 5-325mg $5 QL (360 tabs 30 days) hydrocoapap tab 5-500mg $5 QL (240 tabs 30 days) hydrocoapap tab 75-325 $5 QL (360 tabs 30 days) hydrocoapap tab 75-500 $5 QL (240 tabs 30 days) hydrocoapap tab 75-650 $5 QL (185 tabs 30 days) hydrocoapap tab 75-750 $5 QL (160 tabs 30 days) hydrocoapap tab 10-325mg $5 QL (360 tabs 30 days) hydrocoapap tab 10-500mg $5 QL (240 tabs 30 days) hydrocoapap tab 10-650mg $5 QL (185 tabs 30 days) hydrocoapap tab 10-660mg $5 QL (181 tabs 30 days) hydrocoapap tab 10-750mg $5 QL (160 tabs 30 days) hydrocodone-ibuprofen $5 QL (150 tabs 30 days) stagesic 5500 $5 QL (240 caps 30 days) NARCOTIC ANALGESICS CII astramorph $5 BD AVINZA $80 QL (60 ea 30 days) DILAUDID-5 $40 DURAMORPH $5 BD endocet 5325 $5 QL (360 tabs 30 days) endocet 75325 $5 QL (360 tabs 30 days) endocet 75500 $5 QL (240 tabs 30 days) endocet 10325 $5 QL (360 tabs 30 days) endocet 10650 $5 QL (180 tabs 30 days) ENDODAN $5 QL (360 tabs 30 days) EXALGO $40 QL (60 ea 30 days) fentanyl 12mcghr 25mcghr $5 QL (10 ea 30 days) fentanyl 50mcghr 75mcghr

100mcghr $5 QL (10 ea 30 days) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

7

Drug Name Copayment RequirementsLimits Coinsurance

fentanyl citrate LPOP 25 QL (120 lpop 30 days) PA

hydromorphon inj 10mgml $5 BD hydromorphone hcl LIQD TABS $5

KADIAN $40 QL (60 caps 30 days) LAZANDA 25 QL (8 bottles 30 days)

PA methadone hcl CONC $5 methadone hcl SOLN 5mg5ml $5

10mg5ml methadone hcl TABS $5 QL (240 tabs 30 days)

methadose TABS $5 QL (240 tabs 30 days) MORPHINE SULFATE SOLN 4mgml $5 BD

8mgml 10mgml 15mgml morphine sulfate SOLN 5mgml $5 BD

1mgml MORPHINE SULFATE TABS $5 QL (180 tabs 30 days)

morphine sulfate ext-rel tab 15mg $5 QL (90 tabs 30 days) 30mg 60mg 100mg

morphine sulfate ext-rel tab 200mg $5 QL (60 tabs 30 days) MORPHINE SULFATE ORAL SOL $5

OXYCODONE HCL CAPS $5 QL (180 caps 30 days) OXYCODONE HCL CONC SOLN $5

oxycodone hcl TABS $5 QL (180 tabs 30 days) oxycodone w acetaminophen 25-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 5-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 5-500mg $5 QL (240 caps 30 days) oxycodone w acetaminophen 75-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 75-500mg $5 QL (240 tabs 30 days) oxycodone w acetaminophen 10-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 10-650mg $5 QL (180 tabs 30 days)

oxycodone-aspirin $5 QL (360 tabs 30 days) roxicet SOLN $40 QL (1800 mL 30 days)

NON-NARCOTIC ANALGESICS tramadol hcl TABS $5 QL (240 tabs 30 days)

tramadol-acetaminophen $5 QL (240 tabs 30 days) NSAIDS

CELEBREX 50mg 100mg 200mg $40 QL (60 caps 30 days) CELEBREX 400mg $40 QL (60 caps 30 days)

PA diclofenac potassium $5 diclofenac sodium TB24 TBEC $5

diflunisal $5 etodolac CAPS TABS $5 etodolac er $5

flurbiprofen TABS $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 8

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ibuprofen SUSP $5 ibuprofen TABS 400mg 600mg 800mg $5 ketoprofen CAPS CP24 $5 MELOXICAM SUSP 75 MG5ML $5 meloxicam tabs $5 nabumetone TABS $5 naproxen SUSP TABS TBEC $5 naproxen sodium TABS 275mg 550mg $5 oxaprozin $5 piroxicam CAPS $5 sulindac TABS $5

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth) $5

ANTI-INFECTIVES ANTIBACTERIALS amikacin sulfate SOLN 1gm4ml

50mgml $5

amoxicillin $5 amoxicillin amp pot clavulanate $5 ampicillin $5 ampicillin amp sulbactam sodium $5 ampicillin inj $5 AVELOX $40 AVELOX ABC PACK $40 azithromycin SOLR 500mg $5 azithromycin SUSR $5 azithromycin TABS $5 BICILLIN C-R $80 BICILLIN L-A $80 cefaclor $5 cefaclor er $40 cefadroxil $5 cefazolin inj $5 cefazolindextrose $40 cefdinir $5 cefepime hcl $5 cefotaxime sodium $5 cefoxitin sodium $5 cefpodoxime proxetil $5 cefprozil $5 ceftazidime SOLR 1gm 2gm 6gm $5 CEFTAZIDIMEDEXTROSE $40 ceftriaxone sodium SOLR $5 cefuroxime axetil TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

9

Drug Name Copayment Coinsurance

RequirementsLimits

cefuroxime sodium 15gm 75gm 750mg$5 cephalexin CAPS 250mg 500mg $5 cephalexin SUSR $5 CIPRO SUSR $80 ciprofloxacin er $5 ciprofloxacin hcl TABS $5 ciprofloxacin in d5w $5 ciprofloxacn inj $5 clarithromycin SUSR TABS TB24 $5 dicloxacillin sodium $5 DIFICID 25 ST doxycycl hyc inj $5 doxycycline (monohydrate) TABS $5 doxycycline hyclate CAPS TABS $5 ees $5 EES GRANULES $40 ery-tab $40 ERYPED 200 $40 ERYPED 400 $40 erythrocin stearate $5 erythromycin base TABS $5 erythromycin ethylsuccinate $5 gentamicin in saline 09 mgml $80 gentamicin in saline 14 mgml $80 gentamicin in saline 60mg $5 gentamicin in saline 80mg $5 gentamicin in saline 100mg $5 gentamicin sulfate SOLN $5 levofloxacin TABS $5 levofloxacin in d5w $5 levofloxacin inj 25mgml $5 levofloxacin oral soln 25 mgml $5 minocycline hcl CAPS $5 nafcillin sodium 1gm 10gm $5 neomycin sulfate TABS $5 oxacillin sodium 1gm 10gm $5 paromomycin sulfate CAPS $5 PENICILLIN G POT IN DEXTROSE $40 penicillin g procaine $40 penicillin g sodium $5 penicillin v potassium $5 penicilln gk inj 5mu $5 piperacillin sodium-tazobactam sodium $5 streptomycin sulfate SOLR $5 sulfadiazine TABS $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

10

Drug Name Copayment Coinsurance

RequirementsLimits

SUPRAX CAPS $40 suprax CHEW $80 suprax SUSR TABS $40 SUPRAX SUS 5005ML $40 tazicef vial $5 tetracycline hcl CAPS $5 TIMENTIN SOLR $80 tobramycin sulfate SOLN 10mgml

80mg2ml $5

tobramycin sulfate in saline $40 VIBRAMYCIN SYRUP $40 ZMAX $40 ANTIFUNGALS ABELCET 25 BD AMBISOME 25 BD amphotericin b SOLR $5 BD CANCIDAS 25 ERAXIS 100mg 25 fluconazole SUSR TABS $5 fluconazole in dextrose $5 flucytosine CAPS 25 griseofulvin microsize $5 griseofulvin ultramicrosize $5 itraconazole CAPS $5 PA ketoconazole TABS $5 MYCAMINE 25 NOXAFIL 25 nystatin TABS $5 terbinafine hcl TABS $5 QL (90 tabs year) VFEND SUSR 25 voriconazole TABS 25 VORICONAZOLE INJ 200MG $5 ANTIMALARIALS atovaquone-proguanil hcl $5 chloroquine phosphate TABS $5 COARTEM $80 DARAPRIM $80 mefloquine hcl $5 PRIMAQUINE PHOSPHATE TABS $40 ANTIRETROVIRAL AGENTS abacavir sulfate $5 APTIVUS 25 ATRIPLA 25 COMPLERA 25 CRIXIVAN $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

11

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

ANALGESICS GOUT allopurinol sodium $5 allopurinol tab $5 colchicine w probenecid $5 COLCRYS $40 QL (60 tabs 30 days) probenecid $5 ULORIC $40 ST NARCOTIC ANALGESICS acetaminophen w codeine SOLN $5 QL (5000 mL 30 days) acetaminophen w codeine TABS $5 QL (400 tabs 30 days) butorphanol tartrate SOLN 1mgml

2mgml $5

co-gesic $5 QL (240 tabs 30 days) hydrocoapap sol 75-500 $5 QL (3600 mL 30 days) hydrocoapap tab 25-500 $5 QL (240 tabs 30 days) hydrocoapap tab 5-325mg $5 QL (360 tabs 30 days) hydrocoapap tab 5-500mg $5 QL (240 tabs 30 days) hydrocoapap tab 75-325 $5 QL (360 tabs 30 days) hydrocoapap tab 75-500 $5 QL (240 tabs 30 days) hydrocoapap tab 75-650 $5 QL (185 tabs 30 days) hydrocoapap tab 75-750 $5 QL (160 tabs 30 days) hydrocoapap tab 10-325mg $5 QL (360 tabs 30 days) hydrocoapap tab 10-500mg $5 QL (240 tabs 30 days) hydrocoapap tab 10-650mg $5 QL (185 tabs 30 days) hydrocoapap tab 10-660mg $5 QL (181 tabs 30 days) hydrocoapap tab 10-750mg $5 QL (160 tabs 30 days) hydrocodone-ibuprofen $5 QL (150 tabs 30 days) stagesic 5500 $5 QL (240 caps 30 days) NARCOTIC ANALGESICS CII astramorph $5 BD AVINZA $80 QL (60 ea 30 days) DILAUDID-5 $40 DURAMORPH $5 BD endocet 5325 $5 QL (360 tabs 30 days) endocet 75325 $5 QL (360 tabs 30 days) endocet 75500 $5 QL (240 tabs 30 days) endocet 10325 $5 QL (360 tabs 30 days) endocet 10650 $5 QL (180 tabs 30 days) ENDODAN $5 QL (360 tabs 30 days) EXALGO $40 QL (60 ea 30 days) fentanyl 12mcghr 25mcghr $5 QL (10 ea 30 days) fentanyl 50mcghr 75mcghr

100mcghr $5 QL (10 ea 30 days) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

7

Drug Name Copayment RequirementsLimits Coinsurance

fentanyl citrate LPOP 25 QL (120 lpop 30 days) PA

hydromorphon inj 10mgml $5 BD hydromorphone hcl LIQD TABS $5

KADIAN $40 QL (60 caps 30 days) LAZANDA 25 QL (8 bottles 30 days)

PA methadone hcl CONC $5 methadone hcl SOLN 5mg5ml $5

10mg5ml methadone hcl TABS $5 QL (240 tabs 30 days)

methadose TABS $5 QL (240 tabs 30 days) MORPHINE SULFATE SOLN 4mgml $5 BD

8mgml 10mgml 15mgml morphine sulfate SOLN 5mgml $5 BD

1mgml MORPHINE SULFATE TABS $5 QL (180 tabs 30 days)

morphine sulfate ext-rel tab 15mg $5 QL (90 tabs 30 days) 30mg 60mg 100mg

morphine sulfate ext-rel tab 200mg $5 QL (60 tabs 30 days) MORPHINE SULFATE ORAL SOL $5

OXYCODONE HCL CAPS $5 QL (180 caps 30 days) OXYCODONE HCL CONC SOLN $5

oxycodone hcl TABS $5 QL (180 tabs 30 days) oxycodone w acetaminophen 25-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 5-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 5-500mg $5 QL (240 caps 30 days) oxycodone w acetaminophen 75-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 75-500mg $5 QL (240 tabs 30 days) oxycodone w acetaminophen 10-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 10-650mg $5 QL (180 tabs 30 days)

oxycodone-aspirin $5 QL (360 tabs 30 days) roxicet SOLN $40 QL (1800 mL 30 days)

NON-NARCOTIC ANALGESICS tramadol hcl TABS $5 QL (240 tabs 30 days)

tramadol-acetaminophen $5 QL (240 tabs 30 days) NSAIDS

CELEBREX 50mg 100mg 200mg $40 QL (60 caps 30 days) CELEBREX 400mg $40 QL (60 caps 30 days)

PA diclofenac potassium $5 diclofenac sodium TB24 TBEC $5

diflunisal $5 etodolac CAPS TABS $5 etodolac er $5

flurbiprofen TABS $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 8

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ibuprofen SUSP $5 ibuprofen TABS 400mg 600mg 800mg $5 ketoprofen CAPS CP24 $5 MELOXICAM SUSP 75 MG5ML $5 meloxicam tabs $5 nabumetone TABS $5 naproxen SUSP TABS TBEC $5 naproxen sodium TABS 275mg 550mg $5 oxaprozin $5 piroxicam CAPS $5 sulindac TABS $5

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth) $5

ANTI-INFECTIVES ANTIBACTERIALS amikacin sulfate SOLN 1gm4ml

50mgml $5

amoxicillin $5 amoxicillin amp pot clavulanate $5 ampicillin $5 ampicillin amp sulbactam sodium $5 ampicillin inj $5 AVELOX $40 AVELOX ABC PACK $40 azithromycin SOLR 500mg $5 azithromycin SUSR $5 azithromycin TABS $5 BICILLIN C-R $80 BICILLIN L-A $80 cefaclor $5 cefaclor er $40 cefadroxil $5 cefazolin inj $5 cefazolindextrose $40 cefdinir $5 cefepime hcl $5 cefotaxime sodium $5 cefoxitin sodium $5 cefpodoxime proxetil $5 cefprozil $5 ceftazidime SOLR 1gm 2gm 6gm $5 CEFTAZIDIMEDEXTROSE $40 ceftriaxone sodium SOLR $5 cefuroxime axetil TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

9

Drug Name Copayment Coinsurance

RequirementsLimits

cefuroxime sodium 15gm 75gm 750mg$5 cephalexin CAPS 250mg 500mg $5 cephalexin SUSR $5 CIPRO SUSR $80 ciprofloxacin er $5 ciprofloxacin hcl TABS $5 ciprofloxacin in d5w $5 ciprofloxacn inj $5 clarithromycin SUSR TABS TB24 $5 dicloxacillin sodium $5 DIFICID 25 ST doxycycl hyc inj $5 doxycycline (monohydrate) TABS $5 doxycycline hyclate CAPS TABS $5 ees $5 EES GRANULES $40 ery-tab $40 ERYPED 200 $40 ERYPED 400 $40 erythrocin stearate $5 erythromycin base TABS $5 erythromycin ethylsuccinate $5 gentamicin in saline 09 mgml $80 gentamicin in saline 14 mgml $80 gentamicin in saline 60mg $5 gentamicin in saline 80mg $5 gentamicin in saline 100mg $5 gentamicin sulfate SOLN $5 levofloxacin TABS $5 levofloxacin in d5w $5 levofloxacin inj 25mgml $5 levofloxacin oral soln 25 mgml $5 minocycline hcl CAPS $5 nafcillin sodium 1gm 10gm $5 neomycin sulfate TABS $5 oxacillin sodium 1gm 10gm $5 paromomycin sulfate CAPS $5 PENICILLIN G POT IN DEXTROSE $40 penicillin g procaine $40 penicillin g sodium $5 penicillin v potassium $5 penicilln gk inj 5mu $5 piperacillin sodium-tazobactam sodium $5 streptomycin sulfate SOLR $5 sulfadiazine TABS $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

10

Drug Name Copayment Coinsurance

RequirementsLimits

SUPRAX CAPS $40 suprax CHEW $80 suprax SUSR TABS $40 SUPRAX SUS 5005ML $40 tazicef vial $5 tetracycline hcl CAPS $5 TIMENTIN SOLR $80 tobramycin sulfate SOLN 10mgml

80mg2ml $5

tobramycin sulfate in saline $40 VIBRAMYCIN SYRUP $40 ZMAX $40 ANTIFUNGALS ABELCET 25 BD AMBISOME 25 BD amphotericin b SOLR $5 BD CANCIDAS 25 ERAXIS 100mg 25 fluconazole SUSR TABS $5 fluconazole in dextrose $5 flucytosine CAPS 25 griseofulvin microsize $5 griseofulvin ultramicrosize $5 itraconazole CAPS $5 PA ketoconazole TABS $5 MYCAMINE 25 NOXAFIL 25 nystatin TABS $5 terbinafine hcl TABS $5 QL (90 tabs year) VFEND SUSR 25 voriconazole TABS 25 VORICONAZOLE INJ 200MG $5 ANTIMALARIALS atovaquone-proguanil hcl $5 chloroquine phosphate TABS $5 COARTEM $80 DARAPRIM $80 mefloquine hcl $5 PRIMAQUINE PHOSPHATE TABS $40 ANTIRETROVIRAL AGENTS abacavir sulfate $5 APTIVUS 25 ATRIPLA 25 COMPLERA 25 CRIXIVAN $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

11

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment RequirementsLimits Coinsurance

fentanyl citrate LPOP 25 QL (120 lpop 30 days) PA

hydromorphon inj 10mgml $5 BD hydromorphone hcl LIQD TABS $5

KADIAN $40 QL (60 caps 30 days) LAZANDA 25 QL (8 bottles 30 days)

PA methadone hcl CONC $5 methadone hcl SOLN 5mg5ml $5

10mg5ml methadone hcl TABS $5 QL (240 tabs 30 days)

methadose TABS $5 QL (240 tabs 30 days) MORPHINE SULFATE SOLN 4mgml $5 BD

8mgml 10mgml 15mgml morphine sulfate SOLN 5mgml $5 BD

1mgml MORPHINE SULFATE TABS $5 QL (180 tabs 30 days)

morphine sulfate ext-rel tab 15mg $5 QL (90 tabs 30 days) 30mg 60mg 100mg

morphine sulfate ext-rel tab 200mg $5 QL (60 tabs 30 days) MORPHINE SULFATE ORAL SOL $5

OXYCODONE HCL CAPS $5 QL (180 caps 30 days) OXYCODONE HCL CONC SOLN $5

oxycodone hcl TABS $5 QL (180 tabs 30 days) oxycodone w acetaminophen 25-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 5-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 5-500mg $5 QL (240 caps 30 days) oxycodone w acetaminophen 75-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 75-500mg $5 QL (240 tabs 30 days) oxycodone w acetaminophen 10-325mg $5 QL (360 tabs 30 days) oxycodone w acetaminophen 10-650mg $5 QL (180 tabs 30 days)

oxycodone-aspirin $5 QL (360 tabs 30 days) roxicet SOLN $40 QL (1800 mL 30 days)

NON-NARCOTIC ANALGESICS tramadol hcl TABS $5 QL (240 tabs 30 days)

tramadol-acetaminophen $5 QL (240 tabs 30 days) NSAIDS

CELEBREX 50mg 100mg 200mg $40 QL (60 caps 30 days) CELEBREX 400mg $40 QL (60 caps 30 days)

PA diclofenac potassium $5 diclofenac sodium TB24 TBEC $5

diflunisal $5 etodolac CAPS TABS $5 etodolac er $5

flurbiprofen TABS $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 8

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ibuprofen SUSP $5 ibuprofen TABS 400mg 600mg 800mg $5 ketoprofen CAPS CP24 $5 MELOXICAM SUSP 75 MG5ML $5 meloxicam tabs $5 nabumetone TABS $5 naproxen SUSP TABS TBEC $5 naproxen sodium TABS 275mg 550mg $5 oxaprozin $5 piroxicam CAPS $5 sulindac TABS $5

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth) $5

ANTI-INFECTIVES ANTIBACTERIALS amikacin sulfate SOLN 1gm4ml

50mgml $5

amoxicillin $5 amoxicillin amp pot clavulanate $5 ampicillin $5 ampicillin amp sulbactam sodium $5 ampicillin inj $5 AVELOX $40 AVELOX ABC PACK $40 azithromycin SOLR 500mg $5 azithromycin SUSR $5 azithromycin TABS $5 BICILLIN C-R $80 BICILLIN L-A $80 cefaclor $5 cefaclor er $40 cefadroxil $5 cefazolin inj $5 cefazolindextrose $40 cefdinir $5 cefepime hcl $5 cefotaxime sodium $5 cefoxitin sodium $5 cefpodoxime proxetil $5 cefprozil $5 ceftazidime SOLR 1gm 2gm 6gm $5 CEFTAZIDIMEDEXTROSE $40 ceftriaxone sodium SOLR $5 cefuroxime axetil TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

9

Drug Name Copayment Coinsurance

RequirementsLimits

cefuroxime sodium 15gm 75gm 750mg$5 cephalexin CAPS 250mg 500mg $5 cephalexin SUSR $5 CIPRO SUSR $80 ciprofloxacin er $5 ciprofloxacin hcl TABS $5 ciprofloxacin in d5w $5 ciprofloxacn inj $5 clarithromycin SUSR TABS TB24 $5 dicloxacillin sodium $5 DIFICID 25 ST doxycycl hyc inj $5 doxycycline (monohydrate) TABS $5 doxycycline hyclate CAPS TABS $5 ees $5 EES GRANULES $40 ery-tab $40 ERYPED 200 $40 ERYPED 400 $40 erythrocin stearate $5 erythromycin base TABS $5 erythromycin ethylsuccinate $5 gentamicin in saline 09 mgml $80 gentamicin in saline 14 mgml $80 gentamicin in saline 60mg $5 gentamicin in saline 80mg $5 gentamicin in saline 100mg $5 gentamicin sulfate SOLN $5 levofloxacin TABS $5 levofloxacin in d5w $5 levofloxacin inj 25mgml $5 levofloxacin oral soln 25 mgml $5 minocycline hcl CAPS $5 nafcillin sodium 1gm 10gm $5 neomycin sulfate TABS $5 oxacillin sodium 1gm 10gm $5 paromomycin sulfate CAPS $5 PENICILLIN G POT IN DEXTROSE $40 penicillin g procaine $40 penicillin g sodium $5 penicillin v potassium $5 penicilln gk inj 5mu $5 piperacillin sodium-tazobactam sodium $5 streptomycin sulfate SOLR $5 sulfadiazine TABS $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

10

Drug Name Copayment Coinsurance

RequirementsLimits

SUPRAX CAPS $40 suprax CHEW $80 suprax SUSR TABS $40 SUPRAX SUS 5005ML $40 tazicef vial $5 tetracycline hcl CAPS $5 TIMENTIN SOLR $80 tobramycin sulfate SOLN 10mgml

80mg2ml $5

tobramycin sulfate in saline $40 VIBRAMYCIN SYRUP $40 ZMAX $40 ANTIFUNGALS ABELCET 25 BD AMBISOME 25 BD amphotericin b SOLR $5 BD CANCIDAS 25 ERAXIS 100mg 25 fluconazole SUSR TABS $5 fluconazole in dextrose $5 flucytosine CAPS 25 griseofulvin microsize $5 griseofulvin ultramicrosize $5 itraconazole CAPS $5 PA ketoconazole TABS $5 MYCAMINE 25 NOXAFIL 25 nystatin TABS $5 terbinafine hcl TABS $5 QL (90 tabs year) VFEND SUSR 25 voriconazole TABS 25 VORICONAZOLE INJ 200MG $5 ANTIMALARIALS atovaquone-proguanil hcl $5 chloroquine phosphate TABS $5 COARTEM $80 DARAPRIM $80 mefloquine hcl $5 PRIMAQUINE PHOSPHATE TABS $40 ANTIRETROVIRAL AGENTS abacavir sulfate $5 APTIVUS 25 ATRIPLA 25 COMPLERA 25 CRIXIVAN $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

11

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

ibuprofen SUSP $5 ibuprofen TABS 400mg 600mg 800mg $5 ketoprofen CAPS CP24 $5 MELOXICAM SUSP 75 MG5ML $5 meloxicam tabs $5 nabumetone TABS $5 naproxen SUSP TABS TBEC $5 naproxen sodium TABS 275mg 550mg $5 oxaprozin $5 piroxicam CAPS $5 sulindac TABS $5

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth) $5

ANTI-INFECTIVES ANTIBACTERIALS amikacin sulfate SOLN 1gm4ml

50mgml $5

amoxicillin $5 amoxicillin amp pot clavulanate $5 ampicillin $5 ampicillin amp sulbactam sodium $5 ampicillin inj $5 AVELOX $40 AVELOX ABC PACK $40 azithromycin SOLR 500mg $5 azithromycin SUSR $5 azithromycin TABS $5 BICILLIN C-R $80 BICILLIN L-A $80 cefaclor $5 cefaclor er $40 cefadroxil $5 cefazolin inj $5 cefazolindextrose $40 cefdinir $5 cefepime hcl $5 cefotaxime sodium $5 cefoxitin sodium $5 cefpodoxime proxetil $5 cefprozil $5 ceftazidime SOLR 1gm 2gm 6gm $5 CEFTAZIDIMEDEXTROSE $40 ceftriaxone sodium SOLR $5 cefuroxime axetil TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

9

Drug Name Copayment Coinsurance

RequirementsLimits

cefuroxime sodium 15gm 75gm 750mg$5 cephalexin CAPS 250mg 500mg $5 cephalexin SUSR $5 CIPRO SUSR $80 ciprofloxacin er $5 ciprofloxacin hcl TABS $5 ciprofloxacin in d5w $5 ciprofloxacn inj $5 clarithromycin SUSR TABS TB24 $5 dicloxacillin sodium $5 DIFICID 25 ST doxycycl hyc inj $5 doxycycline (monohydrate) TABS $5 doxycycline hyclate CAPS TABS $5 ees $5 EES GRANULES $40 ery-tab $40 ERYPED 200 $40 ERYPED 400 $40 erythrocin stearate $5 erythromycin base TABS $5 erythromycin ethylsuccinate $5 gentamicin in saline 09 mgml $80 gentamicin in saline 14 mgml $80 gentamicin in saline 60mg $5 gentamicin in saline 80mg $5 gentamicin in saline 100mg $5 gentamicin sulfate SOLN $5 levofloxacin TABS $5 levofloxacin in d5w $5 levofloxacin inj 25mgml $5 levofloxacin oral soln 25 mgml $5 minocycline hcl CAPS $5 nafcillin sodium 1gm 10gm $5 neomycin sulfate TABS $5 oxacillin sodium 1gm 10gm $5 paromomycin sulfate CAPS $5 PENICILLIN G POT IN DEXTROSE $40 penicillin g procaine $40 penicillin g sodium $5 penicillin v potassium $5 penicilln gk inj 5mu $5 piperacillin sodium-tazobactam sodium $5 streptomycin sulfate SOLR $5 sulfadiazine TABS $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

10

Drug Name Copayment Coinsurance

RequirementsLimits

SUPRAX CAPS $40 suprax CHEW $80 suprax SUSR TABS $40 SUPRAX SUS 5005ML $40 tazicef vial $5 tetracycline hcl CAPS $5 TIMENTIN SOLR $80 tobramycin sulfate SOLN 10mgml

80mg2ml $5

tobramycin sulfate in saline $40 VIBRAMYCIN SYRUP $40 ZMAX $40 ANTIFUNGALS ABELCET 25 BD AMBISOME 25 BD amphotericin b SOLR $5 BD CANCIDAS 25 ERAXIS 100mg 25 fluconazole SUSR TABS $5 fluconazole in dextrose $5 flucytosine CAPS 25 griseofulvin microsize $5 griseofulvin ultramicrosize $5 itraconazole CAPS $5 PA ketoconazole TABS $5 MYCAMINE 25 NOXAFIL 25 nystatin TABS $5 terbinafine hcl TABS $5 QL (90 tabs year) VFEND SUSR 25 voriconazole TABS 25 VORICONAZOLE INJ 200MG $5 ANTIMALARIALS atovaquone-proguanil hcl $5 chloroquine phosphate TABS $5 COARTEM $80 DARAPRIM $80 mefloquine hcl $5 PRIMAQUINE PHOSPHATE TABS $40 ANTIRETROVIRAL AGENTS abacavir sulfate $5 APTIVUS 25 ATRIPLA 25 COMPLERA 25 CRIXIVAN $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

11

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

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ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

cefuroxime sodium 15gm 75gm 750mg$5 cephalexin CAPS 250mg 500mg $5 cephalexin SUSR $5 CIPRO SUSR $80 ciprofloxacin er $5 ciprofloxacin hcl TABS $5 ciprofloxacin in d5w $5 ciprofloxacn inj $5 clarithromycin SUSR TABS TB24 $5 dicloxacillin sodium $5 DIFICID 25 ST doxycycl hyc inj $5 doxycycline (monohydrate) TABS $5 doxycycline hyclate CAPS TABS $5 ees $5 EES GRANULES $40 ery-tab $40 ERYPED 200 $40 ERYPED 400 $40 erythrocin stearate $5 erythromycin base TABS $5 erythromycin ethylsuccinate $5 gentamicin in saline 09 mgml $80 gentamicin in saline 14 mgml $80 gentamicin in saline 60mg $5 gentamicin in saline 80mg $5 gentamicin in saline 100mg $5 gentamicin sulfate SOLN $5 levofloxacin TABS $5 levofloxacin in d5w $5 levofloxacin inj 25mgml $5 levofloxacin oral soln 25 mgml $5 minocycline hcl CAPS $5 nafcillin sodium 1gm 10gm $5 neomycin sulfate TABS $5 oxacillin sodium 1gm 10gm $5 paromomycin sulfate CAPS $5 PENICILLIN G POT IN DEXTROSE $40 penicillin g procaine $40 penicillin g sodium $5 penicillin v potassium $5 penicilln gk inj 5mu $5 piperacillin sodium-tazobactam sodium $5 streptomycin sulfate SOLR $5 sulfadiazine TABS $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

10

Drug Name Copayment Coinsurance

RequirementsLimits

SUPRAX CAPS $40 suprax CHEW $80 suprax SUSR TABS $40 SUPRAX SUS 5005ML $40 tazicef vial $5 tetracycline hcl CAPS $5 TIMENTIN SOLR $80 tobramycin sulfate SOLN 10mgml

80mg2ml $5

tobramycin sulfate in saline $40 VIBRAMYCIN SYRUP $40 ZMAX $40 ANTIFUNGALS ABELCET 25 BD AMBISOME 25 BD amphotericin b SOLR $5 BD CANCIDAS 25 ERAXIS 100mg 25 fluconazole SUSR TABS $5 fluconazole in dextrose $5 flucytosine CAPS 25 griseofulvin microsize $5 griseofulvin ultramicrosize $5 itraconazole CAPS $5 PA ketoconazole TABS $5 MYCAMINE 25 NOXAFIL 25 nystatin TABS $5 terbinafine hcl TABS $5 QL (90 tabs year) VFEND SUSR 25 voriconazole TABS 25 VORICONAZOLE INJ 200MG $5 ANTIMALARIALS atovaquone-proguanil hcl $5 chloroquine phosphate TABS $5 COARTEM $80 DARAPRIM $80 mefloquine hcl $5 PRIMAQUINE PHOSPHATE TABS $40 ANTIRETROVIRAL AGENTS abacavir sulfate $5 APTIVUS 25 ATRIPLA 25 COMPLERA 25 CRIXIVAN $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

11

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

SUPRAX CAPS $40 suprax CHEW $80 suprax SUSR TABS $40 SUPRAX SUS 5005ML $40 tazicef vial $5 tetracycline hcl CAPS $5 TIMENTIN SOLR $80 tobramycin sulfate SOLN 10mgml

80mg2ml $5

tobramycin sulfate in saline $40 VIBRAMYCIN SYRUP $40 ZMAX $40 ANTIFUNGALS ABELCET 25 BD AMBISOME 25 BD amphotericin b SOLR $5 BD CANCIDAS 25 ERAXIS 100mg 25 fluconazole SUSR TABS $5 fluconazole in dextrose $5 flucytosine CAPS 25 griseofulvin microsize $5 griseofulvin ultramicrosize $5 itraconazole CAPS $5 PA ketoconazole TABS $5 MYCAMINE 25 NOXAFIL 25 nystatin TABS $5 terbinafine hcl TABS $5 QL (90 tabs year) VFEND SUSR 25 voriconazole TABS 25 VORICONAZOLE INJ 200MG $5 ANTIMALARIALS atovaquone-proguanil hcl $5 chloroquine phosphate TABS $5 COARTEM $80 DARAPRIM $80 mefloquine hcl $5 PRIMAQUINE PHOSPHATE TABS $40 ANTIRETROVIRAL AGENTS abacavir sulfate $5 APTIVUS 25 ATRIPLA 25 COMPLERA 25 CRIXIVAN $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

11

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

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ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

didanosine $5 EDURANT 25 EMTRIVA $40 EPIVIR SOL 10MGML $40 EPZICOM 25 FUZEON KIT 25 INTELENCE 25mg $80 INTELENCE 100mg 200mg 25 INVIRASE CAPS $80 INVIRASE TABS 25 ISENTRESS CHEW 25mg $40 ISENTRESS CHEW 100mg 25 ISENTRESS TABS 25 KALETRA SOL 25 KALETRA TAB 100-25MG $40 KALETRA TAB 200-50MG 25 lamivudine $5 lamivudine-zidovudine 25 LEXIVA $80 NEVIRAPINE SUSP $5 nevirapine TABS $5 NORVIR $40 PREZISTA SUSP 25 PREZISTA TABS 75mg $40 PREZISTA TABS 150mg 400mg 600mg 25

800mg

RESCRIPTOR $80 RETROVIR IV INFUSION $40 REYATAZ $40 SELZENTRY 25 stavudine $5 STRIBILD 25 SUSTIVA $40 TRIZIVIR 25 TRUVADA 25 VIDEX PEDIATRIC 2gm $80 VIRACEPT 25 VIRAMUNE SUSP $80 VIRAMUNE XR $80 VIREAD 25 ZIAGEN SOLN $80 zidovudine $5 ANTITUBERCULAR AGENTS CAPASTAT SULFATE $80 ethambutol hcl TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

12

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment RequirementsLimits Coinsurance

isoniazid inj 100 mgml $5 isoniazid syp 50mg5ml $5 isoniazid tabs $5

MYCOBUTIN $40 PASER DR $80

PRIFTIN $40 pyrazinamide $5 rifampin CAPS SOLR $5 SEROMYCIN $80 SIRTURO 25 LA PA TRECATOR $40

ANTIVIRALS acyclovir CAPS SUSP TABS $5 acyclovir sodium for inj $5 BD

BARACLUDE $40 EPIVIR HBV $40

famciclovir $5 ganciclovir inj 500mg $5 BD

HEPSERA 25 ST INCIVEK 25 PA REBETOL SOLN 25 PA

RELENZA DISKHALER $40 QL (3 inhalers 180 days)

ribapak mis 600day 25 PA ribasphere 25 PA

ribasphere 200mg $5 PA ribasphere ribapak 800 25 PA ribasphere ribapak 1000 25 PA ribasphere ribapak 1200 25 PA

ribavirin 200mg $5 PA rimantadine hydrochloride $5

TAMIFLU CAPS 30mg $40 QL (90 caps 180 days) TAMIFLU CAPS 45mg 75mg $40 QL (50 caps 180 days) TAMIFLU SUSR $40 QL (540 mL 180 days) TYZEKA $80

valacyclovir hcl TABS $5 VALCYTE 25 VICTRELIS 25 PA

MISCELLANEOUS ALBENZA $80 ALINIA SUSR $80 QL (540 mL 30 days) ALINIA TABS $80 QL (20 tabs 30 days) AZACTAM 2gm $80

AZACTAM IN DEXTROSE $80 aztreonam 1gm $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 13 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

BILTRICIDE $40 clindamycin hcl CAPS $5 clindamycin palmitate hydrochloride $5 clindamycin phosphate SOLN 150mgml $5

colistimethate sodium SOLR $5 CUBICIN 25 BD dapsone TABS $5 DORIBAX 500mg $80 imipenem-cilastatin $5 INVANZ $80 MACRODANTIN 25mg $40 PA MEPRON 25 meropenem 500mg $5

methenamine hippurate $5 metronidazole CAPS TABS $5

metronidazole inj $5 NEBUPENT $80 BD nitrofurantoin macrocrystal $5 PA nitrofurantoin monohyd macro $5 PA sulfamethoxazole-trimethop $5

sulfamethoxazole-trimethop iv soln $5 trimethoprim TABS $5 TYGACIL 25

vancomycin hcl CAPS 25 vancomycin hcl SOLR 10gm 500mg

1000mg $5 BD

ZYVOX 25 A NTINEOPLASTIC AGENTS

ALKYLATING AGENTS BICNU $80 BD BUSULFEX $80 BD CEENU $40 cyclophosphamide TABS $5 BD dacarbazine 200mg $5 BD EMCYT $40 HEXALEN 25 IFEX 3gm $80 BD

ifosfamide SOLR 1gm $5 BD LEUKERAN $40

melphalan hcl 25 BD MUSTARGEN $80 BD TREANDA 100mg 25 BD

ANTHRACYCLINES adriamycin SOLN $5 BD daunorubicin hcl INJ $5 BD

All covered drugs are available through our Preferred Mail-pharmacies

Order pharmacy in addition to our Retail 14

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

DOXIL 25 BD doxorubicin hcl SOLN $5 BD epirubicin hcl SOLN 50mg25ml $5 BD idarubicin hcl 10mg10ml 25 BD ANTIBIOTICS bleomycin sulfate 30unit $5 BD COSMEGEN 25 BD mitomycin SOLR 20mg $5 BD ANTIMETABOLITES ALIMTA 500mg 25 BD cytarabine inj 20mgml $5 BD cytarabine inj 500mg $5 BD fluorouracil SOLN 25gm50ml $5 BD gemcitabine hcl 1gm 25 BD mercaptopurine TABS $5 methotrexate sodium inj $5 BD methotrexate sodium inj pf $5 BD pentostatin 25 BD TABLOID $40 VIDAZA 25 BD ANTIMITOTIC TAXOIDS DOCETAXEL CONC 80mg4ml 25 BD DOCETAXEL SOLN 80mg8ml 25 BD paclitaxel 300mg50ml $5 BD TAXOTERE 80mg2ml 80mg4ml 25 BD ANTIMITOTIC VINCA ALKALOIDS vinblastine sulfate SOLR $40 BD vincasar $5 BD vincristine sulfate $5 BD vinorelbine tartrate 50mg5ml $5 BD BIOLOGIC RESPONSE MODIFIERS AVASTIN 100mg4ml 25 BD CAMPATH 25 BD ERIVEDGE 25 LA PA HERCEPTIN 25 BD ISTODAX 25 BD KADCYLA 25 BD ONTAK 25 BD PROLEUKIN 25 BD RITUXAN 25 PA VELCADE 25 BD ZOLINZA 25 HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

15

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

bicalutamide $5 QL (30 tabs 30 days) DEPO-PROVERA $40 BD exemestane $5 ST FARESTON $80 FASLODEX 25 BD flutamide $5 letrozole TABS $5 ST leuprolide acetate KIT $5 PA LUPRON DEPOT 375mg 25 QL (1 box 30 days) PA LUPRON DEPOT-PED 1125mg 15mg 25 PA LUPRON DEPOT-PED (3 MONTH KIT) 25 QL (1 box 84 days) PA LYSODREN 25 MEGACE ES $40 QL (150 mL 30 days) megestrol acetate SUSP TABS $5 NILANDRON $80 SOLTAMOX $80 tamoxifen citrate TABS $5 TRELSTAR DEP INJ 375MG 25 QL (1 vial 28 days) PA TRELSTAR LA INJ 1125MG 25 QL (1 vial 84 days) PA XTANDI 25 LA PA ZYTIGA 25 QL (120 tabs 30 days)

PA KINASE INHIBITORS AFINITOR 25mg 5mg 25 QL (30 tabs 30 days) AFINITOR 75mg 10mg 25 QL (60 tabs 30 days) AFINITOR DISPERZ 25 BOSULIF 100mg 25 QL (180 tabs 30 days)

PA BOSULIF 500mg 25 QL (30 tabs 30 days)

PA CAPRELSA 25 LA PA COMETRIQ 25 PA GLEEVEC 100mg 25 QL (90 tabs 30 days)

PA GLEEVEC 400mg 25 QL (60 tabs 30 days)

PA ICLUSIG 25 PA INLYTA 25 LA PA JAKAFI 25 QL (60 tabs 30 days)

LA PA NEXAVAR 25 QL (120 tabs 30 days)

LA PA SPRYCEL 20mg 50mg 70mg 80mg 25 PA SPRYCEL 100mg 140mg 25 QL (30 tabs 30 days)

PA STIVARGA 25 LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

16

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

SUTENT 125mg 25 QL (112 caps 28 days) PA

SUTENT 25mg 25 QL (56 caps 28 days) PA

SUTENT 50mg 25 QL (28 caps 28 days) PA

TARCEVA 25mg 25 QL (180 tabs 30 days) PA

TARCEVA 100mg 150mg 25 QL (30 tabs 30 days) PA

TASIGNA 25 QL (120 caps 30 days) PA

TYKERB 25 LA VOTRIENT 25 QL (120 tabs 30 days) XALKORI 25 QL (60 caps 30 days)

LA PA ZELBORAF 25 QL (240 tabs 30 days)

LA PA MISCELLANEOUS DROXIA $40 ELSPAR $80 BD hydroxyurea CAPS $5 irinotecan hcl 25 BD MATULANE 25 mitoxantrone hcl $5 BD POMALYST 25 LA PA SYLATRON 25 PA TARGRETIN CAPS 25 PA tretinoin (chemotherapy) 25 TRISENOX 25 BD NUCLEOSIDE ANALOGS cladribine 25 BD fludarabine phosphate $5 BD PLATINUM COORDINATION COMPLEX carboplatin SOLN 150mg15ml $5 BD cisplatin SOLN 100mg100ml $5 BD oxaliplatin SOLN 100mg20ml 25 BD PROTECTIVE AGENTS amifostine crystalline 25 BD dexrazoxane 500mg 25 BD ELITEK 15mg 25 BD leucovorin calcium SOLR 100mg 350mg $5 BD leucovorin calcium TABS $5 mesna $5 BD MESNEX TABS 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

17

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

C

TOPOISOMERASE INHIBITORS etoposide SOLN $5 BD toposar $5 BD

topotecan hcl SOLR 25 BD ARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl $5 QL (30 caps 30 days)

benazepril amp hydrochlorothiazide $5 captopril amp hydrochlorothiazide $5 enalapril maleate amp hydrochlorothiazide $5

fosinopril sodium amp hydrochlorothiazide $5 lisinopril amp hydrochlorothiazide $5

moexipril-hydrochlorothiazide $5 quinapril-hydrochlorothiazide $5

ACE INHIBITORS benazepril hcl TABS $5

captopril TABS $5 enalapril maleate TABS $5

fosinopril sodium $5 lisinopril TABS $5 moexipril hcl $5

perindopril erbumine $5 quinapril hcl $5

ramipril $5 trandolapril $5

ADRENOLYTICS CENTRAL clonidine hcl PTWK TABS $5

guanfacine hcl $5 ALDOSTERONE RECEPTOR ANTAGON ISTS

eplerenone $5 PA spironolactone TABS $5

ALPHA BLOCKERS doxazosin mesylate 1mg 2mg 4mg $5 QL (30 tabs 30 days) doxazosin mesylate 8mg $5 QL (60 tabs 30 days)

prazosin hcl $5 terazosin hcl $5

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBIN ATIONS AZOR $40 QL (30 tabs 30 days)

BENICAR HCT $40 QL (30 tabs 30 days) EXFORGE $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 5-160-25MG $40 QL (60 tabs 30 days) EXFORGE HCT 10-160-125MG $40 QL (30 tabs 30 days) EXFORGE HCT 10-160-25MG $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

18

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

EXFORGE HCT 10-320-25MG $40 QL (30 tabs 30 days) losartan potassium amp hydrochlorothiazide $5 QL (30 tabs 30 days) TRIBENZOR $40 QL (30 tabs 30 days) valsartan-hydrochlorothiazide $5 QL (30 tabs 30 days) ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg $40 QL (60 tabs 30 days) BENICAR 20mg 40mg $40 QL (30 tabs 30 days) DIOVAN 40mg 80mg 160mg $40 QL (60 tabs 30 days) DIOVAN 320mg $40 QL (30 tabs 30 days) losartan potassium 25mg 50mg $5 QL (60 tabs 30 days) losartan potassium 100mg $5 QL (30 tabs 30 days) ANTIARRHYTHMICS amiodarone hcl SOLN 50mgml $5 amiodarone hcl TABS $5 disopyramide phosphate $5 flecainide acetate $5 mexiletine hcl $5 MULTAQ $80 NORPACE CR $80 PACERONE 100mg $80 pacerone 200mg $5 propafenone hcl $5 quinidine gluconate TBCR $5 quinidine sulfate $5 sorine $5 sotalol hcl $5 sotalol hcl (afibafl) $5 TIKOSYN $80 ANTILIPEMICS HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium $5 QL (30 tabs 30 days) CRESTOR $40 QL (30 tabs 30 days) lovastatin 10mg $5 QL (30 tabs 30 days) lovastatin 20mg $5 QL (120 tabs 30 days) lovastatin 40mg $5 QL (60 tabs 30 days) pravastatin sodium $5 QL (30 tabs 30 days) simvastatin TABS $5 QL (30 tabs 30 days) ANTILIPEMICS MISCELLANEOUS ANTARA 43mg $40 QL (60 caps 30 days) ANTARA 130mg $40 QL (30 caps 30 days) cholestyramine $5 cholestyramine light $5 colestipol hcl $5 fenofibrate 48mg 54mg $5 QL (90 tabs 30 days) fenofibrate 145mg 160mg $5 QL (30 tabs 30 days) fenofibrate micronized 43mg $5 QL (60 caps 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

19

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

fenofibrate micronized 67mg 130mg $5 134mg 200mg

QL (30 caps 30 days)

gemfibrozil TABS $5 QL (60 tabs 30 days) LOVAZA $40 NIASPAN 500mg $40 QL (90 tabs 30 days) NIASPAN 750mg 1000mg $40 QL (60 tabs 30 days) prevalite $5 SIMCOR TAB 50-40MG $40 QL (30 ea 30 days) SIMCOR TAB 500-20MG $40 QL (60 ea 30 days) SIMCOR TAB 750-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-20MG $40 QL (60 ea 30 days) SIMCOR TAB 1000-40MG $40 QL (30 ea 30 days) VASCEPA $80 WELCHOL $40 ZETIA $40 BETA-BLOCKERDIURETIC COMBINATIONS atenolol amp chlorthalidone $5 bisoprolol amp hydrochlorothiazide $5 metoprolol amp hydrochlorothiazide $5 propranolol amp hydrochlorothiazide $5 BETA-BLOCKERS acebutolol hcl CAPS $5 atenolol TABS $5 bisoprolol fumarate $5 BYSTOLIC $40 carvedilol $5 labetalol hcl TABS $5 metoprolol succinate 25mg 50mg $5

200mg QL (60 tabs 30 days)

metoprolol succinate 100mg $5 QL (45 tabs 30 days) metoprolol tartrate SOLN TABS $5 nadolol TABS $5 pindolol $5 propranolol hcl SOLN TABS $5 propranolol hcl er $5 timolol maleate TABS $5 CALCIUM CHANNEL BLOCKERS afeditab cr 30mg $5 QL (60 tabs 30 days) afeditab cr 60mg $5 QL (30 tabs 30 days) amlodipine besylate TABS 25mg 5mg $5 QL (45 tabs 30 days) amlodipine besylate TABS 10mg $5 QL (30 tabs 30 days) cartia 120mg $5 QL (30 caps 30 days) cartia 180mg 240mg 300mg $5 dilt 120mg $5 QL (30 caps 30 days) dilt 180mg 240mg 300mg $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

20

Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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Drug Name Copayment RequirementsLimits Coinsurance

diltiazem hcl CP12 $5 diltiazem hcl SOLN 50mg10ml $5 diltiazem hcl TABS $5 diltiazem hcl coated beads 120mg $5 QL (30 caps 30 days) diltiazem hcl coated beads 240mg $5

300mg 360mg diltiazem hcl extended release beads $5 QL (30 ea 30 days)

120mg diltiazem hcl extended release beads $5

180mg 240mg 300mg 360mg 420mg felodipine 25mg 10mg $5 QL (30 tabs 30 days) felodipine 5mg $5 QL (60 tabs 30 days) isradipine $5 matzim $5

nicardipine hcl CAPS $5 nifediac $5 nifediac cc tab 30mg $5 QL (60 ea 30 days) nifediac cc tab 60mg $5 QL (30 ea 30 days)

nifedical 30mg $5 QL (30 tabs 30 days) nifedical 60mg $5 QL (60 tabs 30 days)

nifedipine tab 30mg er $5 QL (60 ea 30 days) nifedipine tab 60mg er $5 QL (30 ea 30 days) nifedipine tab sr 30mg (osm) $5 QL (30 tabs 30 days) nifedipine tab sr 60mg (osm) $5 QL (60 tabs 30 days) nifedipine tab sr 90mg (osm) $5 nimodipine CAPS $5

taztia 120mg $5 QL (30 caps 30 days) taztia 180mg 240mg 300mg 360mg $5

verapamil hcl CP24 SOLN TABS TBCR $5 DIGITALIS GLYCOSIDES

digoxin TABS $5 digoxin inj $5

DIGOXIN SOL 50MCGML $5 LANOXIN TAB $40

DIRECT RENIN INHIBITORSCOMBINATIONS AMTURNIDE $40 QL (30 tabs 30 days) TEKAMLO $40 QL (30 tabs 30 days) TEKTURNA $40 QL (30 tabs 30 days)

TEKTURNA HCT TAB 150-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 150-25MG $40 QL (60 tabs 30 days) TEKTURNA HCT TAB 300-125MG $40 QL (30 tabs 30 days) TEKTURNA HCT TAB 300-25MG $40 QL (30 tabs 30 days) DIURETICS

acetazolamide CP12 TABS $5 amiloride amp hydrochlorothiazide $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 21 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

amiloride hcl $5 bumetanide SOLN TABS $5 chlorothiazide $5 chlorthalidone 25mg 50mg $5 DIURIL SUS 2505ML $40 DYRENIUM $80 EDECRIN $80 furosemide SOLN TABS $5 furosemide inj $5 furosemide oral soln 8 mgml $80 hydrochlorothiazide CAPS TABS $5 indapamide TABS $5 methazolamide TABS $5 methyclothiazide $5 metolazone $5 spironolactone amp hydrochlorothiazide $5 THALITONE $40 torsemide inj 20mg2ml $80 torsemide tabs $5 triamterene amp hydrochlorothiazide cap

375-25 mg $5

triamterene amp hydrochlorothiazide tab 375-25 mg

$5

triamterene amp hydrochlorothiazide tab 75-50 mg

$5

MISCELLANEOUS DIBENZYLINE $80 hydralazine hcl SOLN TABS $5 midodrine hcl $5 minoxidil TABS $5 RANEXA 500mg $80 QL (90 tabs 30 days)

PA RANEXA 1000mg $80 QL (60 tabs 30 days)

PA NITRATES isosorbide dinitrate $5 isosorbide dinitrate sl tab 5 mg $5 isosorbide mononitrate $5 minitran $5 nitro-bid $40 NITRO-DUR 03MGHR $80 NITRO-DUR 08MGHR $80 nitroglycerin patches $5 NITROLINGUAL PUMPSPRAY $40 NITROSTAT $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

22

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 25 QL (60 tabs 30 days)

PA LETAIRIS 25 QL (30 tabs 30 days)

LA PA REMODULIN 25 BD LA sildenafil citrate (pulmonary hypertension) 25 QL (90 tabs 30 days)

PA TRACLEER 625mg 25 QL (120 tabs 30 days)

LA PA TRACLEER 125mg 25 QL (60 tabs 30 days)

LA PA CENTRAL NERVOUS SYSTEM

ANTIANXIETY alprazolam CONC $5 QL (300 ml 30 days) alprazolam TABS 1mg $5 QL (300 tabs 30 days) alprazolam TABS 2mg $5 QL (150 tabs 30 days) alprazolam TABS 5mg $5 QL (600 tabs 30 days) alprazolam TABS 25mg $5 QL (1200 tabs 30 days) buspirone hcl TABS $5 fluvoxamine maleate 25mg 50mg $5 QL (45 tabs 30 days) fluvoxamine maleate 100mg $5 lorazepam CONC $5 QL (150 mls 30 days) lorazepam SOLN $5 lorazepam TABS 1mg $5 QL (300 tabs 30 days) lorazepam TABS 2mg $5 QL (150 tabs 30 days) lorazepam TABS 5mg $5 QL (600 tabs 30 days) ANTICONVULSANTS BANZEL $80 carbamazepine CHEW CP12 SUSP $5

TABS TB12

CELONTIN $80 clonazepam TABS 1mg $5 QL (600 tabs 30 days) clonazepam TABS 2mg $5 QL (300 tabs 30 days) clonazepam TABS 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 1mg $5 QL (600 tabs 30 days) clonazepam TBDP 2mg $5 QL (300 tabs 30 days) clonazepam TBDP 5mg $5 QL (1200 tabs 30 days) clonazepam TBDP 25mg $5 QL (2400 tabs 30 days) clonazepam TBDP 125mg $5 QL (4800 tabs 30 days) clorazepate dipotassium 375mg $5 QL (720 tabs 30 days)

PA clorazepate dipotassium 75mg $5 QL (360 tabs 30 days)

PA clorazepate dipotassium 15mg $5 QL (180 tabs 30 days)

PA All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

23

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

diazepam CONC $5 QL (240 ml 30 days) PA

diazepam SOLN 1mgml $5 QL (1200mL 30 days) PA

diazepam SOLN 5mgml $5 diazepam TABS 2mg $5 QL (600 tabs 30 days)

PA diazepam TABS 5mg $5 QL (240 tabs 30 days)

PA diazepam TABS 10mg $5 QL (120 tabs 30 days)

PA DIAZEPAM GEL $5 dilantin CAPS CHEW $40 DILANTIN SUSP $40 divalproex sodium $5 epitol $5 ethosuximide CAPS SOLN $5 felbamate $5 gabapentin CAPS 100mg $5 QL (1080 caps 30 days) gabapentin CAPS 300mg $5 QL (360 caps 30 days) gabapentin CAPS 400mg $5 QL (270 caps 30 days) gabapentin SOLN $5 QL (2160 mL 30 days) gabapentin TABS 600mg $5 QL (180 tabs 30 days) gabapentin TABS 800mg $5 QL (120 tabs 30 days) GABITRIL 12mg 16mg $80 lamotrigine $5 lamotrigine er $5 levetiracetam SOLN TABS TB24 $5 LYRICA CAPS 25mg 50mg 75mg

100mg 150mg $40 QL (120 caps 30 days)

LYRICA CAPS 200mg $40 QL (90 caps 30 days) LYRICA CAPS 225mg 300mg $40 QL (60 caps 30 days) LYRICA SOLN $40 QL (946mL 30 days) ONFI $80 oxcarbazepine $5 PEGANONE $80 phenobarbital ELIX TABS $5 phenobarbital sodium $5 PHENYTEK $80 phenytoin CHEW SUSP $5 phenytoin sodium SOLN $5 phenytoin sodium extended $5 POTIGA $80 primidone TABS $5 SABRIL PACK 25 QL (180 packets 30

days) LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

24

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

SABRIL TABS 25 QL (180 tabs 30 days) LA PA

TEGRETOL $80 TEGRETOL-XR $80 tiagabine tab 2mg $5 tiagabine tab 4mg $5 topiramate CPSP $5 topiramate TABS 25mg 50mg 100mg $5 QL (90 tabs 30 days) topiramate TABS 200mg $5 QL (240 tabs 30 days) TRILEPTAL SUSP $80 valproate sodium SOLN SYRP $5 valproic acid CAPS $5 VIMPAT SOLN $80 QL (1200 mL 30 days) VIMPAT TABS 50mg $80 QL (180 tabs 30 days) VIMPAT TABS 100mg 150mg 200mg $80 QL (60 tabs 30 days) zonisamide $5 ANTIDEMENTIA ARICEPT 23mg $40 donepezil hydrochloride $5 QL (30 tabs 30 days) EXELON PATCHES $80 QL (30 ea 30 days) EXELON SOLN $80 QL (180 mL 30 days) galantamine hydrobromide CP24 $5 QL (30 caps 30 days) galantamine hydrobromide SOLN $5 QL (180 mL 30 days) galantamine hydrobromide TABS 4mg $5 QL (180 tabs 30 days) galantamine hydrobromide TABS 8mg $5 QL (90 tabs 30 days) galantamine hydrobromide TABS 12mg $5 QL (60 tabs 30 days) NAMENDA SOLN $40 QL (360 mL 30 days) NAMENDA TABS $40 QL (60 tabs 30 days) NAMENDA TITRATION PAK $40 QL (1 pack 28 days) rivastigmine tartrate 15mg $5 QL (240 caps 30 days) rivastigmine tartrate 3mg $5 QL (120 caps 30 days) rivastigmine tartrate 45mg 6mg $5 QL (60 caps 30 days) ANTIDEPRESSANTS amitriptyline hcl TABS $5 amoxapine $40 budeprion $5 bupropion hcl TABS $5 bupropion hcl sr $5 bupropion hcl xl 150mg $5 QL (90 ea 30 days) bupropion hcl xl 300mg $5 QL (30 ea 30 days) citalopram hydrobromide SOLN $5 QL (600 mL 30 days) citalopram hydrobromide TABS 10mg

20mg $5 QL (45 tabs 30 days)

citalopram hydrobromide TABS 40mg $5 QL (30 tabs 30 days) clomipramine hcl CAPS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

25

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

CYMBALTA $40 QL (60 ea 30 days) desipramine hcl TABS $5 doxepin hcl CAPS CONC $5 EMSAM $80 QL (30 ea 30 days) PA escitalopram oxalate SOLN $5 QL (600 ml 30 days) escitalopram oxalate TABS 5mg 10mg $5 QL (45 tabs 30 days) escitalopram oxalate TABS 20mg $5 QL (30 tabs 30 days) fluoxetine hcl CAPS 10mg $5 QL (30 caps 30 days) fluoxetine hcl CAPS 20mg $5 QL (120 caps 30 days) fluoxetine hcl CAPS 40mg $5 QL (60 caps 30 days) fluoxetine hcl SOLN $5 QL (600 mL 30 days) fluoxetine hcl TABS 10mg $5 QL (45 tabs 30 days) fluoxetine hcl TABS 20mg $5 QL (120 tabs 30 days) imipramine hcl TABS $5 maprotiline hcl $5 MARPLAN $80 mirtazapine TABS 75mg 15mg $5 QL (45 tabs 30 days) mirtazapine TABS 30mg 45mg $5 mirtazapine TBDP 15mg $5 QL (30 tabs 30 days) mirtazapine TBDP 30mg 45mg $5 nefazodone hcl $5 nortriptyline hcl CAPS SOLN $5 paroxetine hcl TABS 10mg 20mg

40mg $5 QL (45 tabs 30 days)

paroxetine hcl TABS 30mg $5 QL (60 tabs 30 days) paroxetine hcl TB24 125mg $5 QL (30 tabs 30 days) paroxetine hcl TB24 25mg $5 QL (90 ea 30 days) paroxetine hcl TB24 375mg $5 QL (60 ea 30 days) PAXIL SUSP $80 QL (900 mL 30 days) phenelzine sulfate TABS $5 PRISTIQ $40 QL (30 tabs 30 days) protriptyline hcl $5 sertraline hcl CONC $5 sertraline hcl TABS 25mg 50mg $5 QL (45 tabs 30 days) sertraline hcl TABS 100mg $5 tranylcypromine sulfate $5 trazodone hcl TABS 50mg 100mg

150mg $5

trimipramine maleate $5 venlafaxine hcl CP24 375mg 75mg $5 QL (30 caps 30 days) venlafaxine hcl CP24 150mg $5 QL (60 caps 30 days) venlafaxine hcl TABS $5 VIIBRYD KIT $40 VIIBRYD TABS $40 QL (30 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

26

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS SYRP TABS $5 APOKYN 25 LA AZILECT $40 benztropine mesylate SOLN TABS $5 bromocriptine mesylate CAPS TABS $5 carbidopa-levodopa $5 CARBIDOPALEVODOPAENTACA $5 COMTAN $80 entacapone $5 LODOSYN $80 NEUPRO $80 pramipexole dihydrochloride $5 ropinirole hydrochloride TABS $5 selegiline hcl CAPS TABS $5 STALEVO $40 trihexyphenidyl hcl $5 ANTIPSYCHOTICS ABILIFY SOLN $80 QL (3 vials 1 day) ABILIFY TABS $40 QL (30 tabs 30 days) ABILIFY DISCMELT $40 QL (60 tabs 30 days) ABILIFY MAINTENA 25 QL (1 vial 30 days) PA ABILIFY SOL 1MGML $40 QL (900 mL 30 days) chlorpromazine hcl SOLN $80 chlorpromazine hcl TABS $5 clozapine 25mg 50mg $5 clozapine 100mg $5 QL (270 tabs 30 days) clozapine 200mg $5 QL (135 tabs 30 days) CLOZAPINE ODT 125mg 25mg $5 CLOZAPINE ODT 100mg $5 QL (270 ea 30 days) FANAPT $80 QL (60 tabs 30 days)

ST FANAPT TITRATION PACK $80 QL (1 pack 30 days) ST FAZACLO 125mg 25mg $80 FAZACLO 100mg $80 QL (270 tabs 30 days) FAZACLO 150mg $80 QL (180 tabs 30 days) FAZACLO 200mg $80 QL (135 tabs 30 days) fluphenazine decanoate SOLN $5 fluphenazine hcl $5 GEODON SOLR $80 QL (6 mL 3 days) haloperidol TABS $5 haloperidol decanoate SOLN $5 haloperidol lactate $5 INVEGA 15mg 3mg 9mg $80 QL (30 tabs 30 days) INVEGA 6mg $80 QL (60 tabs 30 days)

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

27

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

INVEGA SUSTENNA 39mg025ml $80 QL (025 mL 28 days) PA

INVEGA SUSTENNA 78mg05ml $80 QL (05 mL 28 days) PA

INVEGA SUSTENNA 117mg075ml 25 QL (075 mL 28 days) PA

INVEGA SUSTENNA 156mgml 25 QL (1 mL 28 days) PA INVEGA SUSTENNA 234mg15ml 25 QL (15 mL 28 days)

PA LATUDA 20mg $80 LATUDA 40mg 120mg $80 QL (30 tabs 30 days) LATUDA 80mg $80 QL (60 tabs 30 days) loxapine succinate CAPS $5 olanzapine SOLR $5 QL (3 vials 1 day) olanzapine TABS 25mg 5mg 75mg $5

15mg 20mg QL (30 tabs 30 days)

olanzapine TABS 10mg $5 QL (60 tabs 30 days) olanzapine TBDP 5mg 15mg 20mg $5 QL (30 tabs 30 days) olanzapine TBDP 10mg $5 QL (60 tabs 30 days) ORAP $40 perphenazine TABS $5 quetiapine fumarate 25mg 50mg $5

100mg 200mg QL (90 tabs 30 days)

quetiapine fumarate 300mg 400mg $5 QL (60 tabs 30 days) RISPERDAL CONSTA 125mg 25mg $80 QL (2 inj 28 days) PA RISPERDAL CONSTA 375mg 50mg 25 QL (2 inj 28 days) PA risperidone SOLN $5 QL (240 mL 30 days) risperidone TABS 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TABS 4mg $5 QL (120 tabs 30 days) risperidone TABS 25mg 5mg $5 QL (90 tabs 30 days) risperidone TBDP 1mg 2mg 3mg $5 QL (60 tabs 30 days) risperidone TBDP 4mg $5 QL (120 tabs 30 days) risperidone TBDP 25mg 5mg $5 QL (90 tabs 30 days) SAPHRIS $80 QL (60 tabs 30 days)

ST SEROQUEL XR 50mg $40 QL (120 ea 30 days) SEROQUEL XR 150mg 200mg $40 QL (30 ea 30 days) SEROQUEL XR 300mg 400mg $40 QL (60 ea 30 days) thioridazine hcl TABS $5 PA thiothixene $5 trifluoperazine hcl $5 ziprasidone hcl $5 QL (60 caps 30 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine $5 INTUNIV $80 ST metadate $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

28

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

methylphenidate hcl SOLN $5 methylphenidate hcl TABS $5 methylphenidate hcl TBCR 20mg $5 STRATTERA 10mg 18mg 25mg $80 QL (120 caps 30 days)

ST STRATTERA 40mg $80 QL (60 caps 30 days)

ST STRATTERA 60mg 80mg 100mg $80 QL (30 caps 30 days)

ST HYPNOTICS LUNESTA $40 QL (30 tabs 30 days) zaleplon $5 QL (30 caps 30 days) zolpidem tartrate TABS $5 QL (30 tabs 30 days) MIGRAINE dihydroergotamine mesylate $5 ergotamine w caffeine $80 naratriptan hcl $5 QL (9 tabs 30 days) RELPAX $40 QL (12 tabs 30 days) rizatriptan benzoate tabs $5 QL (12 tabs 30 days) sumatriptan succinate SOLN $5 QL (12 sprays 30 days) sumatriptan succinate TABS $5 QL (9 tabs 30 days) SUMATRIPTAN SUCCINATE INJ

4mg05ml $5 QL (4 mL 30 days)

sumatriptan succinate inj 6mg05ml $5 QL (4 mL 30 days) zolmitriptan $5 QL (12 tabs 30 days) zolmitriptan odt $5 QL (12 ea 30 days) MISCELLANEOUS lithium carbonate CAPS TABS TBCR $5 LITHIUM CITRATE $40 MESTINON SYRUP $40 MESTINON TIMESPAN $40 NUEDEXTA $40 QL (60 caps 30 days)

PA pyridostigmine bromide TABS $5 REGONOL $40 RILUTEK 25 SAVELLA 125mg $40 QL (480 tabs 30 days) SAVELLA 25mg $40 QL (240 tabs 30 days) SAVELLA 50mg $40 QL (120 tabs 30 days) SAVELLA 100mg $40 QL (60 tabs 30 days) SAVELLA TITRATION PACK $40 XENAZINE 125mg 25 QL (240 tabs 30 days)

LA PA XENAZINE 25mg 25 QL (120 tabs 30 days)

LA PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

29

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

MULTIPLE SCLEROSIS AGENTS AMPYRA 25 QL (60 tabs 30 days)

LA PA AVONEX 25 QL (4 boxes 28 days)

PA BETASERON 25 QL (14 vials 28 days)

PA COPAXONE 25 QL (30 boxes 30 days)

PA GILENYA 25 QL (30 caps 30 days)

PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS $5 dantrolene sodium CAPS $5 tizanidine hcl TABS $5 NARCOLEPSYCATAPLEXY modafinil 100mg 25 QL (30 tabs 30 days)

PA modafinil 200mg 25 QL (60 tabs 30 days)

PA XYREM 25 QL (540mL 30 days)

LA PA PSYCHOTHERAPEUTIC-MISC buprenorphine hcl SUBL $5 PA buprenorphine-naloxone subl $5 QL (120 ea 30 days) PA buproban $5 CAMPRAL $80 CHANTIX $80 QL (336 tabs year) PA CHANTIX STARTER PACK $80 QL (106 tabs year) PA disulfiram TABS $5 naloxone hcl SOLN $5 naltrexone hcl TABS $5 NICOTROL INHALER $80 QL (16 inhalers year) NICOTROL NS $80 QL (36 bottles year) SUBOXONE $80 QL (120 ea 30 days) PA SUBOXONE FILM 2-05MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 4-1MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 8-2MG $80 QL (120 ea 30 days) PA SUBOXONE FILM 12-3MG $80 QL (60 ea 30 days) PA

ENDOCRINE AND METABOLIC ANDROGENS ANDROGEL 1 25mg25gm $40

50mg5gm QL (300 gm 30 days)

PA ANDROGEL 162 2025mg125gm $40

405mg25gm QL (150 gm 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

30

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

androxy $40 PA oxandrolone TABS $5 PA TESTIM $80 QL (300 gm 30 days)

PA testosterone cypionate OIL $5 testosterone enanthate OIL $5 ANTIDIABETICS INJECTABLE alcohol swabs $40 BYETTA $80 QL (1 pen 30 days) PA gauze pads 2 x 2 $40 HUMULIN R U-500 (CONCENTRATE) $40 BD insulin pen needle $40 insulin syringe $40 LANTUS $40 LANTUS SOLOSTAR $40 LEVEMIR $40 LEVEMIR FLEXPEN $40 NOVOLIN 7030 $40 RELION not covered NOVOLIN N $40 RELION not covered NOVOLIN R $40 RELION not covered NOVOLOG $40 NOVOLOG FLEXPEN $40 NOVOLOG MIX 7030 $40 NOVOLOG MIX 7030 PREFILL $40 SYMLINPEN 60 $80 QL (8 vials 30 days) PA SYMLINPEN 120 $80 QL (4 vials 30 days) PA VICTOZA $40 QL (3 pens 30 days) ANTIDIABETICS ORAL acarbose $5 glimepiride 1mg $5 QL (240 tabs 30 days) glimepiride 2mg $5 QL (120 tabs 30 days) glimepiride 4mg $5 QL (60 tabs 30 days) glipizide TABS 5mg $5 QL (240 tabs 30 days) glipizide TABS 10mg $5 QL (120 tabs 30 days) glipizide TB24 25mg $5 QL (240 ea 30 days) glipizide TB24 5mg $5 QL (120 ea 30 days) glipizide TB24 10mg $5 QL (60 ea 30 days) glipizide-metformin 25-250mg $5 QL (240 tabs 30 days) glipizide-metformin 25-500mg $5 QL (120 tabs 30 days) glipizide-metformin 5-500mg $5 QL (120 tabs 30 days) glyburide 125mg $5 QL (480 tabs 30 days)

PA glyburide 25mg $5 QL (240 tabs 30 days)

PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

31

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

glyburide 5mg $5 QL (120 tabs 30 days) PA

glyburide micronized 15mg $5 QL (240 tabs 30 days) PA

glyburide micronized 3mg $5 QL (120 tabs 30 days) PA

glyburide micronized 6mg $5 QL (60 tabs 30 days) PA

glyburide-metformin 125-250mg $5 QL (240 tabs 30 days) PA

glyburide-metformin 25-500mg $5 QL (120 tabs 30 days) PA

glyburide-metformin 5-500mg $5 QL (120 tabs 30 days) PA

JANUMET $40 QL (60 tabs 30 days) JANUMET XR TAB 50-500MG $40 QL (60 ea 30 days) JANUMET XR TAB 50-1000 $40 QL (60 ea 30 days) JANUMET XR TAB 100-1000 $40 QL (30 ea 30 days) JANUVIA $40 QL (30 tabs 30 days) JENTADUETO $40 QL (60 tabs 30 days) JUVISYNC $40 QL (30 tabs 30 days) metformin hcl TABS 500mg $5 QL (150 tabs 30 days) metformin hcl TABS 850mg $5 QL (90 tabs 30 days) metformin hcl TABS 1000mg $5 QL (75 tabs 30 days) metformin hcl TB24 500mg $5 QL (120 ea 30 days) metformin hcl TB24 750mg $5 QL (60 ea 30 days) nateglinide $5 QL (90 tabs 30 days) pioglitazone hcl $5 QL (30 tabs 30 days) pioglitazone hcl-glimepiride $5 QL (30 tabs 30 days) pioglitazone hcl-metformin hcl $5 QL (90 tabs 30 days) PRANDIN 2mg $80 QL (240 tabs 30 days) PRANDIN 5mg 1mg $80 QL (120 tabs 30 days) RIOMET $40 QL (946mL 30 days) TRADJENTA $40 QL (30 tabs 30 days) BISPHOSPHONATES alendronate sodium tabs 5mg 10mg

40mg $5

alendronate sodium tabs 35mg 70mg $5 QL (4 tabs 28 days) BONIVA SOLN $80 BD QL (1 syringe 90

days) ibandronate sodium $5 BD QL (1 tab 30 days) zoledronic acid inj 4mg5ml 25 BD ZOMETA 25 BD CALCITONINS calcitonin (salmon) nasal spray $5 FORTICAL $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

32

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg $40 QL (120 tabs 30 days) SENSIPAR 60mg 25 QL (60 tabs 30 days) SENSIPAR 90mg 25 QL (120 tabs 30 days) CHELATING AGENTS CHEMET $80 EXJADE 25 LA PA kionex $5 sodium polystyrene sulfonate $5 SYPRINE 25 CONTRACEPTIVES apri 28 day $5 aranelle 28 $5 aviane 28 $5 balziva 28 day $5 briellyn 28 day $5 camila 28 day $5 cryselle 28 $5 cyclafem 135 28 day $5 cyclafem 777 28 day $5 drospirenone-ethinyl estradiol $5 ELLA $40 emoquette $5 enpresse 28 day $5 errin 28 day $5 GIANVI $5 gildagia $5 introvale 91 day $5 JOLIVETTE $5 junel 1530 21 day $5 junel 120 21 day $5 junel fe 1530 28 day $5 junel fe 120 28 day $5 kariva 28 day $5 kelnor 135 28 day $5 LEENA $5 lessina 28 day $5 levonest 28 day $5 levonorgestrel (emergency oc) $5 levonorgestrel-ethinyl estradiol (91-day) $5 levora 01530 28 day $5 loryna 28 day $5 low-ogestrel 28 day $5 lutera 28 day $5 marlissa 28 day $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

33

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

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ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

medroxyprogesterone acetate (contraceptive)

$5 QL (1 vial 90 days)

microgestin 1530 21 day $5 microgestin 120 21 day $5 microgestin fe 1530 28 day $5 microgestin fe 120 28 day $5 MONONESSA $5 myzilra $5 necon 0535 28 day $5 necon 135 28 day $5 NECON 777 $5 NECON 1011 28 DAY $80 next choice $5 NORA-BE $5 nortrel 0535 28 day $5 nortrel 135 21 day $5 nortrel 135 28 day $5 nortrel 777 28 day $5 NUVARING $80 OCELLA $5 ogestrel 28 day $5 orsythia 28 day $5 ORTHO EVRA $80 ORTHO TRI-CYCLEN LO $80 philith $5 portia 28 day $5 previfem 28 day $5 quasense 91 day $5 reclipsen 28 day $5 SOLIA $5 sprintec 28 day $5 sronyx 28 day $5 tri-legest 28 $5 tri-previfem 28 day $5 tri-sprintec 28 day $5 TRINESSA $5 trivora 28 day $5 velivet 28 day $5 vestura $5 viorele $5 zovia 135e 28 day $5 zovia 150e 28 day $5 ENDOMETRIOSIS danazol CAPS $5 SYNAREL 25

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

34

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

ENZYME REPLACEMENTS ADAGEN 25 LA ALDURAZYME 25 LA BUPHENYL 25 CARBAGLU 25 LA CEREZYME 200unit 25 CYSTADANE 25 CYSTAGON $40 ELAPRASE 25 ELELYSO 25 PA FABRAZYME 35mg 25 KUVAN 25 levocarnitine (metabolic modifiers) $5 BD LUMIZYME 25 PA MYOZYME 25 NAGLAZYME 25 LA ORFADIN 25 LA sodium phenylbutyrate 25 VPRIV 25 PA ZAVESCA 25 LA ESTROGENPROGESTINS COMBIPATCH $80 jinteli $5 ESTROGENS estradiol PTWK TABS $5 PA estradiol valerate OIL $5 MENEST $40 PA PREMARIN CREAM $80 VAGIFEM $80 GLUCOCORTICOIDS a-hydrocort $5 cortisone acetate TABS $5 dexamethasone CONC $80 dexamethasone ELIX TABS $5 dexamethasone sodium phosphate $5 fludrocortisone acetate TABS $5 hydrocortisone TABS $5 methylprednisolone TABS $5 methylprednisolone acetate $5 methylprednisolone sod succ $5 prednisolone sodium phosphate $5 prednisone CONC $40 prednisone SOLN TABS $5 SOLU-CORTEF 250mg $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

35

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment RequirementsLimits Coinsurance

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT $40 GLUCAGON EMERGENCY KIT $40

PROGLYCEM 25 HUMAN GROWTH HORMONES

NORDITROPIN FLEXPRO 25 PA NORDITROPIN NORDIFLEX PEN 25 PA

TEV-TROPIN 25 PA MISCELLANEOUS

cabergoline $5 INCRELEX 25 LA PA

methylergonovine maleate TABS $5 octreotide acetate 50mcgml $5 PA

100mcgml 200mcgml octreotide acetate 500mcgml 25 PA

1000mcgml PROLIA $80 QL (1 syringe 180 days)

SANDOSTATIN LAR DEPOT 25 PA SOMATULINE DEPOT 25 PA SOMAVERT 25 LA PA

PARATHYROID HORMONES FORTEO 25 QL (1 pen 28 days) PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) $5

FOSRENOL $80 PHOSLO $40 PHOSLYRA $40 RENVELA $40

PROGESTINS medroxyprogesterone acetate $5

norethindrone acetate TABS $5 SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA $40 QL (30 tabs 30 days) THYROID AGENTS

LEVOTHROID $5 levothyroxine sodium TABS $5

LEVOXYL $5 liothyronine sodium TABS $5

methimazole TABS $5 propylthiouracil TABS $5 SYNTHROID $40 UNITHROID $5

VASOPRESSINS desmopressin acetate spray $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 36 pharmacies

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

G

Drug Name Copayment Coinsurance

RequirementsLimits

desmopressin acetate spray refrigerated $5 desmopressin acetate tabs $5

desmopressin inj $5 DESMOPRESSIN SOLN 001 $5

ASTROINTESTINAL

ANTIEMETICS compro $5

dronabinol 25mg 5mg $5 BD QL (60 caps 30 days)

dronabinol 10mg 25 BD QL (60 caps 30 days)

EMEND CAPS 40mg $80 QL (3 caps 180 days) EMEND CAPS 80mg $80 BD QL (4 caps 30

days) EMEND CAPS 125mg $80 BD QL (2 caps 30

days) EMEND PAK 80 amp 125 $80 BD QL (12 caps 30

days) granisetron hcl SOLN 1mgml 1mgml $5 granisetron hcl TABS $5 BD

meclizine hcl TABS $5 metoclopramide hcl SOLN TABS $5

ondansetron hcl TABS $5 BD ondansetron hcl inj $5 ondansetron hcl oral soln $5 BD ondansetron odt $5 BD

phenadoz $5 prochlorperazine $5

prochlorperazine edisylate $5 prochlorperazine maleate TABS $5

promethazine hcl SOLN 25mgml 50mgml

$5

promethazine hcl SUPP $5 promethegan $5 TRANSDERM-SCOP $80 QL (10 ptch 30 days)

PA ANTISPASMODICS

CUVPOSA $80 dicyclomine hcl $5

glycopyrrolate SOLN 4mg20ml $5 glycopyrrolate TABS $5

H2-RECEPTOR ANTAGONISTS famotidine TABS 20mg 40mg $5 famotidine in nacl $5 famotidine inj $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 37

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

famotidine oral sus 40mg5ml $5 ranitidine hcl TABS 150mg 300mg $5 ranitidine hcl inj $5 ranitidine syp $5 INFLAMMATORY BOWEL DISEASE APRISO $40 ASACOL $80 ASACOL HD $80 balsalazide disodium $5 budesonide ec 25 CANASA $40 QL (30 supp 30 days) colocort $5 hydrocortisone (intrarectal) $5 LIALDA $80 mesalamine w cleanser $5 PENTASA $80 sulfasalazine TABS TBEC $5 UCERIS $80 LAXATIVES constulose $5 enulose $5 gaviltye-g $5 gavilyte-c $5 gavilyte-n $5 generlac $5 lactulose SOLN $5 MOVIPREP $80 polyethylene glycol 3350 POWD $5 RELISTOR KIT $80 PA trilyte $5 MISCELLANEOUS AMITIZA $40 QL (60 caps 30 days)

ST CARAFATE SUSP $80 cromolyn sodium (mastocytosis) $5 diphenoxylate w atropine $5 PA HELIDAC $80 loperamide hcl CAPS $5 LOTRONEX 25 misoprostol $5 PREVPAC $80 QL (1 box year) PYLERA $80 SUCRAID $80 sucralfate TABS $5 ursodiol CAPS TABS $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

38

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

XIFAXAN 550mg 25 PA PANCREATIC ENZYMES CREON $80 ZENPEP $40 PROTON PUMP INHIBITORS DEXILANT $40 QL (30 ea 30 days) NEXIUM CPDR $40 QL (30 ea 30 days) NEXIUM PACK 25mg 5mg $40 NEXIUM PACK 10mg 20mg 40mg $40 QL (30 ea 30 days) NEXIUM IV $80 omeprazole CPDR 10mg 40mg $5 QL (30 ea 30 days) omeprazole CPDR 20mg $5 QL (60 ea 30 days) pantoprazole sodium TBEC $5 QL (30 ea 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl $5 QL (30 ea 30 days) AVODART $40 QL (30 caps 30 days) finasteride TABS 5mg $5 QL (30 tabs 30 days) JALYN $40 QL (30 caps 30 days) tamsulosin hcl $5 QL (60 caps 30 days) MISCELLANEOUS bethanechol chloride TABS $5 ELMIRON $80 potassium citrate (alkalinizer) $5 URINARY ANTISPASMODICS DETROL LA $40 QL (30 ea 30 days) oxybutynin chloride SYRP $5 oxybutynin chloride TABS $5 oxybutynin chloride TB24 5mg $5 QL (30 ea 30 days) oxybutynin chloride TB24 10mg 15mg $5 QL (60 ea 30 days) tolterodine tartrate $5 TOVIAZ $40 QL (30 ea 30 days) trospium cl tab 20mg $5 QL (60 tabs 30 days) VESICARE $80 QL (30 tabs 30 days) VAGINAL ANTI-INFECTIVES CLEOCIN SUPP $40 clindamycin phosphate vaginal $5 metronidazole vaginal $5 terconazole vaginal $5 VANDAZOLE $5 zazole 4 $5 ZAZOLE 8 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

39

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment RequirementsLimits Coinsurance

HEMATOLOGIC ANTICOAGULANTS COUMADIN TABS $80 ELIQUIS $40 enoxaparin sodium 30mg03ml $5 QL (200 syringes 180

days) enoxaparin sodium 40mg04ml $5 QL (150 syringes 180

days) enoxaparin sodium 60mg06ml $5 QL (100 syringes 180

days) enoxaparin sodium 80mg08ml $5 QL (75 syringes 180

days) enoxaparin sodium 100mgml 25 QL (60 syringes 180

150mgml days) enoxaparin sodium 120mg08ml 25 QL (75 syringes 180

days) enoxaparin sodium 300mg3ml 25 QL (60mL 180 days) fondaparinux sodium 25mg05ml $5 QL (60 syringes 180

days) fondaparinux sodium 5mg04ml 25 QL (75 syringes 180

days) fondaparinux sodium 75mg06ml 25 QL (50 syringes 180

days) fondaparinux sodium 10mg08ml 25 QL (37 syringes 180

days) HEPARIN SODIUM SOLN 2000unitml $40 BD heparin sodium (porcine) $5 BD HEPARIN SODIUMD5W $5 HEPARIN SODIUMNACL 045 $40 HEPARIN SODIUMSODIUM CHL $5 jantoven $5 PRADAXA $40 warfarin sodium $5 XARELTO $40 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg042ml $40 PA

25mcgml 40mcg04ml 40mcgml 60mcg03ml 60mcgml

ARANESP ALBUMIN FREE 100mcg05ml 25 PA 100mcgml 150mcg03ml

200mcg04ml 200mcgml 300mcg06ml 300mcgml 500mcgml

LEUKINE 25 PA MOZOBIL 25 QL (8 vials 4 days) PA NEUMEGA 25 NEUPOGEN 300mcg05ml 25 PA

480mcg08ml 480mcg16ml All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 40

pharmacies

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

I

Drug Name Copayment Coinsurance

RequirementsLimits

PROCRIT 2000unitml 3000unitml 4000unitml 10000unitml

$40 PA

PROCRIT 20000unitml 40000unitml 25 PA MISCELLANEOUS

anagrelide hcl $5 PA cilostazol $5 pentoxifylline TBCR $5 PROMACTA 125mg 25mg 50mg 25 LA PA PROMACTA 75mg 25 QL (30 tabs 30 days)

LA PA tranexamic acid SOLN TABS $5

PLATELET AGGREGATION INHIBITO RS AGGRENOX $80 BRILINTA $80

clopidogrel bisulfate 75mg $5 QL (30 tabs 30 days) EFFIENT $80

MMUNOLOGIC AGENTS

DISEASE-MODIFYING ANTI-RHEUMA TIC DRUGS (D MARDS) ACTEMRA 200mg10ml 25 PA

ENBREL KIT 25 QL (4 boxes 28 days) PA

ENBREL SOLN 25 QL (8 syringes 28 days) PA

HUMIRA 20mg04ml 25 QL (2 boxes 28 days) PA

HUMIRA 40mg08ml 25 QL (4 boxes 28 days) PA

HUMIRA PEN 25 QL (4 boxes 28 days) PA

HUMIRA PEN-CROHNS DISEASE 25 PA hydroxychloroquine sulfate $5

leflunomide TABS $5 methotrexate sodium tabs $5

REMICADE 25 PA IMMUNOGLOBULINS

CARIMUNE NANOFILTERED 3gm 25 PA FLEBOGAMMA 5gm10ml 25 PA

GAMASTAN SD $40 BD GAMMAGARD LIQUID 25 PA

GAMMAKED 1gm10ml 25 PA GAMMAPLEX 10gm200ml 25 PA

GAMUNEX-C 1gm10ml 25 PA HIZENTRA 1gm5ml 25 PA OCTAGAM 1gm20ml 25 PA PRIVIGEN 20gm200ml 40gm400ml 25 PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

41

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

IMMUNOMODULATORS ACTIMMUNE 25 LA PA ARCALYST 25 PA INFERGEN 15mcg05ml 25 PA INTRON-A KIT 3mu02ml 5mu02ml 25 BD INTRON-A KIT 10mu02ml $80 BD INTRON-A SOLN 6000000unitml 25 BD INTRON-A WDILUENT 10mu 25 BD PEG-INTRON 25 PA PEG-INTRON REDIPEN 25 PA PEGASYS KIT 25 PA PEGASYS SOLN 180mcgml 25 PA PEGASYS PROCLICK 135mcg05ml 25 PA REVLIMID 25mg 5mg 10mg 20mg 25 LA PA REVLIMID 15mg 25 QL (30 caps 30 days)

LA PA REVLIMID 25mg 25 QL (21 caps 28 days)

LA PA THALOMID 50mg 100mg 25 QL (28 caps 28 days)

PA THALOMID 150mg 200mg 25 QL (60 caps 30 days)

PA IMMUNOSUPPRESSANTS azathioprine TABS $5 BD azathioprine sodium $5 BD CELLCEPT SUSR 25 BD cyclosporine CAPS SOLN $5 BD cyclosporine modified (for microemulsion) $5 BD gengraf $5 BD mycophenolate mofetil $5 BD MYFORTIC 180mg $80 BD MYFORTIC 360mg 25 BD NEORAL $40 BD NULOJIX 25 BD PROGRAF CAPS 5mg 25 BD PROGRAF CAPS 5mg 1mg $80 BD RAPAMUNE SOLN 25 BD RAPAMUNE TABS 1mg 2mg 25 BD RAPAMUNE TABS 5mg $80 BD SANDIMMUNE CAPS $40 BD SANDIMMUNE SOLN 100mgml $40 BD tacrolimus CAPS 5mg 25 BD tacrolimus CAPS 5mg 1mg $5 BD ZORTRESS 25 BD VACCINES

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

42

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

N

Drug Name Copayment Coinsurance

RequirementsLimits

ACTHIB $40 ADACEL $40

BOOSTRIX $40 CERVARIX $40 COMVAX $40 DAPTACEL $40 DECAVAC $40 BD

DIPHTHERIATETANUS TOXOID $40 BD ENGERIX-B SUSP $40 BD

GARDASIL $40 HAVRIX $40

IMOVAX RABIES (HDCV) $40 INFANRIX $40

IPOL INACTIVATED IPV $40 IXIARO $40

M-M-R II WDILUENT 10 DOS $40 MENACTRA $40 MENHIBRIX $40 MENOMUNE-ACYW-135 $40 MENVEO $40

PEDVAX HIB $40 PROQUAD $40 RABAVERT $40

RECOMBIVAX HB 10mcgml 40mcgml $40 BD ROTATEQ $40

TETANUS TOXOID ADSORBED $40 BD TETANUSDIPHTHERIA TOXOID $40 BD

TWINRIX $40 BD TYPHIM VI $40

VAQTA 25unit05ml $40 VARIVAX $40 YF-VAX $40 ZOSTAVAX $40 QL (1 vial)

UTRITIONALSUPPLEMENTS

ELECTROLYTES KLOR-CON TBCR 15meq $80 klor-con TBCR 20meq $5

KLOR-CON 8 $5 KLOR-CON 10 $5

MAGNESIUM SULFATE SOLN 40mgml 80mgml

$40

magnesium sulfate SOLN 50 $5 MAGNESIUM SULFATE IN D5W $40

potassium chloride caps er $5

All covered drugs are available through our Preferred Mail-Opharmacies

rder pharmacy in additi on to our Retail 43

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment RequirementsLimits Coinsurance

potassium chloride microencapsulated $5 crystals cr

sod fluoride 22mg tab $5 SODIUM CHLORIDE SOLN 25meqml $5

TPN ELECTROLYTES $5 BD IV NUTRITION

amino acid infusion $5 BD AMINOSYN $80 BD

AMINOSYN 85ELECTROLYTE $5 BD AMINOSYN II $80 BD AMINOSYN II 85ELECTROL $5 BD AMINOSYN M $80 BD

AMINOSYN-HBC $80 BD AMINOSYN-PF $80 BD

AMINOSYN-PF 7 $80 BD CLINIMIX 275DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 5 $80 BD CLINIMIX 425DEXTROSE 10 $80 BD CLINIMIX 425DEXTROSE 20 $80 BD CLINIMIX 425DEXTROSE 25 $80 BD CLINIMIX 5DEXTROSE 15 $80 BD CLINIMIX 5DEXTROSE 20 $80 BD CLINIMIX 5DEXTROSE 25 $80 BD CLINIMIX E 275DEXTROSE 5 $80 BD CLINIMIX E 275DEXTROSE 10 $80 BD CLINIMIX E 425DEXTROSE 5 $80 BD CLINIMIX E 425DEXTROSE 25 $80 BD CLINIMIX E 5DEXTROSE 15 $80 BD CLINIMIX E 5DEXTROSE 20 $80 BD CLINIMIX E 5DEXTROSE 25 $80 BD CLINISOL SF 15 $5 BD FREAMINE III $5 BD FREAMINE III 3 $80 BD

HEPATAMINE $5 BD hepatasol 8 $5 BD

INTRALIPID INJ 20 $5 BD INTRALIPID INJ 30 $40 BD

NEPHRAMINE $80 BD premasol $80 BD

PROCALAMINE $80 BD PROSOL $80 BD

TRAVASOL $80 BD TROPHAMINE INJ 10 $80 BD

IV REPLACEMENT SOLUTIONS DEXTROSE 25NACL 045 $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 44 pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

DEXTROSE 5 $5 DEXTROSE 5 ELECTROLYTE $40 DEXTROSE 5LACTATED RING $5 DEXTROSE 5NACL 02 $5 DEXTROSE 5NACL 09 $5 DEXTROSE 5NACL 033 $5 DEXTROSE 5NACL 045 $5 DEXTROSE 5NACL 0225 $5 DEXTROSE 5POTASSIUM CHL $5 DEXTROSE 10 FLEX CONTAIN $5 DEXTROSE 10NACL 02 $80 DEXTROSE 10NACL 045 $5 IONOSOL-BDEXTROSE 5 $80 IONOSOL-MBDEXTROSE 5 $80 isolyte m $5 isolyte p $80 isolyte s $80 isolyte s in 5 dextrose $80 ISOLYTE-HDEXTROSE 5 $40 KCL 03D5WNACL 09 $40 KCL 03D5WNACL 045 $5 KCL 015D5WNACL 02 $5 KCL 015D5WNACL 09 $5 KCL 015D5WNACL 0225 $40 KCL 0075D5WNACL 045 $5 KCLNACL INJ 03-09 $5 LACTATED RINGERS INJ $5 normosol-m $5 NORMOSOL-R $80 NORMOSOL-R IN D5W $80 PLASMA-LYTE A $80 PLASMA-LYTE-56D5W $80 PLASMA-LYTE-148 $80 potassium chloride SOLN 4meqml

2meqml 10meq100ml 10meq50ml 30meq100ml

$5

POTASSIUM CHLORIDE 03D $5 POTASSIUM CHLORIDE 015 $5 POTASSIUM CHLORIDE 022 $5 POTASSIUM CHLORIDE 0224 $5 potassium chloride in nacl $5 ringers $5 SODIUM CHLORIDE SOLN 9 3 5 $5 SODIUM CHLORIDE 045 VIA $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

45

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

O

VITAMINS calcitriol CAPS $5 BD calcitriol inj $5 BD calcitriol oral soln 1 mcgml $5 BD prenatal vitaminfolic acid gt 08 mg $5

(generic)

ZEMPLAR CAPS $40 BD ZEMPLAR SOLN $80 BD

PHTHALMIC

ANTI-INFECTIVEANTI-INFLAMMATORY bacitracin-poly-neomycin-hc $5

blephamide OINT $40 neomycin-polymy-dexameth $5

neomycin-polymyxin-hc (ophth) $5 sulfacetamide sod-prednisolone $5

TOBRADEX OINT $40 TOBRADEX ST $40

tobramycin-dexamethasone $5 ZYLET $40

ANTI-INFECTIVES AZASITE $40

bacitracin (ophthalmic) $5 bacitracin-polymyxin b (ophth) $5 BESIVANCE $40

CILOXAN OINT $40 ciprofloxacin hcl (ophth) $5 erythromycin (ophth) $5

gentak $5 gentamicin sulfate (ophth) $5 MOXEZA $40 NATACYN $80 neomycin-bacitracin zn-polymyxin $5 neomycin-polymy-gramicid $5 ofloxacin (ophth) $5 polymyxin b-trimethoprim $5

sulfacetamide sodium (ophth) $5 tobramycin sulfate (ophth) $5

TOBREX OINT $40 trifluridine SOLN $5 VIGAMOX $40 ZYMAXID $80

ANTI-INFLAMMATORIES ALREX $40 BROMDAY $40

dexamethasone sodium phosphate (ophth) $5 All covered drugs are available through our Preferred Mail-Order pharmacy in additi

pharmacies on to our Retail 46

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment RequirementsLimits Coinsurance

diclofenac sodium (ophth) $5 DUREZOL $40 FLUOROMETHOLONE SUSP $5

flurbiprofen sodium $5 FML $40 FML FORTE $40 ILEVRO $40

ketorolac tromethamine (ophth) $5 LOTEMAX $40 MAXIDEX $80 NEVANAC $40

PRED MILD $40 PREDNISOLONE ACETATE SUSP $5

prednisolone sodium phosphate (ophth) $40 ANTIALLERGICS

azelastine hcl (ophth) $5 BEPREVE $40

cromolyn sodium (ophth) $5 PATADAY $40 PATANOL $40

ANTIGLAUCOMA ALPHAGAN P $40

AZOPT $40 betaxolol hcl (ophth) $5

BETOPTIC-S $40 brimonidine sol 02 op $5

BRIMONIDINE TARTRATE $5 carteolol hcl (ophth) $5

COMBIGAN $40 dorzolamide hcl $5 dorzolamide hcl-timolol maleate $5

ISOPTO CARPINE $80 ISTALOL $40

latanoprost $5 levobunolol hcl 5 $5

LEVOBUNOLOL HCL 25 $5 LUMIGAN $40 metipranolol $5

PHOSPHOLINE IODIDE $80 PILOCARPINE HCL SOLN $5

PILOPINE HS $40 timolol maleate (ophth) $5

TIMOLOL MALEATE GEL $5 TRAVATAN Z $40

MISCELLANEOUS All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 47

pharmacies

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

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ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

ak-con $5 PROLENSA $40 proparacaine hcl SOLN $5 RESTASIS $40 QL (64 ea 30 days) tropicamide SOLN $5

RESPIRATORY ANTICHOLINERGICBETA AGONIST COMBINATIONS COMBIVENT $80 QL (2 inhalers 30 days) COMBIVENT RESPIMAT $80 QL (2 inhalers 30 days) ipratropium-albuterol $5 BD ANTICHOLINERGICS ATROVENT HFA $80 QL (2 inhalers 30 days) ipratropium bromide SOLN $5 BD ipratropium bromide (nasal) $5 SPIRIVA HANDIHALER $40 QL (30 caps 30 days) ANTIHISTAMINES ASTEPRO $40 QL (2 inhalers 30 days) azelastine hcl $5 QL (2 inhalers 30 days) cetirizine syrup $5 diphenhydramine hcl SOLN $5 hydroxyz hcl inj $5 levocetirizine dihydrochloride $5 PATANASE $40 BETA AGONISTS albuterol sulfate NEBU $5 BD albuterol sulfate SYRP TABS TB12 $5 FORADIL AEROLIZER $40 QL (60 caps 30 days) levalbuterol conc 125mg05ml $5 BD PERFOROMIST $80 BD PROAIR HFA $40 QL (2 inhalers 30 days) SEREVENT DISKUS $80 QL (1 inhaler 30 days) terbutaline sulfate SOLN TABS $5 XOPENEX HFA $40 QL (2 inhalers 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW TABS $5 QL (30 tabs 30 days) montelukast sodium PACK $5 QL (30 packets 30

days) zafirlukast $5 MAST CELL STABILIZERS cromolyn sodium nebu $5 BD MISCELLANEOUS acetylcysteine SOLN 10 20 $5 BD ARALAST NP 400mg 25 LA PA AUVI-Q $40

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail pharmacies

48

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

CAYSTON 25 LA PA DALIRESP $40 EPIPEN 2-PAK $40 EPIPEN-JR 2-PAK $40 GLASSIA 25 LA PA PROLASTIN-C 25 LA PA PULMOZYME 25 BD TOBI 25 BD XOLAIR 25 QL (6 vials 30 days)

LA PA ZEMAIRA 25 LA PA NASAL STEROIDS flunisolide (nasal) $5 QL (2 inhalers 30 days) fluticasone propionate (nasal) $5 QL (1 inhaler 30 days) NASONEX $40 QL (2 inhalers 30 days) triamcinolone acetonide (nasal) $5 QL (1 inhaler 30 days) STEROID INHALANTS ASMANEX $40 QL (2 inhalers 30 days) budesonide (inhalation) $5 BD FLOVENT DISKUS 50mcgblist $40

100mcgblist QL (2 inhalers 30 days)

FLOVENT DISKUS 250mcgblist $40 QL (4 inhalers 30 days) FLOVENT HFA $40 QL (2 inhalers 30 days) PULMICORT 1mg2ml $80 BD QVAR $40 QL (3 inhalers 30 days) STEROIDBETA-AGONIST COMBINATIONS ADVAIR DISKUS $40 QL (1 inhaler 30 days) ADVAIR HFA $40 QL (1 inhaler 30 days) DULERA $40 QL (1 inhaler 30 days) SYMBICORT $40 QL (1 inhaler 30 days) XANTHINES aminophylline inj $5 ELIXOPHYLLIN $80 THEO-24 $80 theophylline TB12 TB24 $5 TOPICAL DERMATOLOGY ACNE adapalene $5 amnesteem $5 AVITA $5 benzoyl peroxide-erythromycin $5 claravis $5 clindamycin phosphate (topical) GEL $5

LOTN SOLN SWAB

ery $5 All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 49

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

erythromycin (acne aid) $5 myorisan $5 sulfacetamide sodium (acne) $5 tretinoin CREA GEL $5 zenatane $5 DERMATOLOGY ACTINIC KERATOSIS CARAC $80 FLUOROPLEX $80 fluorouracil (topical) $5 SOLARAZE $80 PA DERMATOLOGY ANTIBIOTICS gentamicin sulfate (topical) $5 mafenide acetate PACK $5 mupirocin oint 2 $5 SILVER SULFADIAZINE CREA $5 SSD $5 SULFAMYLON $80 THERMAZENE $5 DERMATOLOGY ANTIFUNGALS ciclopirox CREA GEL SUSP $5 ciclopirox shampoo 1 $5 clotrimazole (topical) $5 econazole nitrate CREA $5 ketoconazole cream $5 nyamyc $5 nystatin (topical) $5 nystop $5 pedi-dri $5 DERMATOLOGY ANTIPRURITIC proctocream $5 proctozone hc $5 PRUDOXIN $5 ZONALON $80 DERMATOLOGY ANTIPSORIATICS calcipotriene CREA OINT SOLN $5 OXSORALEN ULTRA 25 SORIATANE 25 PA TAZORAC $80 DERMATOLOGY ANTISEBORRHEICS ketoconazole shampoo $5 selenium sulfide LOTN $5 DERMATOLOGY ANTIVIRALS acyclovir topical $5 DENAVIR $80

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 50

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Drug Name Copayment Coinsurance

RequirementsLimits

ZOVIRAX CREA OINT $80 DERMATOLOGY CORTICOSTEROIDS ala-cort $5 alclometasone dipropionate $5 amcinonide CREA LOTN $5 amcinonide OINT $80 betamethasone dipropionate (topical) $5 betamethasone dipropionate augmented $5 betamethasone valerate CREA LOTN $5

OINT

clobetasol propionate GEL $5 clobetasol propionate OINT $5 clobetasol propionate SOLN $5 clobetasol propionate emollient base $5 DESONIDE CREA $5 desonide LOTN OINT $5 desoximetasone CREA $5 desoximetasone GEL $5 DESOXIMETASONE OINT 05 $5 desoximetasone OINT 25 $5 diflorasone diacetate $5 fluocinolone acetonide CREA OIL OINT $5

SOLN

fluocinonide GEL $5 fluocinonide OINT $5 fluocinonide SOLN $5 fluocinonide emulsified base $5 fluticasone propionate CREA $5 fluticasone propionate OINT $5 halobetasol propionate $5 hydrocortisone (topical) $5 hydrocortisone butyrate $5 hydrocortisone valerate $5 lokara $5 mometasone furoate CREA OINT SOLN $5 procto-pak $5 triamcinolone acetonide (topical) $5 triderm $5 DERMATOLOGY LOCAL ANESTHETICS lidocaine OINT $5 lidocaine hcl GEL $5 lidocaine hcl SOLN 4 $5 lidocaine-prilocaine $5 BD LIDODERM $40 QL (3 ptch 1 day) PA

All covered drugs are available through our Preferred Mail-Order pharmacy in addition pharmacies

to our Retail 51

Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

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ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

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trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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Drug Name Copayment RequirementsLimits Coinsurance

DERMATOLOGY MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL $80 ELIDEL $80 PA imiquimod CREA $5 laclotion $5 lactic acid (ammonium lactate) $5 metronidazole (topical) $5 PANRETIN 25 podofilox SOLN $5 PROTOPIC $80 PA TARGRETIN GEL 25 PA VOLTAREN $40

DERMATOLOGY SCABICIDES AND PEDICULIDES EURAX $80 malathion $5 permethrin CREA $5

DERMATOLOGY WOUND CARE AGENTS REGRANEX 25 PA SANTYL $80 SODIUM CHLORIDE 09 $5 STERILE WATER IRRIGATION $5

MOUTHTHROATDENTAL AGENTS cevimeline hcl $5 chlorhexidine gluconate (mouth-throat) $5 clotrimazole TROC $5 lidocaine hcl (mouth-throat) $5 nystatin (mouth-throat) $5 periogard $5 pilocarpine hcl (oral) $5 triamcinolone acetonide (mouth) $5

OTIC acetic acid (otic) $5 CIPRODEX $40 fluocinolone acetonide (otic) $5 neomycin-polymyxin-hc (otic) $5 ofloxacin (otic) $5

All covered drugs are available through our Preferred Mail-Order pharmacy in addition to our Retail 52 pharmacies

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

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ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

Index A13 amantadine hcl 27 abacavir sulfate 11 AMBISOME 11 ABELCET 11 amcinonide 51 ABILIFY 27 amifostine crystalline 17 ABILIFY DISCMELT 27 amikacin sulfate 9 ABILIFY MAINTENA 27 amiloride amp hydrochlorothiazide 21 ABILIFY SOL 1MGML 27 amiloride hcl 22 acarbose 31 amino acid infusion 44 acebutolol hcl 20 aminophylline inj 49 acetaminophen w codeine 7 AMINOSYN 44 acetazolamide 21 AMINOSYN 85ELECTROLYTE 44 acetic acid (otic) 52 AMINOSYN II 44 acetylcysteine 48 AMINOSYN II 85ELECTROL 44 ACTEMRA 41 AMINOSYN M 44 ACTHIB 43 AMINOSYN-HBC 44 ACTIMMUNE 42 AMINOSYN-PF 44 acyclovir 13 AMINOSYN-PF 7 44 acyclovir sodium for inj 13 amiodarone hcl 19 acyclovir topical 50 AMITIZA 38 ADACEL 43 amitriptyline hcl 25 ADAGEN 35 amlodipine besylate 20 adapalene 49 amlodipine besylate-benazepril hcl 18 ADCIRCA 23 amnesteem 49 adriamycin 14 amoxapine 25 ADVAIR DISKUS 49 amoxicillin 9 ADVAIR HFA 49 amoxicillin amp pot clavulanate 9 afeditab cr 20 amphetamine-dextroamphetamine 28 AFINITOR 16 amphotericin b 11 AFINITOR DISPERZ 16 ampicillin 9 AGGRENOX 41 ampicillin amp sulbactam sodium 9 a-hydrocort 35 ampicillin inj 9 ak-con 48 AMPYRA 30 ala-cort 51 AMTURNIDE 21 ALBENZA 13 anagrelide hcl 41 albuterol sulfate 48 anastrozole 15 alclometasone dipropionate 51 ANDROGEL 30 alcohol swabs 31 androxy 31 ALDURAZYME 35 ANTARA 19 alendronate sodium tabs 32 APOKYN 27 alfuzosin hcl 39 apri 28 day 33 ALIMTA 15 APRISO 38 ALINIA 13 APTIVUS 11 allopurinol sodium 7 ARALAST NP 48 allopurinol tab 7 aranelle 28 33 ALPHAGAN P 47 ARANESP ALBUMIN FREE 40 alprazolam 23 ARCALYST 42 ALREX 46 ARICEPT 25

53

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

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ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

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hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

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trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

ASACOL 38 BESIVANCE 46 ASACOL HD 38 betamethasone dipropionate (topical) 51 ASMANEX 49 betamethasone dipropionate augmentedASTEPRO 48 51 astramorph 7 betamethasone valerate 51 atenolol 20 BETASERON 30 atenolol amp chlorthalidone 20 betaxolol hcl (ophth) 47 atorvastatin calcium 19 bethanechol chloride 39 atovaquone-proguanil hcl 11 BETOPTIC-S 47 ATRIPLA 11 bicalutamide 16 ATROVENT HFA 48 BICILLIN C-R 9 AUVI-Q 48 BICILLIN L-A 9 AVASTIN 15 BICNU 14 AVELOX 9 BILTRICIDE 14 AVELOX ABC PACK 9 bisoprolol amp hydrochlorothiazide 20 aviane 28 33 bisoprolol fumarate 20 AVINZA 7 bleomycin sulfate 15 AVITA 49 blephamide 46 AVODART 39 BONIVA 32 AVONEX 30 BOOSTRIX 43 AZACTAM 13 BOSULIF 16 AZACTAM IN DEXTROSE 13 briellyn 28 day 33 AZASITE 46 BRILINTA 41 azathioprine 42 brimonidine sol 02 op 47 azathioprine sodium 42 BRIMONIDINE TARTRATE 47 azelastine hcl 48 BROMDAY 46 azelastine hcl (ophth) 47 bromocriptine mesylate 27 AZILECT 27 budeprion 25 azithromycin 9 budesonide (inhalation) 49 AZOPT 47 budesonide ec 38 AZOR 18 bumetanide 22 aztreonam 13 BUPHENYL 35 B13 buprenorphine hcl 30 bacitracin (ophthalmic) 46 buprenorphine-naloxone subl 30 bacitracin-polymyxin b (ophth) 46 buproban 30 bacitracin-poly-neomycin-hc 46 bupropion hcl 25 baclofen 30 bupropion hcl sr 25 balsalazide disodium 38 bupropion hcl xl 25 balziva 28 day 33 buspirone hcl 23 BANZEL 23 BUSULFEX 14 BARACLUDE 13 butorphanol tartrate 7 benazepril amp hydrochlorothiazide 18 BYETTA 31 benazepril hcl 18 BYSTOLIC 20 BENICAR 19 C13 BENICAR HCT 18 cabergoline 36 benzoyl peroxide-erythromycin 49 calcipotriene 50 benztropine mesylate 27 calcitonin (salmon) nasal spray 32 BEPREVE 47 calcitriol 46

54

calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

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diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

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trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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calcitriol inj 46 cevimeline hcl 52 calcitriol oral soln 1 mcgml 46 CHANTIX 30 calcium acetate (phosphate binder) 36 CHANTIX STARTER PACK 30 camila 28 day 33 CHEMET 33 CAMPATH 15 chlorhexidine gluconate (mouth-throat)CAMPRAL 30 52 CANASA 38 chloroquine phosphate 11 CANCIDAS 11 chlorothiazide 22 CAPASTAT SULFATE 12 chlorpromazine hcl 27 CAPRELSA 16 chlorthalidone 22 captopril 18 cholestyramine 19 captopril amp hydrochlorothiazide 18 cholestyramine light 19 CARAC 50 ciclopirox 50 CARAFATE 38 ciclopirox shampoo 1 50 CARBAGLU 35 cilostazol 41 carbamazepine 23 CILOXAN OINT 46 CARBIDOPALEVODOPAENTACA 27 CIPRO 10 carbidopa-levodopa 27 CIPRODEX 52 carboplatin 17 ciprofloxacin er 10 CARIMUNE NANOFILTERED 41 ciprofloxacin hcl 10 carteolol hcl (ophth) 47 ciprofloxacin hcl (ophth) 46 cartia 20 ciprofloxacin in d5w 10 carvedilol 20 ciprofloxacn inj 10 CAYSTON 49 cisplatin 17 CEENU 14 citalopram hydrobromide 25 cefaclor 9 cladribine 17 cefaclor er 9 claravis 49 cefadroxil 9 clarithromycin 10 cefazolin inj 9 CLEOCIN 39 cefazolindextrose 9 clindamycin hcl 14 cefdinir 9 clindamycin palmitate hydrochloride 14 cefepime hcl 9 clindamycin phosphate 14 cefotaxime sodium 9 clindamycin phosphate (topical) 49 cefoxitin sodium 9 clindamycin phosphate vaginal 39 cefpodoxime proxetil 9 CLINIMIX 275DEXTROSE 5 44 cefprozil 9 CLINIMIX 425DEXTROSE 10 44 ceftazidime 9 CLINIMIX 425DEXTROSE 20 44 CEFTAZIDIMEDEXTROSE 9 CLINIMIX 425DEXTROSE 25 44 ceftriaxone sodium 9 CLINIMIX 425DEXTROSE 5 44 cefuroxime axetil 9 CLINIMIX 5DEXTROSE 15 44 cefuroxime sodium 10 CLINIMIX 5DEXTROSE 20 44 CELEBREX 8 CLINIMIX 5DEXTROSE 25 44 CELLCEPT 42 CLINIMIX E 275DEXTROSE 10 44 CELONTIN 23 CLINIMIX E 275DEXTROSE 5 44 cephalexin 10 CLINIMIX E 425DEXTROSE 25 44 CEREZYME 35 CLINIMIX E 425DEXTROSE 5 44 CERVARIX 43 CLINIMIX E 5DEXTROSE 15 44 cetirizine syrup 48 CLINIMIX E 5DEXTROSE 20 44

55

CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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CLINIMIX E 5DEXTROSE 25 44 cyclosporine modified (for microemulsion)CLINISOL SF 15 44 42 clobetasol propionate 51 CYMBALTA 26 clobetasol propionate emollient base 51 CYSTADANE 35 clomipramine hcl 25 CYSTAGON 35 clonazepam 23 cytarabine inj 20mgml 15 clonidine hcl 18 cytarabine inj 500mg 15 clopidogrel bisulfate 41 D13 clorazepate dipotassium 23 dacarbazine 14 clotrimazole 52 DALIRESP 49 clotrimazole (topical) 50 danazol 34 clozapine 27 dantrolene sodium 30 CLOZAPINE ODT 27 dapsone 14 COARTEM 11 DAPTACEL 43 co-gesic 7 DARAPRIM 11 colchicine w probenecid 7 daunorubicin hcl 14 COLCRYS 7 DECAVAC 43 colestipol hcl 19 DENAVIR 50 colistimethate sodium 14 DEPO-PROVERA 16 colocort 38 desipramine hcl 26 COMBIGAN 47 desmopressin acetate spray 36 COMBIPATCH 35 desmopressin acetate spray refrigeratedCOMBIVENT 48 37 COMBIVENT RESPIMAT 48 desmopressin acetate tabs 37 COMETRIQ 16 desmopressin inj 37 COMPLERA 11 DESMOPRESSIN SOLN 001 37 compro 37 DESONIDE 51 COMTAN 27 desoximetasone 51 COMVAX 43 DETROL LA 39 CONDYLOX 52 dexamethasone 35 constulose 38 dexamethasone sodium phosphate 35 COPAXONE 30 dexamethasone sodium phosphate cortisone acetate 35 (ophth) 46 COSMEGEN 15 DEXILANT 39 COUMADIN 40 dexrazoxane 17 CREON 39 DEXTROSE 10 FLEX CONTAIN 45 CRESTOR 19 DEXTROSE 10NACL 02 45 CRIXIVAN 11 DEXTROSE 10NACL 045 45 cromolyn sodium (mastocytosis) 38 DEXTROSE 25NACL 045 44 cromolyn sodium (ophth) 47 DEXTROSE 5 45 cromolyn sodium nebu 48 DEXTROSE 5 ELECTROLYTE 45 cryselle 28 33 DEXTROSE 5LACTATED RING 45 CUBICIN 14 DEXTROSE 5NACL 02 45 CUVPOSA 37 DEXTROSE 5NACL 0225 45 cyclafem 135 28 day 33 DEXTROSE 5NACL 033 45 cyclafem 777 28 day 33 DEXTROSE 5NACL 045 45 cyclophosphamide 14 DEXTROSE 5NACL 09 45 cyclosporine 42 DEXTROSE 5POTASSIUM CHL 45

56

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

diazepam 24 DYRENIUM 22 DIAZEPAM GEL 24 E13 DIBENZYLINE 22 ees 10 diclofenac potassium 8 EES GRANULES 10 diclofenac sodium 8 econazole nitrate 50 diclofenac sodium (ophth) 47 EDECRIN 22 dicloxacillin sodium 10 EDURANT 12 dicyclomine hcl 37 EFFIENT 41 didanosine 12 ELAPRASE 35 DIFICID 10 ELELYSO 35 diflorasone diacetate 51 ELIDEL 52 diflunisal 8 ELIQUIS 40 digoxin 21 ELITEK 17 digoxin inj 21 ELIXOPHYLLIN 49 DIGOXIN SOL 50MCGML 21 ELLA 33 dihydroergotamine mesylate 29 ELMIRON 39 dilantin 24 ELSPAR 17 DILAUDID-5 7 EMCYT 14 dilt 20 EMEND 37 diltiazem hcl 21 EMEND PAK 80 amp 125 37 diltiazem hcl coated beads 21 emoquette 33 diltiazem hcl extended release beads 21 EMSAM 26 DIOVAN 19 EMTRIVA 12 diphenhydramine hcl 48 enalapril maleate 18 diphenoxylate w atropine 38 enalapril maleate amp hydrochlorothiazideDIPHTHERIATETANUS TOXOID 43 18 disopyramide phosphate 19 ENBREL 41 disulfiram 30 endocet 10325 7 DIURIL SUS 2505ML 22 endocet 10650 7 divalproex sodium 24 endocet 5325 7 DOCETAXEL 15 endocet 75325 7 donepezil hydrochloride 25 endocet 75500 7 DORIBAX 14 ENDODAN 7 dorzolamide hcl 47 ENGERIX-B 43 dorzolamide hcl-timolol maleate 47 enoxaparin sodium 40 doxazosin mesylate 18 enpresse 28 day 33 doxepin hcl 26 entacapone 27 DOXIL 15 enulose 38 doxorubicin hcl 15 EPIPEN 2-PAK 49 doxycycl hyc inj 10 EPIPEN-JR 2-PAK 49 doxycycline (monohydrate) 10 epirubicin hcl 15 doxycycline hyclate 10 epitol 24 dronabinol 37 EPIVIR HBV 13 drospirenone-ethinyl estradiol 33 EPIVIR SOL 10MGML 12 DROXIA 17 eplerenone 18 DULERA 49 EPZICOM 12 DURAMORPH 7 ERAXIS 11 DUREZOL 47 ergotamine w caffeine 29

57

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

ERIVEDGE 15 fentanyl 7 errin 28 day 33 fentanyl citrate 8 ery 49 finasteride 39 ERYPED 200 10 FLEBOGAMMA 41 ERYPED 400 10 flecainide acetate 19 ery-tab 10 FLOVENT DISKUS 49 erythrocin stearate 10 FLOVENT HFA 49 erythromycin (acne aid) 50 fluconazole 11 erythromycin (ophth) 46 fluconazole in dextrose 11 erythromycin base 10 flucytosine 11 erythromycin ethylsuccinate 10 fludarabine phosphate 17 escitalopram oxalate 26 fludrocortisone acetate 35 estradiol 35 flunisolide (nasal) 49 estradiol valerate 35 fluocinolone acetonide 51 ethambutol hcl 12 fluocinolone acetonide (otic) 52 ethosuximide 24 fluocinonide 51 etodolac 8 fluocinonide emulsified base 51 etodolac er 8 FLUOROMETHOLONE 47 etoposide 18 FLUOROPLEX 50 EURAX 52 fluorouracil 15 EVISTA 36 fluorouracil (topical) 50 EXALGO 7 fluoxetine hcl 26 EXELON PATCHES 25 fluphenazine decanoate 27 EXELON SOLN 25 fluphenazine hcl 27 exemestane 16 flurbiprofen 8 EXFORGE 18 flurbiprofen sodium 47 EXFORGE HCT 10-160-125MG 18 flutamide 16 EXFORGE HCT 10-160-25MG 18 fluticasone propionate 51 EXFORGE HCT 10-320-25MG 19 fluticasone propionate (nasal) 49 EXFORGE HCT 5-160-125MG 18 fluvoxamine maleate 23 EXFORGE HCT 5-160-25MG 18 FML 47 EXJADE 33 FML FORTE 47 F13 fondaparinux sodium 40 FABRAZYME 35 FORADIL AEROLIZER 48 famciclovir 13 FORTEO 36 famotidine 37 FORTICAL 32 famotidine in nacl 37 fosinopril sodium 18 famotidine inj 37 fosinopril sodium amp hydrochlorothiazidefamotidine oral sus 40mg5ml 38 18 FANAPT 27 FOSRENOL 36 FANAPT TITRATION PACK 27 FREAMINE III 44 FARESTON 16 FREAMINE III 3 44 FASLODEX 16 furosemide 22 FAZACLO 27 furosemide inj 22 felbamate 24 furosemide oral soln 8 mgml 22 felodipine 21 FUZEON 12 fenofibrate 19 G13 fenofibrate micronized 19 20 gabapentin 24

58

GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

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medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

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pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

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ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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GABITRIL 24 guanfacine hcl 18 galantamine hydrobromide 25 H13 GAMASTAN SD 41 halobetasol propionate 51 GAMMAGARD LIQUID 41 haloperidol 27 GAMMAKED 41 haloperidol decanoate 27 GAMMAPLEX 41 haloperidol lactate 27 GAMUNEX-C 41 HAVRIX 43 ganciclovir inj 500mg 13 HELIDAC 38 GARDASIL 43 HEPARIN SODIUM 40 gauze pads 2 x 2 31 heparin sodium (porcine) 40 gaviltye-g 38 HEPARIN SODIUMD5W 40 gavilyte-c 38 HEPARIN SODIUMNACL 045 40 gavilyte-n 38 HEPARIN SODIUMSODIUM CHL 40 gemcitabine hcl 15 HEPATAMINE 44 gemfibrozil 20 hepatasol 8 44 generlac 38 HEPSERA 13 gengraf 42 HERCEPTIN 15 gentak 46 HEXALEN 14 gentamicin in saline 09 mgml 10 HIZENTRA 41 gentamicin in saline 14 mgml 10 HUMIRA 41 gentamicin in saline 100mg 10 HUMIRA PEN 41 gentamicin in saline 60mg 10 HUMIRA PEN-CROHNS DISEASE 41 gentamicin in saline 80mg 10 HUMULIN R U-500 (CONCENTRATE) 31 gentamicin sulfate 10 hydralazine hcl 22 gentamicin sulfate (ophth) 46 hydrochlorothiazide 22 gentamicin sulfate (topical) 50 hydrocoapap sol 75-500 7 GEODON 27 hydrocoapap tab 10-325mg 7 GIANVI 33 hydrocoapap tab 10-500mg 7 gildagia 33 hydrocoapap tab 10-650mg 7 GILENYA 30 hydrocoapap tab 10-660mg 7 GLASSIA 49 hydrocoapap tab 10-750mg 7 GLEEVEC 16 hydrocoapap tab 25-500 7 glimepiride 31 hydrocoapap tab 5-325mg 7 glipizide 31 hydrocoapap tab 5-500mg 7 glipizide-metformin 25-250mg 31 hydrocoapap tab 75-325 7 glipizide-metformin 25-500mg 31 hydrocoapap tab 75-500 7 glipizide-metformin 5-500mg 31 hydrocoapap tab 75-650 7 GLUCAGEN HYPOKIT 36 hydrocoapap tab 75-750 7 GLUCAGON EMERGENCY KIT 36 hydrocodone-ibuprofen 7 glyburide 31 32 hydrocortisone 35 glyburide micronized 32 hydrocortisone (intrarectal) 38 glyburide-metformin 125-250mg 32 hydrocortisone (topical) 51 glyburide-metformin 25-500mg 32 hydrocortisone butyrate 51 glyburide-metformin 5-500mg 32 hydrocortisone valerate 51 glycopyrrolate 37 hydromorphon inj 10mgml 8 granisetron hcl 37 hydromorphone hcl 8 griseofulvin microsize 11 hydroxychloroquine sulfate 41 griseofulvin ultramicrosize 11 hydroxyurea 17

59

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

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KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

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ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

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SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

hydroxyz hcl inj 48 ISOPTO CARPINE 47 I13 isosorbide dinitrate 22 ibandronate sodium 32 isosorbide dinitrate sl tab 5 mg 22 ibuprofen 9 isosorbide mononitrate 22 ICLUSIG 16 isradipine 21 idarubicin hcl 15 ISTALOL 47 IFEX 14 ISTODAX 15 ifosfamide 14 itraconazole 11 ILEVRO 47 IXIARO 43 imipenem-cilastatin 14 J13 imipramine hcl 26 JAKAFI 16 imiquimod 52 JALYN 39 IMOVAX RABIES (HDCV) 43 jantoven 40 INCIVEK 13 JANUMET 32 INCRELEX 36 JANUMET XR TAB 100-1000 32 indapamide 22 JANUMET XR TAB 50-1000 32 INFANRIX 43 JANUMET XR TAB 50-500MG 32 INFERGEN 42 JANUVIA 32 INLYTA 16 JENTADUETO 32 insulin pen needle 31 jinteli 35 insulin syringe 31 JOLIVETTE 33 INTELENCE 12 junel 1530 21 day 33 INTRALIPID INJ 20 44 junel 120 21 day 33 INTRALIPID INJ 30 44 junel fe 1530 28 day 33 INTRON-A 42 junel fe 120 28 day 33 INTRON-A WDILUENT 42 JUVISYNC 32 introvale 91 day 33 K13 INTUNIV 28 KADCYLA 15 INVANZ 14 KADIAN 8 INVEGA 27 KALETRA SOL 12 INVEGA SUSTENNA 28 KALETRA TAB 100-25MG 12 INVIRASE 12 KALETRA TAB 200-50MG 12 IONOSOL-BDEXTROSE 5 45 kariva 28 day 33 IONOSOL-MBDEXTROSE 5 45 KCL 0075D5WNACL 045 45 IPOL INACTIVATED IPV 43 KCL 015D5WNACL 02 45 ipratropium bromide 48 KCL 015D5WNACL 0225 45 ipratropium bromide (nasal) 48 KCL 015D5WNACL 09 45 ipratropium-albuterol 48 KCL 03D5WNACL 045 45 irinotecan hcl 17 KCL 03D5WNACL 09 45 ISENTRESS 12 KCLNACL INJ 03-09 45 isolyte m 45 kelnor 135 28 day 33 isolyte p 45 ketoconazole 11 isolyte s 45 ketoconazole cream 50 isolyte s in 5 dextrose 45 ketoconazole shampoo 50 ISOLYTE-HDEXTROSE 5 45 ketoprofen 9 isoniazid inj 100 mgml 13 ketorolac tromethamine (ophth) 47 isoniazid syp 50mg5ml 13 kionex 33 isoniazid tabs 13 KLOR-CON 43

60

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

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NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

KLOR-CON 10 43 LIALDA 38 KLOR-CON 8 43 lidocaine 51 KUVAN 35 lidocaine hcl 51 L13 lidocaine hcl (local anesth) 9 labetalol hcl 20 lidocaine hcl (mouth-throat) 52 laclotion 52 lidocaine-prilocaine 51 LACTATED RINGERS INJ 45 LIDODERM 51 lactic acid (ammonium lactate) 52 liothyronine sodium 36 lactulose 38 lisinopril 18 lamivudine 12 lisinopril amp hydrochlorothiazide 18 lamivudine-zidovudine 12 lithium carbonate 29 lamotrigine 24 LITHIUM CITRATE 29 lamotrigine er 24 LODOSYN 27 LANOXIN TAB 21 lokara 51 LANTUS 31 loperamide hcl 38 LANTUS SOLOSTAR 31 lorazepam 23 latanoprost 47 loryna 28 day 33 LATUDA 28 losartan potassium 19 LAZANDA 8 losartan potassium amp hydrochlorothiazideLEENA 33 19 leflunomide 41 LOTEMAX 47 lessina 28 day 33 LOTRONEX 38 LETAIRIS 23 lovastatin 19 letrozole 16 LOVAZA 20 leucovorin calcium 17 low-ogestrel 28 day 33 LEUKERAN 14 loxapine succinate 28 LEUKINE 40 LUMIGAN 47 leuprolide acetate 16 LUMIZYME 35 levalbuterol conc 125mg05ml 48 LUNESTA 29 LEVEMIR 31 LUPRON DEPOT 16 LEVEMIR FLEXPEN 31 LUPRON DEPOT-PED 16 levetiracetam 24 LUPRON DEPOT-PED (3 MONTH KIT) 16 levobunolol hcl 47 lutera 28 day 33 levocarnitine (metabolic modifiers) 35 LYRICA 24 levocetirizine dihydrochloride 48 LYSODREN 16 levofloxacin 10 M13 levofloxacin in d5w 10 MACRODANTIN 14 levofloxacin inj 25mgml 10 mafenide acetate 50 levofloxacin oral soln 25 mgml 10 MAGNESIUM SULFATE 43 levonest 28 day 33 MAGNESIUM SULFATE IN D5W 43 levonorgestrel (emergency oc) 33 malathion 52 levonorgestrel-ethinyl estradiol (91-day) maprotiline hcl 26 33 marlissa 28 day 33 levora 01530 28 day 33 MARPLAN 26 LEVOTHROID 36 MATULANE 17 levothyroxine sodium 36 matzim 21 LEVOXYL 36 MAXIDEX 47 LEXIVA 12 meclizine hcl 37

61

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

medroxyprogesterone acetate 36 mexiletine hcl 19 medroxyprogesterone acetate microgestin 1530 21 day 34 (contraceptive) 34 microgestin 120 21 day 34 mefloquine hcl 11 microgestin fe 1530 28 day 34 MEGACE ES 16 microgestin fe 120 28 day 34 megestrol acetate 16 midodrine hcl 22 MELOXICAM SUSP 75 MG5ML 9 minitran 22 meloxicam tabs 9 minocycline hcl 10 melphalan hcl 14 minoxidil 22 MENACTRA 43 mirtazapine 26 MENEST 35 misoprostol 38 MENHIBRIX 43 mitomycin 15 MENOMUNE-ACYW-135 43 mitoxantrone hcl 17 MENVEO 43 M-M-R II WDILUENT 10 DOS 43 MEPRON 14 modafinil 30 mercaptopurine 15 moexipril hcl 18 meropenem 14 moexipril-hydrochlorothiazide 18 mesalamine w cleanser 38 mometasone furoate 51 mesna 17 MONONESSA 34 MESNEX 17 montelukast sodium 48 MESTINON SYRUP 29 MORPHINE SULFATE 8 MESTINON TIMESPAN 29 morphine sulfate ext-rel tab 8 metadate 28 MORPHINE SULFATE ORAL SOL 8 metformin hcl 32 MOVIPREP 38 methadone hcl 8 MOXEZA 46 methadose 8 MOZOBIL 40 methazolamide 22 MULTAQ 19 methenamine hippurate 14 mupirocin oint 2 50 methimazole 36 MUSTARGEN 14 methotrexate sodium inj 15 MYCAMINE 11 methotrexate sodium inj pf 15 MYCOBUTIN 13 methotrexate sodium tabs 41 mycophenolate mofetil 42 methyclothiazide 22 MYFORTIC 42 methylergonovine maleate 36 myorisan 50 methylphenidate hcl 29 MYOZYME 35 methylprednisolone 35 myzilra 34 methylprednisolone acetate 35 N13 methylprednisolone sod succ 35 nabumetone 9 metipranolol 47 nadolol 20 metoclopramide hcl 37 nafcillin sodium 10 metolazone 22 NAGLAZYME 35 metoprolol amp hydrochlorothiazide 20 naloxone hcl 30 metoprolol succinate 20 naltrexone hcl 30 metoprolol tartrate 20 NAMENDA 25 metronidazole 14 NAMENDA TITRATION PAK 25 metronidazole (topical) 52 naproxen 9 metronidazole inj 14 naproxen sodium 9 metronidazole vaginal 39 naratriptan hcl 29

62

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

NASONEX 49 NORA-BE 34 NATACYN 46 NORDITROPIN FLEXPRO 36 nateglinide 32 NORDITROPIN NORDIFLEX PEN 36 NEBUPENT 14 norethindrone acetate 36 necon 0535 28 day 34 normosol-m 45 necon 135 28 day 34 NORMOSOL-R 45 NECON 1011 28 DAY 34 NORMOSOL-R IN D5W 45 NECON 777 34 NORPACE CR 19 nefazodone hcl 26 nortrel 0535 28 day 34 neomycin sulfate 10 nortrel 135 21 day 34 neomycin-bacitracin zn-polymyxin 46 nortrel 135 28 day 34 neomycin-polymy-dexameth 46 nortrel 777 28 day 34 neomycin-polymy-gramicid 46 nortriptyline hcl 26 neomycin-polymyxin-hc (ophth) 46 NORVIR 12 neomycin-polymyxin-hc (otic) 52 NOVOLIN 7030 31 NEORAL 42 NOVOLIN N 31 NEPHRAMINE 44 NOVOLIN R 31 NEUMEGA 40 NOVOLOG 31 NEUPOGEN 40 NOVOLOG FLEXPEN 31 NEUPRO 27 NOVOLOG MIX 7030 31 NEVANAC 47 NOVOLOG MIX 7030 PREFILL 31 NEVIRAPINE 12 NOXAFIL 11 NEXAVAR 16 NUEDEXTA 29 NEXIUM 39 NULOJIX 42 NEXIUM IV 39 NUVARING 34 next choice 34 nyamyc 50 NIASPAN 20 nystatin 11 nicardipine hcl 21 nystatin (mouth-throat) 52 NICOTROL INHALER 30 nystatin (topical) 50 NICOTROL NS 30 nystop 50 nifediac 21 O13 nifediac cc tab 21 OCELLA 34 nifedical 21 OCTAGAM 41 nifedipine tab 30mg er 21 octreotide acetate 36 nifedipine tab 60mg er 21 ofloxacin (ophth) 46 nifedipine tab sr 30mg (osm) 21 ofloxacin (otic) 52 nifedipine tab sr 60mg (osm) 21 ogestrel 28 day 34 nifedipine tab sr 90mg (osm) 21 olanzapine 28 NILANDRON 16 omeprazole 39 nimodipine 21 ondansetron hcl 37 nitro-bid 22 ondansetron hcl inj 37 NITRO-DUR 03MGHR 22 ondansetron hcl oral soln 37 NITRO-DUR 08MGHR 22 ondansetron odt 37 nitrofurantoin macrocrystal 14 ONFI 24 nitrofurantoin monohyd macro 14 ONTAK 15 nitroglycerin patches 22 ORAP 28 NITROLINGUAL PUMPSPRAY 22 ORFADIN 35 NITROSTAT 22 orsythia 28 day 34

63

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

ORTHO EVRA 34 pentostatin 15 ORTHO TRI-CYCLEN LO 34 pentoxifylline 41 oxacillin sodium 10 PERFOROMIST 48 oxaliplatin 17 perindopril erbumine 18 oxandrolone 31 periogard 52 oxaprozin 9 permethrin 52 oxcarbazepine 24 perphenazine 28 OXSORALEN ULTRA 50 phenadoz 37 oxybutynin chloride 39 phenelzine sulfate 26 OXYCODONE HCL 8 phenobarbital 24 oxycodone w acetaminophen 10-325mg phenobarbital sodium 24 8 PHENYTEK 24 oxycodone w acetaminophen 10-650mg phenytoin 24 8 phenytoin sodium 24 oxycodone w acetaminophen 25-325mg phenytoin sodium extended 24 8 philith 34 oxycodone w acetaminophen 5-325mg 8 PHOSLO 36 oxycodone w acetaminophen 5-500mg 8 PHOSLYRA 36 oxycodone w acetaminophen 75-325mg PHOSPHOLINE IODIDE 47 8 PILOCARPINE HCL 47 oxycodone w acetaminophen 75-500mg pilocarpine hcl (oral) 52 8 PILOPINE HS 47 oxycodone-aspirin 8 pindolol 20 P13 pioglitazone hcl 32 PACERONE 19 pioglitazone hcl-glimepiride 32 paclitaxel 15 pioglitazone hcl-metformin hcl 32 PANRETIN 52 piperacillin sodium-tazobactam sodium 10 pantoprazole sodium 39 piroxicam 9 paromomycin sulfate 10 PLASMA-LYTE A 45 paroxetine hcl 26 PLASMA-LYTE-148 45 PASER DR 13 PLASMA-LYTE-56D5W 45 PATADAY 47 podofilox 52 PATANASE 48 polyethylene glycol 3350 38 PATANOL 47 polymyxin b-trimethoprim 46 PAXIL 26 POMALYST 17 pedi-dri 50 portia 28 day 34 PEDVAX HIB 43 potassium chloride 45 PEGANONE 24 POTASSIUM CHLORIDE 015 45 PEGASYS 42 POTASSIUM CHLORIDE 022 45 PEGASYS PROCLICK 42 POTASSIUM CHLORIDE 0224 45 PEG-INTRON 42 POTASSIUM CHLORIDE 03D 45 PEG-INTRON REDIPEN 42 potassium chloride caps er 43 PENICILLIN G POT IN DEXTROSE 10 potassium chloride in nacl 45 penicillin g procaine 10 potassium chloride microencapsulated penicillin g sodium 10 crystals cr 44 penicillin v potassium 10 potassium citrate (alkalinizer) 39 penicilln gk inj 5mu 10 POTIGA 24 PENTASA 38 PRADAXA 40

64

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

pramipexole dihydrochloride 27 PROQUAD 43 PRANDIN 32 PROSOL 44 pravastatin sodium 19 PROTOPIC 52 prazosin hcl 18 protriptyline hcl 26 PRED MILD 47 PRUDOXIN 50 PREDNISOLONE ACETATE 47 PULMICORT 49 prednisolone sodium phosphate 35 PULMOZYME 49 prednisolone sodium phosphate (ophth) PYLERA 38 47 pyrazinamide 13 prednisone 35 pyridostigmine bromide 29 PREMARIN CREAM 35 Q13 premasol 44 quasense 91 day 34 prenatal vitaminfolic acid gt 08 mg quetiapine fumarate 28 (generic) 46 quinapril hcl 18 prevalite 20 quinapril-hydrochlorothiazide 18 previfem 28 day 34 quinidine gluconate 19 PREVPAC 38 quinidine sulfate 19 PREZISTA 12 QVAR 49 PRIFTIN 13 R13 PRIMAQUINE PHOSPHATE 11 RABAVERT 43 primidone 24 ramipril 18 PRISTIQ 26 RANEXA 22 PRIVIGEN 41 ranitidine hcl 38 PROAIR HFA 48 ranitidine hcl inj 38 probenecid 7 ranitidine syp 38 PROCALAMINE 44 RAPAMUNE 42 prochlorperazine 37 REBETOL 13 prochlorperazine edisylate 37 reclipsen 28 day 34 prochlorperazine maleate 37 RECOMBIVAX HB 43 PROCRIT 41 REGONOL 29 proctocream 50 REGRANEX 52 procto-pak 51 RELENZA DISKHALER 13 proctozone hc 50 RELISTOR 38 PROGLYCEM 36 RELPAX 29 PROGRAF 42 REMICADE 41 PROLASTIN-C 49 REMODULIN 23 PROLENSA 48 RENVELA 36 PROLEUKIN 15 RESCRIPTOR 12 PROLIA 36 RESTASIS 48 PROMACTA 41 RETROVIR IV INFUSION 12 promethazine hcl 37 REVLIMID 42 promethegan 37 REYATAZ 12 propafenone hcl 19 ribapak mis 600day 13 proparacaine hcl 48 ribasphere 13 propranolol amp hydrochlorothiazide 20 ribasphere 200mg 13 propranolol hcl 20 ribasphere ribapak 1000 13 propranolol hcl er 20 ribasphere ribapak 1200 13 propylthiouracil 36 ribasphere ribapak 800 13

65

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

ribavirin 200mg 13 SOLTAMOX 16 rifampin 13 SOLU-CORTEF 35 RILUTEK 29 SOMATULINE DEPOT 36 rimantadine hydrochloride 13 SOMAVERT 36 ringers 45 SORIATANE 50 RIOMET 32 sorine 19 RISPERDAL CONSTA 28 sotalol hcl 19 risperidone 28 sotalol hcl (afibafl) 19 RITUXAN 15 SPIRIVA HANDIHALER 48 rivastigmine tartrate 25 spironolactone 18 rizatriptan benzoate tabs 29 spironolactone amp hydrochlorothiazide 22 ropinirole hydrochloride 27 sprintec 28 day 34 ROTATEQ 43 SPRYCEL 16 roxicet 8 sronyx 28 day 34 S13 SSD 50 SABRIL 24 25 stagesic 5500 7 SANDIMMUNE 42 STALEVO 27 SANDOSTATIN LAR DEPOT 36 stavudine 12 SANTYL 52 STERILE WATER IRRIGATION 52 SAPHRIS 28 STIVARGA 16 SAVELLA 29 STRATTERA 29 SAVELLA TITRATION PACK 29 streptomycin sulfate 10 selegiline hcl 27 STRIBILD 12 selenium sulfide 50 SUBOXONE 30 SELZENTRY 12 SUBOXONE FILM 12-3MG 30 SENSIPAR 33 SUBOXONE FILM 2-05MG 30 SEREVENT DISKUS 48 SUBOXONE FILM 4-1MG 30 SEROMYCIN 13 SUBOXONE FILM 8-2MG 30 SEROQUEL XR 28 SUCRAID 38 sertraline hcl 26 sucralfate 38 sildenafil citrate (pulmonary sulfacetamide sodium (acne) 50 hypertension) 23 sulfacetamide sodium (ophth) 46 SILVER SULFADIAZINE 50 sulfacetamide sod-prednisolone 46 SIMCOR TAB 1000-20MG 20 sulfadiazine 10 SIMCOR TAB 1000-40MG 20 sulfamethoxazole-trimethop 14 SIMCOR TAB 500-20MG 20 sulfamethoxazole-trimethop iv soln 14 SIMCOR TAB 50-40MG 20 SULFAMYLON 50 SIMCOR TAB 750-20MG 20 sulfasalazine 38 simvastatin 19 sulindac 9 SIRTURO 13 sumatriptan succinate 29 sod fluoride 22mg tab 44 SUMATRIPTAN SUCCINATE INJ 29 SODIUM CHLORIDE 44 45 SUPRAX 11 SODIUM CHLORIDE 045 VIA 45 SUPRAX SUS 5005ML 11 SODIUM CHLORIDE 09 52 SUSTIVA 12 sodium phenylbutyrate 35 SUTENT 17 sodium polystyrene sulfonate 33 SYLATRON 17 SOLARAZE 50 SYMBICORT 49 SOLIA 34 SYMLINPEN 120 31

66

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

68

ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

69

SYMLINPEN 60 31 timolol maleate (ophth) 47 SYNAREL 34 TIMOLOL MALEATE GEL 47 SYNTHROID 36 tizanidine hcl 30 SYPRINE 33 TOBI 49 T13 TOBRADEX 46 TABLOID 15 TOBRADEX ST 46 tacrolimus 42 tobramycin sulfate 11 TAMIFLU 13 tobramycin sulfate (ophth) 46 tamoxifen citrate 16 tobramycin sulfate in saline 11 tamsulosin hcl 39 tobramycin-dexamethasone 46 TARCEVA 17 TOBREX 46 TARGRETIN 17 52 tolterodine tartrate 39 TASIGNA 17 topiramate 25 TAXOTERE 15 toposar 18 tazicef vial 11 topotecan hcl 18 TAZORAC 50 torsemide inj 20mg2ml 22 taztia 21 torsemide tabs 22 TEGRETOL 25 TOVIAZ 39 TEGRETOL-XR 25 TPN ELECTROLYTES 44 TEKAMLO 21 TRACLEER 23 TEKTURNA 21 TRADJENTA 32 TEKTURNA HCT TAB 150-125MG 21 tramadol hcl 8 TEKTURNA HCT TAB 150-25MG 21 tramadol-acetaminophen 8 TEKTURNA HCT TAB 300-125MG 21 trandolapril 18 TEKTURNA HCT TAB 300-25MG 21 tranexamic acid 41 terazosin hcl 18 TRANSDERM-SCOP 37 terbinafine hcl 11 tranylcypromine sulfate 26 terbutaline sulfate 48 TRAVASOL 44 terconazole vaginal 39 TRAVATAN Z 47 TESTIM 31 trazodone hcl 26 testosterone cypionate 31 TREANDA 14 testosterone enanthate 31 TRECATOR 13 TETANUS TOXOID ADSORBED 43 TRELSTAR DEP INJ 375MG 16 TETANUSDIPHTHERIA TOXOID 43 TRELSTAR LA INJ 1125MG 16 tetracycline hcl 11 tretinoin 50 TEV-TROPIN 36 tretinoin (chemotherapy) 17 THALITONE 22 triamcinolone acetonide (mouth) 52 THALOMID 42 triamcinolone acetonide (nasal) 49 THEO-24 49 triamcinolone acetonide (topical) 51 theophylline 49 triamterene amp hydrochlorothiazide cap THERMAZENE 50 375-25 mg 22 thioridazine hcl 28 triamterene amp hydrochlorothiazide tab thiothixene 28 375-25 mg 22 tiagabine tab 2mg 25 triamterene amp hydrochlorothiazide tab tiagabine tab 4mg 25 75-50 mg 22 TIKOSYN 19 TRIBENZOR 19 TIMENTIN 11 triderm 51 timolol maleate 20 trifluoperazine hcl 28

67

trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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trifluridine 46 VICTRELIS 13 trihexyphenidyl hcl 27 VIDAZA 15 tri-legest 28 34 VIDEX PEDIATRIC 12 TRILEPTAL 25 VIGAMOX 46 trilyte 38 VIIBRYD 26 trimethoprim 14 VIMPAT 25 trimipramine maleate 26 vinblastine sulfate 15 TRINESSA 34 vincasar 15 tri-previfem 28 day 34 vincristine sulfate 15 TRISENOX 17 vinorelbine tartrate 15 tri-sprintec 28 day 34 viorele 34 trivora 28 day 34 VIRACEPT 12 TRIZIVIR 12 VIRAMUNE 12 TROPHAMINE INJ 10 44 VIRAMUNE XR 12 tropicamide 48 VIREAD 12 trospium cl tab 20mg 39 VOLTAREN 52 TRUVADA 12 voriconazole 11 TWINRIX 43 VORICONAZOLE INJ 200MG 11 TYGACIL 14 VOTRIENT 17 TYKERB 17 VPRIV 35 TYPHIM VI 43 W13 TYZEKA 13 warfarin sodium 40 U13 WELCHOL 20 UCERIS 38 X13 ULORIC 7 XALKORI 17 UNITHROID 36 XARELTO 40 ursodiol 38 XENAZINE 29 V13 XIFAXAN 39 VAGIFEM 35 XOLAIR 49 valacyclovir hcl 13 XOPENEX HFA 48 VALCYTE 13 XTANDI 16 valproate sodium 25 XYREM 30 valproic acid 25 Y13 valsartan-hydrochlorothiazide 19 YF-VAX 43 vancomycin hcl 14 Z13 VANDAZOLE 39 zafirlukast 48 VAQTA 43 zaleplon 29 VARIVAX 43 ZAVESCA 35 VASCEPA 20 zazole 39 VELCADE 15 ZELBORAF 17 velivet 28 day 34 ZEMAIRA 49 venlafaxine hcl 26 ZEMPLAR 46 verapamil hcl 21 zenatane 50 VESICARE 39 ZENPEP 39 vestura 34 ZETIA 20 VFEND 11 ZIAGEN 12 VIBRAMYCIN SYRUP 11 zidovudine 12 VICTOZA 31 ziprasidone hcl 28

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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ZMAX 11 ZORTRESS 42 zoledronic acid inj 4mg5ml 32 ZOSTAVAX 43 ZOLINZA 15 zovia 135e 28 day 34 zolmitriptan 29 zovia 150e 28 day 34 zolmitriptan odt 29 ZOVIRAX 51 zolpidem tartrate 29 ZYLET 46 ZOMETA 32 ZYMAXID 46 ZONALON 50 ZYTIGA 16 zonisamide 25 ZYVOX 14 13

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