AFTERA

ECONTRA EZ

ECONTRA ONE-STEP

LEVONORGESTREL

MY CHOICE

BISACODYL

BISACODYL EC

Preventative Care Medication List$0 Cost Share Medications and Products

U.S. Preventive Services Task Force A & B Recommendation Medications and SupplementsThe health reform law (Affordable Care Act) makes certain preventive medications and

supplements available to you at no cost—both prescription and over-the-counter

(OTC). The following preventive medications are covered at 100% with $0 copay when:

• Prescribed by a health care professional

• Age and/or condition appropriate

• Filled at a network pharmacy

The following is a list of the most commonly prescribed drugs. It represents an

abbreviated version of the drug list (formulary) that is at the core of your prescription

drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In

addition to using this list, you are encouraged to ask your doctor to prescribe generic

drugs whenever appropriate.

PLEASE NOTE: Not all the drugs listed are covered by all prescription-drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription-drug benefit program. For specific questions about your coverage, please call the phone number printed on your member ID card.

ASPIRIN 300 MG SUPP

ASPIRIN 325 MG TAB

ASPIRIN 600 MG SUPP

ASPIRIN 81 MG CHEW TAB

ASPIRIN ADULT LOW DOSE 81 MG TAB DR

ASPIRIN CHILDRENS 81 MG CHEW TAB

ASPIRIN EC 325 MG TAB DR

ASPIRIN EC 81 MG TAB DR

ASPIRIN EC LOW DOSE 81 MG TAB

ASPIRIN EC LOW STRENGTH 81 MG TAB DR

ECOTRIN (all strengths/forms)

ECPIRIN 325 MG TAB DR

GOODSENSE ASPIRIN (all strengths/forms)

MEDIQUE ASPIRIN 325 MG TAB

MINIPRIN LOW DOSE | 81 MG TAB DR

NORWICH ASPIRIN 325 MG TAB

ST JOSEPH ASPIRIN (all strengths/forms)

TAMOXIFEN CITRATE

RALOXIFENE HYDROCHLORIDE

CITRATE OF MAGNESIA

GAVILYTE-C

GAVILYTE-H

GAVILYTE-N/FLAVOR PACK

Colorectal Cancer Screening (bowel prep)(Coverage Criteria: Persons aged 50 to 75 years)

Aspirin(Coverage Criteria: Women age 55-79; Men age 45-79; Pregnant women after 12 weeks of gestation who are at high risk for preeclampsia)

Breast Cancer Prevention(Coverage Criteria: Persons > 35 years who meet criteria)

ASPIRIN LOW DOSE 81 MG CHEW TAB

ASPIR-LOW 81 MG TAB DR

ASPIRTAB 324 MG TAB DR

ASPIRTAB MAXIMUM STRENGTH 500 MG TAB

BAYER ASPIRIN (all strengths/forms)

MAGNESIUM CITRATE

MILK OF MAGNESIA

PEG 3350/ELECTROLYTES

PEG-3350/NACL/NA BICARBONATE/KCL

PEG-PREP

TRILYTE

Contraceptives(Coverage Criteria: Females < 51 years of age)

MY WAY

NEW DAY

OPCICON ONE-STEP

OPTION 2

PREVENTEZA

REACT

TAKE ACTION

OC Injectable

MEDROXYPR AC INJ 150MG/ML

OC Oral

AFIRMELLE

ALTAVERA

ALYACEN 1/35

ALYACEN 7/7/7

AMETHIA

AMETHIA LO

AMETHYST

APRI

ARANELLE

ASHLYNA

AUBRA

AUBRA EQ

AUROVELA 1.5/30

AUROVELA 1/20

AUROVELA 24 FE

AUROVELA FE 1.5/30

AUROVELA FE 1/20

AVIANE

AYUNA

AZURETTE

BALZIVA

BEKYREE

BLISOVI 24 FE

BLISOVI FE 1.5/30

BLISOVI FE 1/20

BRIELLYN

CAMILA (Continued)

CAMRESE

CAMRESE LO

CAZIANT

CESIA

CHATEAL

CHATEAL EQ

CRYSELLE-28

CYCLAFEM 1/35

CYCLAFEM 7/7/7

CYRED

CYRED EQ

DASETTA 1/35

DASETTA 7/7/7

DAYSEE

DEBLITANE

DELYLA

DESOGESTREL/ETHINYL ESTRADIOL

DROSPIRENONE/ETHINYL ESTRADIOL

DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE

CALCIUM

ELINEST

EMOQUETTE

ENPRESSE-28

ENSKYCE

ERRIN

ESTARYLLA

ETHYNODIOL DIACETATE/ETHINYL ESTRADIOL

FALMINA

FAYOSIM

FEMYNOR

GIANVI

HAILEY 1.5/30

HAILEY 24 FE

HEATHER

INCASSIA

INTROVALE

ISIBLOOM

JASMIEL

JENCYCLA

JOLESSA

JULEBER

JUNEL 1.5/30

JUNEL 1/20

JUNEL FE 1.5/30

JUNEL FE 1/20

JUNEL FE 24

KAITLIB FE

KALLIGA

KARIVA

KELNOR 1/35

KELNOR 1/50

KURVELO

LARIN 1.5/30

LARIN 1/20

LARIN 24 FE

LARIN FE 1.5/30

LARIN FE 1/20

LARISSIA

LAYOLIS FE

LEENA

LESSINA

LEVONEST

LEVONORGESTREL & ETHINYL ESTRADIOL

LEVONORGESTREL/ETHINYL ESTRADIOL

LEVORA 0.15/30-28

LILLOW

LO-ZUMANDIMINE

LORYNA

LOW-OGESTREL

LUTERA

LYZA

MARLISSA

MELODETTA 24 FE

MIBELAS 24 FE

MICROGESTIN 1.5/30

MICROGESTIN 1/20

MICROGESTIN 24 FE

MICROGESTIN FE 1.5/30

MILI

MONO-LINYAH

MONONESSA

NECON 0.5/35-28

NECON 1/35

NIKKI

NORA-BE

NORETHINDRONE

NORETHINDRONE & ETHINYL ESTRADIOL FERROUS FUMARATE

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL

NORETHINDRONE ACETATE/ETHINYL ESTRADIOL/FERROUS FUMARATE

NORETHINDRONE/ETHINYL ESTRADIOL/FERROUS FUMARATE

NORGESTIMATE/ETHINYL ESTRADIOL

NORLYDA

NORLYROC

NORTREL 0.5/35 (28)

NORTREL 1/35

NORTREL 7/7/7

OCELLA

ORSYTHIA

PHILITH

PIMTREA

PIRMELLA 1/35

PIRMELLA 7/7/7

PORTIA-28

PREVIFEM

RECLIPSEN

RIVELSA

SETLAKIN

SHAROBEL

SIMLIYA

SIMPESSE

SOLIA

SPRINTEC 28

SRONYX

SYEDA

TARINA 24 FE

TARINA FE 1/20

TARINA FE 1/20 EQ

TILIA FE

TRI FEMYNOR

TRI-ESTARYLLA

TRI-LEGEST FE

TRI-LINYAH

TRI-LO-ESTARYLLA

TRI-LO-MARZIA

TRI-LO-MILI

TRI-LO-SPRINTEC

TRI-MILI

TRI-PREVIFEM

TRI-SPRINTEC

TRI-VYLIBRA

TRI-VYLIBRA LO

TRINESSA

TRIVORA-28

TULANA

TYDEMY

VELIVET

VIENVA

VIORELE

VYFEMLA

VYLIBRA

WERA

WYMZYA FE

ZARAH

ZOVIA 1/35E

ZUMANDIMINE

Folic Acid(Coverage Criteria: Women who are planning or capable of pregnancy)

FA-8 800 MCG TAB

FOLATE 400 MCG TAB

FOLIC ACID 1 MG TAB

FOLIC ACID 400 MCG TAB

FOLIC ACID 800 MCG TAB

ATORVASTATIN CALCIUM

FLUVASTATIN

FLUVASTATIN SODIUM ER

LOVASTATIN

PRAVASTATIN SODIUM

ROSUVASTATIN CALCIUM

SIMVASTATIN

Statin Prevention(Coverage Criteria: Adults age 40-75 with no history of CVD, 1 or more CVD risk factors and a calculated 10-year CVD event risk of 10% or greater)

Tobacco Cessation

BUPROPION HYDROCHLORIDE ER (SR)

CHANTIX

CHANTIX CONTINUING MONTHPAK

CHANTIX STARTING MONTH PAK

NICOTINE LOZENGE

NICOTINE POLACRILEX

NICOTINE TRANSDERMAL SYSTEM

Iron supplements

FER-IRON

FERROUS SULFATE

IRON SUPPLEMENT CHILDRENS

BPROTECTED PEDIA IRON

Ophthalmic antibiotics

ERYTHROMYCIN 5 MG/GM OINTMENT

ILOTYCIN 5 MG/GM OINTMENT

ROMYCIN 5 MG/GM OINTMENT

Under the health reform law, health plans must cover U.S. Preventive Services Task Force A & B Recommendation medications and FDA-approved prescription and over- the counter (OTC) contraceptives for women at 100 percent without charging a copayment, coinsurance or deductible when:Prescribed by a health care professionalAge and/or condition appropriateFilled at a network pharmacy

To comply with these regulations which continue to be clarified further by the U.S. Dept. of Labor, Health & Human Services and the Treasury, we offer this list of $0 cost-share Preventive Care Medications.

Which preventive care medications are available at $0 cost-share? Refer to the list in this document, sign in to the member website provided in you program materials, or call the number on the back of your health plan ID card for a list of medications covered at $0 cost-share.

Please note, in order to obtain coverage at no cost for preventive care medications and products (including over-the-counter) you will need a prescription from your doctor.

What if my doctor says I need birth control that is not on this list? This list covers all methods of FDA-approved birth control available through your pharmacy benefit. However, your doctor may decide you need birth control (contraception) that is not on this list for

medical reasons. If so, you can request the type you need by calling the number on your health plan ID card, you will be required to pay a copay or coinsurance . Medical reasons may include side effects,

whether the birth control is permanent or can be reversed, and whether you can use the product as required.

Your medical benefit may also cover other forms of birth control such as IUDs, implants and surgical sterilization.

What if my plan has a religious exemption for covering contraceptives? Some plans may not have coverage for contraceptives if your plan is a religious employer under California law. However, you will still have coverage at $0 cost-share of the U.S. Preventive Services Task

Force A & B Recommendation medications listed on the Preventive Care Medications list, such as aspirin and vitamin D, tobacco cessation and breast cancer preventive medications.

If I need to take preparation medications before a preventive colonoscopy, how can I get these for no cost? If you are scheduled for a preventive colonoscopy, ask your doctor for a prescription for one of the $0 cost preparation medications. You can fill this prescription at a retail network pharmacy.

What if my doctor prescribes a preparation medication for my preventive colonoscopy that is not on this list? You can ask your doctor for a prescription for one of the medications on this list that your doctor feels would work for you. For some medical reasons, your doctor may decide you need a medication that is not on this list to prepare for your preventive colonoscopy. If so, you can request the medication you need by calling the number on your health plan ID card, you will be required to pay a copay or

coinsurance. Medical reasons may include side effects, and whether you can use the product as required.

If you need a prescription medication to prepare for a colonoscopy that is not preventive, these medications may still be covered with a copayment or coinsurance.

If I’m at risk for cardiovascular disease, how can I get statin medications at no cost to me? If you are a member age 40-75, and at risk for cardiovascular disease, your doctor may offer to prescribe statin medications. Select statins are covered at no cost-share for individuals who have certain risk

factors for cardiovascular disease. Depending on the medication, your doctor may need to submit a prior authorization request to get medications approved for you at no cost if you meet coverage

criteria. For members who don’t meet this $0 cost-share criteria or don’t request prior authorization, those statins will continue to be covered at the customary cost share amount for your plan.

Statin prevention medications are typically covered at the customary cost-share amount for your plan. However, they are available at $0 cost-share to prevent cardiovascular disease if a prior

authorization is obtained. If you qualify based on criteria above, you can receive these drugs at $0 cost-share.

Preventative Care Medications CoverageFrequently Asked Questions:

How can I get preventive medications to help me stop using tobacco at no cost? If you are age 18 or older and want to quit using tobacco products, talk to your doctor about medications that can help. If your doctor decides this therapy is right for you, they may prescribe an over-the-counter or prescription medication.

If I’m at risk for breast cancer, how can I get preventive medications for no cost? If you are a member age 35 or older, talk to your doctor about your risk of getting breast cancer if you have not had it. If your doctor decides these drugs are appropriate for you, your doctor may offer to prescribe risk-reducing medications, such as raloxifene or tamoxifen. Your doctor can submit a prior authorization request to get these approved for you at $0 cost-share if you meet coverage criteria.

These medications are typically covered at the customary cost-share amount for your plan. However, they are available at $0 cost-share when used for breast cancer prevention if a prior authorization is obtained. If you qualify based on criteria above, you can receive these drugs at $0 cost-share.

How can I get aspirin to prevent preeclampsia during pregnancy for no cost? Low-dose or baby aspirin (81 mg) is available at no cost to pregnant women at risk for preeclampsia. If you are pregnant and at risk for preeclampsia, ask your doctor about whether low-dose aspirin can help. If so, your doctor can give you a prescription for low-dose aspirin to be filled at a retail network pharmacy at no cost to you.

Will this drug list change? Drug lists can and do change, so it’s always good to check. You can find updated information by:• Signing in to the member website provided in you program materials• Calling the number on your health plan ID card

What if I have a high-deductible or consumer-driven health (CDH) plan? The same no-cost options on the list applicable to your plan will be available to you if you are in one of these plans. If you fill a prescription for covered products not on your plan’s no-cost drug list, you will need to pay the full cost, until your pharmacy plan deductible is reached.

Are the no-cost Preventive Care Medications available at both retail and mail pharmacies? Preventive Care Medications are available at both network retail pharmacies and the mail order pharmacy for plans with a mail order benefit.

What if the health care reform law requirements for preventive care medication coverage change? If the law requiring plans to provide preventive care medications at no cost changes, information on how your costs may be impacted will be available to you by:• Signing in to the member website provided in you program materials• Calling the number on your health plan ID card

What if my doctor prescribes a similar preventive medication that is not on this list? The health reform law allows plans to use reasonable medical management to decide which product/medications are provided at $0 cost-share. If you choose a no-cost product from the list applicable to your plan, your cost at the pharmacy will be $0. If you choose a covered product/medication that is not on the list, a copay or coinsurance may be required. And this cost will apply to your deductible if you have one.

You can ask your doctor for a prescription for one of the medications on this list that your doctor feels would work for you. For some medical reasons, your doctor may decide you need a medication that is not on this list. If so, you can request the medication you need by calling the number on your health plan ID card, you will be required to pay a copay or coinsurance . Medical reasons may include side effects, and whether you can use the medication/product as required.

Preventative Care Medications CoverageFrequently Asked Questions (Continued):

A

Preferred Non-Preventative Care Medication ListTier 1 | 30-day supply cost: $0.0 0

ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML ACETAMINOPHEN W/ CODEINE TAB 300-15 MG ACETAMINOPHEN W/ CODEINE TAB 300-30 MG ACETYLCYSTEINE CAP 600 MG ALBUTEROL SULFATE SYRUP 2 MG/5ML ALLOPURINOL TAB 100 MG AMANTADINE HCL SYRUP 50 MG/5ML AMITRIPTYLINE HCL TAB 10 MG AMITRIPTYLINE HCL TAB 25 MG AMOXICILLIN (TRIHYDRATE) CAP 250 MG

(Continued)

B-COMPLEX W/ C & FOLIC ACID CAP 1 MG*** BACITRACIN ZINC OINT 500 UNIT/GM BENZOYL PEROXIDE GEL 10% BENZTROPINE MESYLATE TAB 0.5 MG BETAMETHASONE VALERATE OINT 0.1% (BASE EQUIVALENT) BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)

CEFTRIAXONE SODIUM FOR INJ 250 MG CEPHALEXIN CAP 250 MG CEPHALEXIN FOR SUSP 125 MG/5ML CHLORDIAZEPOXIDE HCL CAP 10 MG CHLORHEXIDINE GLUCONATE SOLN 0.12% CLINDAMYCIN HCL CAP 75 MG CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG

CLONIDINE HCL TAB 0.1 MG CLOTRIMAZOLE VAGINAL CREAM 2% CYANOCOBALAMIN INJ 1000 MCG/ML CYCLOPENTOLATE HCL OPHTH SOLN 1% CYCLOPENTOLATE HCL OPHTH SOLN 2% CYPROHEPTADINE HCL SYRUP 2 MG/5ML

DEXAMETHASONE SODIUM PHOSPHATE INJ 120 MG/30ML DEXAMETHASONE SODIUM PHOSPHATE INJ 20 MG/5ML DEXAMETHASONE SODIUM PHOSPHATE INJ 4 MG/ML DEXAMETHASONE TAB 0.5 MG DEXAMETHASONE TAB 0.75 MG DEXAMETHASONE TAB 1.5 MG DEXAMETHASONE TAB 4 MG DEXAMETHASONE TAB 6 MG DIAZEPAM TAB 2 MG DIAZEPAM TAB 5 MG DICLOXACILLIN SODIUM CAP 500 MG DICYCLOMINE HCL ORAL SOLN 10 MG/5ML DICYCLOMINE HCL TAB 20 MG DIETHYLPROPION HCL TAB 25 MG DIFLUNISAL TAB 500 MG DIPHENHYDRAMINE HCL CAP 25 MG DIPHENHYDRAMINE HCL CAP 50 MG DIPYRIDAMOLE TAB 25 MG DOXEPIN HCL CAP 10 MG

B

C

D

EENALAPRIL MALEATE TAB 5 MG ERGOCALCIFEROL CAP 1.25 MG (50000 UNIT) ESTRADIOL TAB 0.5 MG ESTRADIOL TAB 1 MG ESTRADIOL TAB 2 MG ETODOLAC CAP 200 MG

FE FUM-IRON POLYSACCH COMPLEX-FA-B CMPLX-C-ZN-MN-CU CAP*** FERROUS FUMARATE-FA-B COMPLEX-C-ZN-MG-MN-CU TAB 106-1 MG***FERROUS FUMARATE-FOLIC ACID TAB 324-1 MG FLAVOXATE HCL TAB 100 MG FLUCONAZOLE TAB 150 MG FLUMAZENIL IV SOLN 0.5 MG/5ML (0.1 MG/ML) FOLIC ACID TAB 1 MG FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-0.5 MG FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.2-25-1 MG FOLIC ACID-VITAMIN B6-VITAMIN B12 TAB 2.5-25-1 MG FOSINOPRIL SODIUM TAB 40 MG FUROSEMIDE INJ 10 MG/ML FUROSEMIDE ORAL SOLN 10 MG/ML FUROSEMIDE TAB 20 MG FUROSEMIDE TAB 40 MG FUROSEMIDE TAB 80 MG

F

G

(Continued)

H

I

L

N

GENTAMICIN SULFATE INJ 40 MG/ML GLIMEPIRIDE TAB 1 MG GLIPIZIDE TAB ER 24HR 2.5 MG GLIPIZIDE TAB ER 24HR 5 MG GLYBURIDE MICRONIZED TAB 1.5 MG GLYBURIDE TAB 1.25 MG GLYBURIDE TAB 2.5 MG GLYCOPYRROLATE TAB 1 MG

HALOPERIDOL LACTATE ORAL CONC 2 MG/ML HALOPERIDOL TAB 1 MG HYDRALAZINE HCL TAB 10 MG HYDROCHLOROTHIAZIDE CAP 12.5 MG HYDROCHLOROTHIAZIDE TAB 25 MG HYDROCHLOROTHIAZIDE TAB 50 MG HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG HYDROCORTISONE OINT 2.5% HYDROXYZINE PAMOATE CAP 25 MG

IBUPROFEN TAB 400 MG IBUPROFEN TAB 600 MG IMIPRAMINE HCL TAB 10 MG IMIPRAMINE HCL TAB 25 MG INDOMETHACIN CAP 25 MG IRON POLYSACCH COMPLEX-VIT B12-FA CAP 150-0.025-1 MG IRON-DOCUSATE-B12-FOLIC ACID-C-E-CU-BIOTIN TAB 150-1 MG*** IVERMECTIN TAB 3 MG

LACTIC ACID (AMMONIUM LACTATE) CREAM 12% LEVOTHYROXINE SODIUM TAB 100 MCG LEVOTHYROXINE SODIUM TAB 25 MCG LEVOTHYROXINE SODIUM TAB 50 MCG LEVOTHYROXINE SODIUM TAB 75 MCG LIDOCAINE HCL LOCAL INJ 1% LIDOCAINE HCL LOCAL INJ 2% LIDOCAINE HCL LOCAL PRESERVATIVE FREE (PF) INJ 2% LIDOCAINE HCL VISCOUS SOLN 2% LIDOCAINE-HYDROCORTISONE ACETATE RECTAL CREAM 3-0.5% LITHIUM CARBONATE CAP 300 MG LITHIUM CARBONATE TAB 300 MG

MMECLIZINE HCL TAB 12.5 MG MEDROXYPROGESTERONE ACETATE TAB 10 MG MEDROXYPROGESTERONE ACETATE TAB 2.5 MG MEDROXYPROGESTERONE ACETATE TAB 5 MG MEPERIDINE HCL INJ 50 MG/ML METFORMIN HCL TAB 500 MG METHENAMINE-HYOSC-METH BLUE-SOD PHOS-PHEN SAL CAP 120 MG***METHIMAZOLE TAB 5 MG METHOTREXATE SODIUM INJ 50 MG/2ML (25 MG/ML) METHOTREXATE SODIUM INJ PF 250 MG/10ML (25 MG/ML) METHOTREXATE SODIUM INJ PF 50 MG/2ML (25 MG/ML) METHYLDOPA TAB 250 MG METHYLPREDNISOLONE TAB 32 MG METOCLOPRAMIDE HCL TAB 5 MG (BASE EQUIVALENT) METOPROLOL & HYDROCHLOROTHIAZIDE TAB 50-25 MG METOPROLOL TARTRATE TAB 25 MG METRONIDAZOLE TAB 250 MG

MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) MULTIPLE VITAMINS W/ MINERALS CAP** MULTIPLE VITAMINS W/ MINERALS TAB** MUPIROCIN OINT 2%

NEOMYCIN SULFATE TAB 500 MG NITROGLYCERIN SL TAB 0.4 MG

OONDANSETRON HCL TAB 8 MG OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG

PPEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG*** PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML*** PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM PENICILLIN V POTASSIUM TAB 250 MG PENTAZOCINE W/ NALOXONE TAB 50-0.5 MG PHENAZOPYRIDINE HCL TAB 100 MG PHENDIMETRAZINE TARTRATE TAB 35 MG PHENOBARBITAL TAB 100 MG PHENOBARBITAL TAB 16.2 MG POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1% POTASSIUM BICARBONATE EFFER TAB 25 MEQ POTASSIUM CHLORIDE TAB ER 10 MEQ POTASSIUM CHLORIDE TAB ER 8 MEQ (600 MG) PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE)PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV) PREDNISONE TAB 1 MG PREDNISONE TAB 10 MG PREDNISONE TAB 2.5 MG

(Continued)

R

S

PREDNISONE TAB 20 MG PREDNISONE TAB 5 MG PRIMIDONE TAB 50 MG PROCHLORPERAZINE SUPPOS 25 MG PROMETHAZINE HCL INJ 25 MG/ML PROMETHAZINE HCL SYRUP 6.25 MG/5ML PROMETHAZINE HCL TAB 25 MG PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML PROPRANOLOL HCL TAB 80 MG PYRAZINAMIDE TAB 500 MG

ROPINIROLE HYDROCHLORIDE TAB ER 24HR 2 MG (BASE EQUIVALENT)

SCOPOLAMINE TD PATCH 72HR 1 MG/3DAYS SELENIUM SULFIDE LOTION 2.5% SODIUM CHLORIDE IRRIGATION SOLN 0.9% SODIUM CHLORIDE SOLN NEBU 0.9% SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF) SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF) SODIUM FLUORIDE CREAM 1.1% SODIUM FLUORIDE GEL 1.1% (0.5% F) SODIUM FLUORIDE PASTE 1.1% SODIUM FLUORIDE RINSE 0.2% SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF) SODIUM POLYSTYRENE SULFONATE POWDER** SPIRONOLACTONE TAB 25 MG SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG

TTELMISARTAN-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG

THIAMINE HCL INJ 100 MG/ML THIORIDAZINE HCL TAB 25 MG THYROID TAB 30 MG (1/2 GRAIN) TIMOLOL MALEATE OPHTH SOLN 0.25% TIMOLOL MALEATE OPHTH SOLN 0.5% TORSEMIDE TAB 5 MG TRIAMCINOLONE ACETONIDE CREAM 0.025% TRIAMCINOLONE ACETONIDE CREAM 0.1% TRIAMCINOLONE ACETONIDE CREAM 0.5% TRIAMCINOLONE ACETONIDE INJ SUSP 40 MG/ML TRIAMCINOLONE ACETONIDE OINT 0.025% TRIAMCINOLONE ACETONIDE OINT 0.5% TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG TRIAZOLAM TAB 0.125 MG TRIAZOLAM TAB 0.25 MG TRIHEXYPHENIDYL HCL TAB 5 MG

VVALPROATE SODIUM ORAL SOLN 250 MG/5ML (BASE EQUIV) VERAPAMIL HCL TAB 120 MG VERAPAMIL HCL TAB 40 MG

WARFARIN SODIUM TAB 1 MG WARFARIN SODIUM TAB 2 MG WARFARIN SODIUM TAB 2.5 MG WARFARIN SODIUM TAB 3 MG WARFARIN SODIUM TAB 5 MG

W

ZIDOVUDINE SYRUP 10 MG/ML

Z

Tier 2 | 30-day supply cost: $10.00 (or less)

AACAMPROSATE CALCIUM TAB DELAYED RELEASE 333 MG ACETAZOLAMIDE TAB 125 MG ACETIC ACID OTIC SOLN 2% ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML) ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML) ALCLOMETASONE DIPROPIONATE CREAM 0.05% ALCLOMETASONE DIPROPIONATE OINT 0.05% ALLOPURINOL TAB 300 MG ALPRAZOLAM TAB 0.25 MG AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50 MG AMILORIDE HCL TAB 5 MG AMITRIPTYLINE HCL TAB 150 MG AMITRIPTYLINE HCL TAB 50 MG AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML AMOXICILLIN CAP-CLARITHRO TAB-LANSOPRAZ CAP DR THERAPY PACK ATENOLOL TAB 100 MG ATENOLOL TAB 25 MG ATENOLOL TAB 50 MG ATOMOXETINE HCL CAP 25 MG (BASE EQUIV) AZITHROMYCIN FOR SUSP 100 MG/5ML

BBACITRACIN-POLYMYXIN B OPHTH OINT BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1% BENAZEPRIL HCL TAB 10 MG BENAZEPRIL HCL TAB 40 MG BENAZEPRIL HCL TAB 5 MG BENZOYL PEROXIDE LIQ 10% BENZTROPINE MESYLATE TAB 1 MG

(Continued)

C

D

E

G

BENZTROPINE MESYLATE TAB 2 MG BETAMETHASONE DIPROPIONATE CREAM 0.05% BETAMETHASONE DIPROPIONATE OINT 0.05% BETAMETHASONE VALERATE CREAM 0.1% (BASE EQUIVALENT) BRIMONIDINE TARTRATE OPHTH SOLN 0.2% BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV) BUPRENORPHINE HCL-NALOXONE HCL SL FILM 4-1 MG (BASE EQUIV) BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV) BUPROPION HCL TAB 100 MG BUPROPION HCL TAB 75 MG BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-325-40-30 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG

CALCITRIOL CAP 0.25 MCG CAPTOPRIL TAB 25 MG CARBAMAZEPINE CAP ER 12HR 200 MG CARBAMAZEPINE CHEW TAB 100 MG CARBIDOPA & LEVODOPA TAB 25-250 MG CARBINOXAMINE MALEATE TAB 4 MG CARISOPRODOL TAB 250 MG CEFPROZIL FOR SUSP 125 MG/5ML CEFTRIAXONE SODIUM FOR INJ 1 GM CEPHALEXIN CAP 500 MG CHLORDIAZEPOXIDE HCL CAP 25 MG CHLORPROMAZINE HCL TAB 25 MG CIMETIDINE TAB 300 MG CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG CLONIDINE HCL TAB 0.2 MG CLOTRIMAZOLE TROCHE 10 MG COLESTIPOL HCL TAB 1 GM CYCLOSPORINE MODIFIED CAP 25 MG CYPROHEPTADINE HCL TAB 4 MG

DESIPRAMINE HCL TAB 25 MG DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MGDEXAMETHASONE ELIXIR 0.5 MG/5ML DEXAMETHASONE SODIUM PHOSPHATE INJ 100 MG/10ML DEXMETHYLPHENIDATE HCL TAB 2.5 MG DEXMETHYLPHENIDATE HCL TAB 5 MG DICLOXACILLIN SODIUM CAP 250 MG DIGOXIN TAB 125 MCG (0.125 MG) DILTIAZEM HCL COATED BEADS CAP ER 24HR 120 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 120 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 180 MG DIVALPROEX SODIUM TAB DELAYED RELEASE 125 MG DOXAZOSIN MESYLATE TAB 1 MG DOXAZOSIN MESYLATE TAB 8 MG DOXEPIN HCL CAP 25 MG DOXEPIN HCL CAP 50 MG DOXEPIN HCL CONC 10 MG/ML DOXYCYCLINE MONOHYDRATE CAP 50 MG DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML

ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 10-25 MG ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TAB 5-12.5 MG ENALAPRIL MALEATE TAB 2.5 MG ERYTHROMYCIN OPHTH OINT 5 MG/GM ERYTHROMYCIN SOLN 2% ETHAMBUTOL HCL TAB 100 MG ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG

FFE FUMARATE W/ B12-VIT C-FA-IFC CAP 110-0.015-75-0.5-240 MG FE FUMARATE-VIT C-VIT B12-FA CAP 460 (151 FE)-60-0.01-1 MG FELODIPINE TAB ER 24HR 2.5 MG

FELODIPINE TAB ER 24HR 5 MG FENOFIBRATE MICRONIZED CAP 67 MG FENOFIBRATE TAB 54 MG FLUCONAZOLE FOR SUSP 10 MG/ML FLUCONAZOLE TAB 200 MG FLUDROCORTISONE ACETATE TAB 0.1 MG FLUOCINOLONE ACETONIDE CREAM 0.025% FLUOCINOLONE ACETONIDE OINT 0.025% FOSINOPRIL SODIUM TAB 10 MG FOSINOPRIL SODIUM TAB 20 MG

GENTAMICIN SULFATE OPHTH SOLN 0.3% GLIMEPIRIDE TAB 2 MG GLIPIZIDE TAB 10 MG GLIPIZIDE TAB 5 MG GLIPIZIDE TAB ER 24HR 10 MG GLIPIZIDE-METFORMIN HCL TAB 2.5-500 MG GLYBURIDE MICRONIZED TAB 3 MG GUANFACINE HCL TAB 1 MG

HHALOPERIDOL TAB 10 MG HALOPERIDOL TAB 2 MG HALOPERIDOL TAB 5 MG HEPARIN SODIUM (PORCINE) INJ 5000 UNIT/ML HOMATROPINE HBR OPHTH SOLN 5% HYDROCHLOROTHIAZIDE TAB 12.5 MG HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG HYDROCODONE-ACETAMINOPHEN TAB 5-300 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-300 MG HYDROCORTISONE CREAM 2.5% HYDROCORTISONE TAB 10 MG HYDROCORTISONE TAB 20 MG

(Continued)

I

M

N

HYDROCORTISONE TAB 5 MG

HYDROMORPHONE HCL TAB 2 MG

HYDROXYUREA CAP 500 MG

HYDROXYZINE HCL SYRUP 10 MG/5ML

HYDROXYZINE HCL TAB 10 MG

HYDROXYZINE HCL TAB 25 MG

HYDROXYZINE HCL TAB 50 MG

HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML

HYOSCYAMINE SULFATE SL TAB 0.125 MG

HYOSCYAMINE SULFATE SOLN 0.125 MG/ML

HYOSCYAMINE SULFATE TAB 0.125 MG

IBUPROFEN SUSP 100 MG/5ML

IBUPROFEN TAB 800 MG

INDAPAMIDE TAB 1.25 MG

INDOMETHACIN CAP 50 MG

ISONIAZID TAB 300 MG

ISOSORBIDE DINITRATE TAB 20 MG

ISOSORBIDE DINITRATE TAB 30 MG

ISOSORBIDE MONONITRATE TAB 10 MG

ISOSORBIDE MONONITRATE TAB 20 MG

ISOSORBIDE MONONITRATE TAB ER 24HR 30 MG

K

KETOCONAZOLE TAB 200 MG

KETOROLAC TROMETHAMINE IM INJ 60 MG/2ML (30 MG/ML)

L

LACTIC ACID (AMMONIUM LACTATE) LOTION 12%

LACTULOSE SOLUTION 10 GM/15ML

LAMOTRIGINE TAB ER 24HR 100 MG

LEUCOVORIN CALCIUM TAB 5 MG

LEVOCETIRIZINE DIHYDROCHLORIDE SOLN 2.5 MG/5ML (0.5 MG/ML)

LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG

LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG

LEVOTHYROXINE SODIUM TAB 112 MCG

LEVOTHYROXINE SODIUM TAB 125 MCG

LEVOTHYROXINE SODIUM TAB 137 MCG

LEVOTHYROXINE SODIUM TAB 150 MCG

LEVOTHYROXINE SODIUM TAB 175 MCG

LEVOTHYROXINE SODIUM TAB 200 MCG

LEVOTHYROXINE SODIUM TAB 300 MCG

LIOTHYRONINE SODIUM TAB 25 MCG

LIOTHYRONINE SODIUM TAB 5 MCG

LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG

LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG

LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG

LISINOPRIL TAB 10 MG

LISINOPRIL TAB 2.5 MG

LISINOPRIL TAB 20 MG

LISINOPRIL TAB 5 MG

LITHIUM CARBONATE TAB ER 300 MG

LITHIUM CARBONATE TAB ER 450 MG

LOVASTATIN TAB 10 MG

LOXAPINE SUCCINATE CAP 5 MG

MECLIZINE HCL CHEW TAB 25 MG

MECLIZINE HCL TAB 25 MG

MERCAPTOPURINE TAB 50 MG

METFORMIN HCL TAB 1000 MG

METFORMIN HCL TAB ER 24HR 750 MG

METHADONE HCL TAB 5 MG

METHIMAZOLE TAB 10 MG

METHYLDOPA TAB 500 MG

METHYLPREDNISOLONE TAB 4 MG

METHYLPREDNISOLONE TAB 8 MG

METHYLPREDNISOLONE TAB THERAPY PACK 4 MG (21)

METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML) (BASE EQUIV)

METOLAZONE TAB 10 MG

METOPROLOL & HYDROCHLOROTHIAZIDE TAB 100-25 MG

METOPROLOL SUCCINATE TAB ER 24HR 25 MG (TARTRATE EQUIV)

METOPROLOL SUCCINATE TAB ER 24HR 50 MG (TARTRATE EQUIV)

METOPROLOL TARTRATE TAB 50 MG

METRONIDAZOLE TAB 500 MG

MIDAZOLAM HCL INJ 5 MG/ML (BASE EQUIVALENT)

MIRTAZAPINE ORALLY DISINTEGRATING TAB 30 MG

MISOPROSTOL TAB 100 MCG

MOEXIPRIL HCL TAB 15 MG

MOMETASONE FUROATE CREAM 0.1%

MORPHINE SULFATE TAB ER 30 MG

NAPROXEN TAB EC 375 MG

NATEGLINIDE TAB 60 MG

NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN

NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%

NIFEDIPINE TAB ER 24HR 30 MG

NITROGLYCERIN SL TAB 0.3 MG

NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG

NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG

NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG

NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG

NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG

NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG

NORETHINDRONE TAB 0.35 MG

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG

NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG

NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG

NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG

NORTRIPTYLINE HCL CAP 10 MG

NORTRIPTYLINE HCL CAP 25 MG

NYSTATIN CREAM 100000 UNIT/GM

NYSTATIN OINT 100000 UNIT/GM

(Continued)

O

P

Q

OFLOXACIN OPHTH SOLN 0.3% OXAPROZIN TAB 600 MG OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML

PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C DROPS 45 MG/ML**PENICILLIN V POTASSIUM TAB 500 MG PHENAZOPYRIDINE HCL TAB 200 MG PHENOBARBITAL TAB 15 MG PHENOBARBITAL TAB 30 MG PHENOBARBITAL TAB 32.4 MG PHENOBARBITAL TAB 60 MG PHENYLEPHRINE-CHLORPHEN-DM LIQUID 10-4-15 MG/5ML PHENYTOIN CHEW TAB 50 MG PHYTONADIONE INJ 1 MG/0.5ML (2 MG/ML) POLYETHYLENE GLYCOL 3350 ORAL PACKET POT PHOS MONOBASIC W/SOD PHOS DI & MONOBAS TAB 155-852-130MGPOTASSIUM CHLORIDE CAP ER 10 MEQ POTASSIUM CHLORIDE CAP ER 8 MEQ POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 10 MEQ POTASSIUM CHLORIDE MICROENCAPSULATED CRYS ER TAB 20 MEQ POTASSIUM CHLORIDE ORAL SOLN 10% (20 MEQ/15ML) POTASSIUM CHLORIDE POWDER PACKET 20 MEQ PRAZOSIN HCL CAP 1 MG PRAZOSIN HCL CAP 2 MG PRIMIDONE TAB 250 MG PROMETHAZINE HCL SUPPOS 25 MG PROMETHAZINE HCL TAB 12.5 MG PROPRANOLOL HCL TAB 10 MG PROPRANOLOL HCL TAB 40 MG PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML PSEUDOEPHEDRINE HCL TAB 60 MG

QUINAPRIL HCL TAB 20 MG QUINAPRIL HCL TAB 40 MG QUINAPRIL HCL TAB 5 MG

S

QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG QUININE SULFATE CAP 324 MG

SALSALATE TAB 500 MG SODIUM CHLORIDE SOLN NEBU 3% SODIUM CITRATE & CITRIC ACID SOLN 500-334 MG/5ML SODIUM POLYSTYRENE SULFONATE ORAL SUSP 15 GM/60ML SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG SPIRONOLACTONE TAB 50 MG

TTAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT) TEMAZEPAM CAP 15 MG TERAZOSIN HCL CAP 1 MG (BASE EQUIVALENT) TERAZOSIN HCL CAP 10 MG (BASE EQUIVALENT) TERAZOSIN HCL CAP 2 MG (BASE EQUIVALENT) TERAZOSIN HCL CAP 5 MG (BASE EQUIVALENT) THEOPHYLLINE TAB ER 24HR 400 MG THYROID TAB 15 MG (1/4 GRAIN) THYROID TAB 60 MG (1 GRAIN) TIZANIDINE HCL CAP 6 MG (BASE EQUIVALENT) TOBRAMYCIN OPHTH SOLN 0.3% TORSEMIDE TAB 10 MG TORSEMIDE TAB 20 MG TRANDOLAPRIL TAB 2 MG TRANDOLAPRIL TAB 4 MG TRAZODONE HCL TAB 50 MG TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG TRIHEXYPHENIDYL HCL TAB 2 MG TRIMETHOPRIM TAB 100 MG

UURSODIOL TAB 250 MG

V

WVALPROIC ACID CAP 250 MG

WARFARIN SODIUM TAB 10 MG WARFARIN SODIUM TAB 4 MG WARFARIN SODIUM TAB 6 MG WARFARIN SODIUM TAB 7.5 MG WATER FOR INJECTION

Tier 3 | 30-day supply cost: $25.00 (or less)

AACARBOSE TAB 100 MG ACARBOSE TAB 25 MG ACARBOSE TAB 50 MG ACEBUTOLOL HCL CAP 200 MG ACEBUTOLOL HCL CAP 400 MG ACETAZOLAMIDE TAB 250 MG ACETYLCYSTEINE INHAL SOLN 20% ACYCLOVIR CAP 200 MG ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV) ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV) ALENDRONATE SODIUM TAB 10 MG ALENDRONATE SODIUM TAB 35 MG ALENDRONATE SODIUM TAB 70 MG ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG ALPRAZOLAM TAB 0.5 MG

(Continued)

B

C

ALPRAZOLAM TAB 1 MG ALPRAZOLAM TAB ER 24HR 0.5 MG ALPRAZOLAM TAB ER 24HR 1 MG ALPRAZOLAM TAB ER 24HR 2 MG AMANTADINE HCL CAP 100 MG AMANTADINE HCL TAB 100 MG AMIKACIN SULFATE INJ 500 MG/2ML (250 MG/ML) AMIODARONE HCL TAB 200 MG AMITRIPTYLINE HCL TAB 100 MG AMITRIPTYLINE HCL TAB 75 MG AMLODIPINE BESYLATE TAB 10 MG (BASE EQUIVALENT) AMLODIPINE BESYLATE TAB 2.5 MG (BASE EQUIVALENT) AMLODIPINE BESYLATE TAB 5 MG (BASE EQUIVALENT) AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 5-160-12.5 MG AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML AMOXICILLIN & K CLAVULANATE TAB 250-125 MG AMOXICILLIN & K CLAVULANATE TAB 500-125 MG AMOXICILLIN & K CLAVULANATE TAB 875-125 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG APREPITANT CAPSULE 40 MG ATENOLOL & CHLORTHALIDONE TAB 100-25 MG ATENOLOL & CHLORTHALIDONE TAB 50-25 MG ATOMOXETINE HCL CAP 10 MG (BASE EQUIV) ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT) AZELASTINE HCL OPHTH SOLN 0.05% AZITHROMYCIN FOR SUSP 200 MG/5ML AZITHROMYCIN TAB 250 MG AZITHROMYCIN TAB 500 MG

BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG BENAZEPRIL HCL TAB 20 MG BENZONATATE CAP 100 MG BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05% BETAMETHASONE DIPROPIONATE LOTION 0.05% BETAMETHASONE VALERATE LOTION 0.1% (BASE EQUIVALENT) BETAXOLOL HCL TAB 10 MG BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG BISOPROLOL FUMARATE TAB 10 MG BISOPROLOL FUMARATE TAB 5 MG BUMETANIDE TAB 0.5 MG BUMETANIDE TAB 1 MG BUMETANIDE TAB 2 MG BUPROPION HCL (SMOKING DETERRENT) TAB ER 12HR 150 MG BUPROPION HCL TAB ER 12HR 100 MG BUPROPION HCL TAB ER 12HR 150 MG BUSPIRONE HCL TAB 10 MG BUSPIRONE HCL TAB 5 MG BUSPIRONE HCL TAB 7.5 MG BUTALBITAL-ACETAMINOPHEN TAB 50-300 MG BUTALBITAL-ACETAMINOPHEN-CAFF W/ COD CAP 50-300-40-30 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-300-40 MG BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG BUTORPHANOL TARTRATE NASAL SOLN 10 MG/ML

CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT CALCITRIOL CAP 0.5 MCG CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA) CANDESARTAN CILEXETIL TAB 16 MG CANDESARTAN CILEXETIL TAB 4 MG CANDESARTAN CILEXETIL TAB 8 MG

CAPTOPRIL TAB 12.5 MG CARBAMAZEPINE TAB 200 MG CARBAMAZEPINE TAB ER 12HR 100 MG CARBAMAZEPINE TAB ER 12HR 200 MG CARBIDOPA & LEVODOPA TAB 10-100 MG CARBIDOPA & LEVODOPA TAB 25-100 MG CARBIDOPA & LEVODOPA TAB ER 25-100 MG CARBIDOPA & LEVODOPA TAB ER 50-200 MG CEFACLOR CAP 500 MG CEFADROXIL CAP 500 MG CEFDINIR CAP 300 MG CEFDINIR FOR SUSP 125 MG/5ML CEFDINIR FOR SUSP 250 MG/5ML CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML CEFPODOXIME PROXETIL TAB 100 MG CEFPROZIL FOR SUSP 250 MG/5ML CEFPROZIL TAB 250 MG CELECOXIB CAP 50 MG CEPHALEXIN FOR SUSP 250 MG/5ML CETIRIZINE HCL ORAL SOLN 1 MG/ML (5 MG/5ML) CHLORDIAZEPOXIDE HCL CAP 5 MG CHLORPROMAZINE HCL TAB 10 MG CHLORTHALIDONE TAB 25 MG CHLORTHALIDONE TAB 50 MG CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM CHOLESTYRAMINE POWDER PACKETS 4 GM CHOLINE FENOFIBRATE CAP DR 45 MG (FENOFIBRIC ACID EQUIV) CICLOPIROX GEL 0.77% CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV) CILOSTAZOL TAB 50 MG CIPROFLOXACIN HCL OPHTH SOLN 0.3% (BASE EQUIVALENT) CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV) CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE ORAL SOLN 10 MG/5ML CITALOPRAM HYDROBROMIDE TAB 10 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 20 MG (BASE EQUIV) CITALOPRAM HYDROBROMIDE TAB 40 MG (BASE EQUIV) CLARITHROMYCIN TAB 500 MG CLINDAMYCIN HCL CAP 150 MG CLINDAMYCIN PHOSPHATE GEL 1% CLINDAMYCIN PHOSPHATE SOLN 1% CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2%

(Continued)

D

E

CLOBETASOL PROPIONATE EMOLLIENT BASE CREAM 0.05% CLOMIPRAMINE HCL CAP 75 MG CLONAZEPAM TAB 0.5 MG CLONAZEPAM TAB 1 MG CLONAZEPAM TAB 2 MG CLONIDINE HCL TAB 0.3 MG CLORAZEPATE DIPOTASSIUM TAB 3.75 MG CLORAZEPATE DIPOTASSIUM TAB 7.5 MG CLOTRIMAZOLE CREAM 1% CLOTRIMAZOLE SOLN 1% CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05% COLCHICINE W/ PROBENECID TAB 0.5-500 MG COLESTIPOL HCL GRANULE PACKETS 5 GM CROMOLYN SODIUM OPHTH SOLN 4% CYCLOBENZAPRINE HCL TAB 10 MG CYCLOBENZAPRINE HCL TAB 5 MG CYCLOBENZAPRINE HCL TAB 7.5 MG

DAPSONE TAB 25 MG DESIPRAMINE HCL TAB 10 MG DESMOPRESSIN ACETATE TAB 0.1 MG DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG DESONIDE CREAM 0.05% DESONIDE OINT 0.05% DESOXIMETASONE CREAM 0.25% DESOXIMETASONE GEL 0.05% DESOXIMETASONE OINT 0.25% DEXMETHYLPHENIDATE HCL TAB 10 MG DEXTROAMPHETAMINE SULFATE CAP ER 24HR 10 MG DEXTROAMPHETAMINE SULFATE TAB 5 MG DIAZEPAM TAB 10 MG DICLOFENAC POTASSIUM TAB 50 MG DICLOFENAC SODIUM GEL 1%

DICLOFENAC SODIUM OPHTH SOLN 0.1% DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG DICLOFENAC W/ MISOPROSTOL TAB DELAYED RELEASE 50-0.2 MG DICYCLOMINE HCL CAP 10 MG DIGOXIN TAB 250 MCG (0.25 MG) DILTIAZEM HCL COATED BEADS CAP ER 24HR 180 MG DILTIAZEM HCL COATED BEADS CAP ER 24HR 240 MG DILTIAZEM HCL COATED BEADS CAP ER 24HR 300 MG DILTIAZEM HCL COATED BEADS TAB ER 24HR 180 MG DILTIAZEM HCL COATED BEADS TAB ER 24HR 240 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 240 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 300 MG DILTIAZEM HCL EXTENDED RELEASE BEADS CAP ER 24HR 360 MG DILTIAZEM HCL TAB 120 MG DILTIAZEM HCL TAB 30 MG DILTIAZEM HCL TAB 60 MG DILTIAZEM HCL TAB 90 MG DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG DIPYRIDAMOLE TAB 50 MG DIPYRIDAMOLE TAB 75 MG DISULFIRAM TAB 250 MG DIVALPROEX SODIUM TAB DELAYED RELEASE 250 MG DIVALPROEX SODIUM TAB ER 24 HR 250 MG DORZOLAMIDE HCL OPHTH SOLN 2% DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML DOXAZOSIN MESYLATE TAB 2 MG DOXAZOSIN MESYLATE TAB 4 MG DOXEPIN HCL CAP 100 MG DOXEPIN HCL CAP 75 MG DOXYCYCLINE HYCLATE CAP 50 MG DOXYCYCLINE HYCLATE TAB 20 MG DOXYCYCLINE MONOHYDRATE CAP 100 MG DOXYCYCLINE MONOHYDRATE TAB 100 MG DOXYCYCLINE MONOHYDRATE TAB 50 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG

ENALAPRIL MALEATE TAB 10 MG ENALAPRIL MALEATE TAB 20 MG

F

ENOXAPARIN SODIUM INJ 30 MG/0.3ML ERYTHROMYCIN GEL 2% ERYTHROMYCIN TAB 500 MG ESTAZOLAM TAB 1 MG ESTAZOLAM TAB 2 MG ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5-0.1 MG ESTRADIOL TD PATCH TWICE WEEKLY 0.075 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR) ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR ESTRADIOL VAGINAL TAB 10 MCG ETHAMBUTOL HCL TAB 400 MG ETODOLAC CAP 300 MG ETODOLAC TAB 500 MG

FELODIPINE TAB ER 24HR 10 MG FENOFIBRATE MICRONIZED CAP 134 MG FENOFIBRATE MICRONIZED CAP 200 MG FENOFIBRATE TAB 48 MG FINASTERIDE TAB 1 MG FINASTERIDE TAB 5 MG FLUCONAZOLE TAB 100 MG FLUCONAZOLE TAB 50 MG FLUOCINONIDE CREAM 0.05% FLUOCINONIDE EMULSIFIED BASE CREAM 0.05% FLUOCINONIDE GEL 0.05% FLUOCINONIDE OINT 0.05% FLUOCINONIDE SOLN 0.05% FLUOROMETHOLONE OPHTH SUSP 0.1% FLUOXETINE HCL CAP 10 MG FLUOXETINE HCL CAP 20 MG FLUOXETINE HCL SOLUTION 20 MG/5ML FLUOXETINE HCL TAB 10 MG FLURBIPROFEN TAB 100 MG

(Continued)

G

I

K

FLUTICASONE PROPIONATE CREAM 0.05% FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT FLUVOXAMINE MALEATE TAB 100 MG FLUVOXAMINE MALEATE TAB 25 MG FLUVOXAMINE MALEATE TAB 50 MG

GABAPENTIN CAP 100 MG GABAPENTIN CAP 300 MG GABAPENTIN ORAL SOLN 250 MG/5ML GALANTAMINE HYDROBROMIDE TAB 4 MG GENTAMICIN SULFATE CREAM 0.1% GENTAMICIN SULFATE OINT 0.1% GLIMEPIRIDE TAB 4 MG GLIPIZIDE-METFORMIN HCL TAB 2.5-250 MG GLYBURIDE MICRONIZED TAB 6 MG GLYBURIDE TAB 5 MG GLYBURIDE-METFORMIN TAB 1.25-250 MG GLYBURIDE-METFORMIN TAB 2.5-500 MG GLYBURIDE-METFORMIN TAB 5-500 MG GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML GUANFACINE HCL TAB 2 MG

HHALOBETASOL PROPIONATE CREAM 0.05% HALOBETASOL PROPIONATE OINT 0.05% HALOPERIDOL DECANOATE IM SOLN 100 MG/ML HALOPERIDOL LACTATE INJ 5 MG/ML HYDRALAZINE HCL TAB 100 MG HYDRALAZINE HCL TAB 25 MG HYDRALAZINE HCL TAB 50 MG HYDROCOD POLST-CHLORPHEN POLST ER SUSP 10-8 MG/5ML HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG

HYDROCODONE-IBUPROFEN TAB 10-200 MG HYDROCORTISONE CREAM 1% HYDROCORTISONE LOTION 2.5% HYDROCORTISONE OINT 1% HYDROCORTISONE RECTAL CREAM 2.5% HYDROCORTISONE VALERATE CREAM 0.2% HYDROCORTISONE VALERATE OINT 0.2% HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2% HYDROMORPHONE HCL TAB 4 MG HYDROQUINONE MICROSPHERES CREAM 4% HYDROXYZINE PAMOATE CAP 50 MG HYOSCYAMINE SULFATE TAB DISINT 0.125 MG HYOSCYAMINE SULFATE TAB ER 12HR 0.375 MG

IMIPRAMINE HCL TAB 50 MG INDAPAMIDE TAB 2.5 MG INDOMETHACIN CAP ER 75 MG IODOQUINOL-HC CREAM 1% IPRATROPIUM BROMIDE INHAL SOLN 0.02% IPRATROPIUM BROMIDE NASAL SOLN 0.06% (42 MCG/SPRAY) IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML IRBESARTAN TAB 150 MG IRBESARTAN TAB 300 MG IRBESARTAN TAB 75 MG IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 150-12.5 MG IRBESARTAN-HYDROCHLOROTHIAZIDE TAB 300-12.5 MG ISOSORBIDE DINITRATE TAB 10 MG ISOSORBIDE DINITRATE TAB 5 MG ISOSORBIDE MONONITRATE TAB ER 24HR 120 MG ISOSORBIDE MONONITRATE TAB ER 24HR 60 MG

KETOCONAZOLE SHAMPOO 2% KETOROLAC TROMETHAMINE INJ 30 MG/ML

H

KETOROLAC TROMETHAMINE OPHTH SOLN 0.4% KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% KETOROLAC TROMETHAMINE TAB 10 MG KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV)

LABETALOL HCL TAB 100 MG LABETALOL HCL TAB 200 MG LABETALOL HCL TAB 300 MG LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML LEVETIRACETAM ORAL SOLN 100 MG/ML LEVOCARNITINE TAB 330 MG LEVOCETIRIZINE DIHYDROCHLORIDE TAB 5 MG LEVOFLOXACIN TAB 250 MG LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MGLEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG LEVOTHYROXINE SODIUM TAB 88 MCG LIDOCAINE HCL GEL 2% LIDOCAINE HCL SOLN 4% LIDOCAINE-PRILOCAINE CREAM 2.5-2.5% LIOTHYRONINE SODIUM TAB 50 MCG LISINOPRIL TAB 30 MG LISINOPRIL TAB 40 MG LOPERAMIDE HCL CAP 2 MG LORAZEPAM CONC 2 MG/ML LORAZEPAM TAB 0.5 MG LORAZEPAM TAB 1 MG LORAZEPAM TAB 2 MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG LOSARTAN POTASSIUM TAB 100 MG LOSARTAN POTASSIUM TAB 25 MG LOSARTAN POTASSIUM TAB 50 MG LOVASTATIN TAB 20 MG

MMEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML MEGESTROL ACETATE TAB 20 MG

(Continued)

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MEGESTROL ACETATE TAB 40 MG MELOXICAM TAB 7.5 MG MESNA INJ 100 MG/ML METFORMIN HCL TAB 850 MG METFORMIN HCL TAB ER 24HR 500 MG METHADONE HCL TAB 10 MG METHENAMINE HIPPURATE TAB 1 GM METHENAMINE MANDELATE TAB 1 GM METHENAMINE-HYOSC-METH BLUE-SOD PHOS-PHEN SAL CAP 118 MG***METHENAMINE-HYOSCAMINE-METH BLUE-SOD PHOS TAB 81.6 MG*** METHOCARBAMOL TAB 500 MG METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV) METHYLPHENIDATE HCL CAP ER 50 MG (CD) METHYLPHENIDATE HCL TAB 10 MG METHYLPHENIDATE HCL TAB 20 MG METHYLPHENIDATE HCL TAB 5 MG METHYLPREDNISOLONE TAB 16 MG METOCLOPRAMIDE HCL TAB 10 MG (BASE EQUIVALENT) METOLAZONE TAB 2.5 MG METOLAZONE TAB 5 MG METOPROLOL SUCCINATE TAB ER 24HR 100 MG (TARTRATE EQUIV) METOPROLOL SUCCINATE TAB ER 24HR 200 MG (TARTRATE EQUIV) METOPROLOL TARTRATE TAB 100 MG METRONIDAZOLE VAGINAL GEL 0.75% MIDODRINE HCL TAB 2.5 MG MINOCYCLINE HCL CAP 50 MG MINOCYCLINE HCL CAP 75 MG MINOCYCLINE HCL TAB 50 MG MINOXIDIL TAB 10 MG MINOXIDIL TAB 2.5 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 15 MG MIRTAZAPINE ORALLY DISINTEGRATING TAB 45 MG MIRTAZAPINE TAB 15 MG MIRTAZAPINE TAB 30 MG MIRTAZAPINE TAB 45 MG MIRTAZAPINE TAB 7.5 MG MISOPROSTOL TAB 200 MCG MOMETASONE FUROATE OINT 0.1% MOMETASONE FUROATE SOLUTION 0.1% (LOTION) MYCOPHENOLATE SODIUM TAB DR 180 MG (MYCOPHENOLIC ACID EQUIV)

NABUMETONE TAB 500 MG NADOLOL TAB 20 MG NALBUPHINE HCL INJ 20 MG/ML NAPROXEN SODIUM TAB 550 MG NAPROXEN TAB 250 MG NAPROXEN TAB 375 MG NAPROXEN TAB 500 MG NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1% NIFEDIPINE CAP 10 MG NIFEDIPINE TAB ER 24HR 60 MG NIFEDIPINE TAB ER 24HR 90 MG NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 30 MG NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 60 MG NIFEDIPINE TAB ER 24HR OSMOTIC RELEASE 90 MG NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE CAP 100 MG NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24) NORETHINDRONE ACETATE TAB 5 MG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG NORTRIPTYLINE HCL CAP 50 MG NORTRIPTYLINE HCL CAP 75 MG NYSTATIN SUSP 100000 UNIT/ML NYSTATIN TOPICAL POWDER 100000 UNIT/GM

ORPHENADRINE CITRATE TAB ER 12HR 100 MG OXCARBAZEPINE TAB 150 MG OXYBUTYNIN CHLORIDE TAB 5 MG OXYBUTYNIN CHLORIDE TAB ER 24HR 15 MG OXYBUTYNIN CHLORIDE TAB ER 24HR 5 MG OXYCODONE HCL CAP 5 MG OXYCODONE HCL TAB 10 MG

OXYCODONE HCL TAB 20 MG OXYCODONE HCL TAB 5 MG OXYMORPHONE HCL TAB 5 MG

PAROXETINE HCL TAB 10 MG PAROXETINE HCL TAB 20 MG PAROXETINE HCL TAB 30 MG PAROXETINE HCL TAB 40 MG PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM PENTOXIFYLLINE TAB ER 400 MG PERINDOPRIL ERBUMINE TAB 8 MG PERPHENAZINE TAB 2 MG PERPHENAZINE TAB 4 MG PHENOBARBITAL ELIXIR 20 MG/5ML PHENOBARBITAL TAB 64.8 MG PHENOBARBITAL TAB 97.2 MG PHENTERMINE HCL CAP 15 MG PHENTERMINE HCL CAP 30 MG PHENTERMINE HCL CAP 37.5 MG PHENTERMINE HCL TAB 37.5 MG PHENYTOIN SODIUM EXTENDED CAP 100 MG PHENYTOIN SODIUM EXTENDED CAP 300 MG PHYTONADIONE TAB 5 MG PILOCARPINE HCL OPHTH SOLN 1% PILOCARPINE HCL OPHTH SOLN 2% PILOCARPINE HCL TAB 5 MG PIROXICAM CAP 10 MG PODOFILOX SOLN 0.5% POTASSIUM CITRATE & CITRIC ACID SOLN 1100-334 MG/5ML PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG PRAMOXINE-HC CREAM 1-2.5% PRAVASTATIN SODIUM TAB 20 MG PRAZOSIN HCL CAP 5 MG PROBENECID TAB 500 MG PROCHLORPERAZINE MALEATE TAB 10 MG (BASE EQUIVALENT)

(Continued)

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PROCHLORPERAZINE MALEATE TAB 5 MG (BASE EQUIVALENT) PROGESTERONE MICRONIZED CAP 100 MG PROGESTERONE MICRONIZED CAP 200 MG PROMETHAZINE HCL INJ 50 MG/ML PROMETHAZINE HCL SUPPOS 12.5 MG PROMETHAZINE HCL TAB 50 MG PROPAFENONE HCL TAB 150 MG PROPRANOLOL HCL CAP ER 24HR 120 MG PROPRANOLOL HCL CAP ER 24HR 60 MG PROPRANOLOL HCL CAP ER 24HR 80 MG PROPRANOLOL HCL TAB 20 MG PROPRANOLOL HCL TAB 60 MG PYRIDOSTIGMINE BROMIDE TAB 60 MG

QQUETIAPINE FUMARATE TAB 25 MG QUINAPRIL HCL TAB 10 MG

RQUINAPRIL HCL TAB 10 MG RAMIPRIL CAP 1.25 MG RAMIPRIL CAP 10 MG RAMIPRIL CAP 2.5 MG RAMIPRIL CAP 5 MG RANITIDINE HCL CAP 300 MG RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML) RANITIDINE HCL TAB 300 MG RIFAMPIN CAP 150 MG RIFAMPIN CAP 300 MG RISPERIDONE SOLN 1 MG/ML RIVASTIGMINE TARTRATE CAP 3 MG (BASE EQUIVALENT) ROPINIROLE HYDROCHLORIDE TAB 0.25 MG ROPINIROLE HYDROCHLORIDE TAB 0.5 MG ROPINIROLE HYDROCHLORIDE TAB 1 MG ROPINIROLE HYDROCHLORIDE TAB 2 MG

ROPINIROLE HYDROCHLORIDE TAB 3 MG ROPINIROLE HYDROCHLORIDE TAB 4 MG ROPINIROLE HYDROCHLORIDE TAB 5 MG

SERTRALINE HCL TAB 100 MG SERTRALINE HCL TAB 25 MG SERTRALINE HCL TAB 50 MG SILVER SULFADIAZINE CREAM 1% SIMVASTATIN TAB 10 MG SIMVASTATIN TAB 5 MG SODIUM CHLORIDE FLUSH IV SOLN 0.9% SODIUM CHLORIDE SOLN NEBU 7% SPIRONOLACTONE TAB 100 MG SUCRALFATE TAB 1 GM SULFACETAMIDE SODIUM LIQUID 10% SULFACETAMIDE SODIUM OPHTH SOLN 10% SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML SULFASALAZINE TAB 500 MG SULFASALAZINE TAB DELAYED RELEASE 500 MG SULINDAC TAB 150 MG SULINDAC TAB 200 MG SUMATRIPTAN NASAL SPRAY 20 MG/ACT SUMATRIPTAN NASAL SPRAY 5 MG/ACT

TADALAFIL TAB 2.5 MG TADALAFIL TAB 20 MG (PAH) TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT) TEMAZEPAM CAP 30 MG TERBUTALINE SULFATE TAB 5 MG TERCONAZOLE VAGINAL CREAM 0.4% TESTOSTERONE CYPIONATE IM INJ IN OIL 100 MG/ML TESTOSTERONE CYPIONATE IM INJ IN OIL 200 MG/ML TESTOSTERONE TD GEL 50 MG/5GM (1%)

THYROID TAB 120 MG (2 GRAIN) THYROID TAB 90 MG (1 1/2 GRAIN) TIZANIDINE HCL CAP 2 MG (BASE EQUIVALENT) TIZANIDINE HCL TAB 2 MG (BASE EQUIVALENT) TOLTERODINE TARTRATE TAB 1 MG TOPIRAMATE SPRINKLE CAP 25 MG TORSEMIDE TAB 100 MG TRAMADOL HCL TAB 50 MG TRAMADOL-ACETAMINOPHEN TAB 37.5-325 MG TRANEXAMIC ACID TAB 650 MG TRAZODONE HCL TAB 100 MG TRAZODONE HCL TAB 150 MG TRETINOIN CREAM 0.025% TRETINOIN CREAM 0.05% TRETINOIN GEL 0.01% TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1% TRIAMCINOLONE ACETONIDE LOTION 0.025% TRIAMCINOLONE ACETONIDE LOTION 0.1% TRIAMCINOLONE ACETONIDE OINT 0.1% TRIFLUOPERAZINE HCL TAB 5 MG (BASE EQUIVALENT) TRIMETHOBENZAMIDE HCL CAP 300 MG

VALSARTAN TAB 40 MG VARDENAFIL HCL TAB 10 MG VARDENAFIL HCL TAB 20 MG VENLAFAXINE HCL CAP ER 24HR 37.5 MG (BASE EQUIVALENT) VENLAFAXINE HCL TAB 25 MG (BASE EQUIVALENT) VENLAFAXINE HCL TAB 37.5 MG (BASE EQUIVALENT) VENLAFAXINE HCL TAB 50 MG (BASE EQUIVALENT) VENLAFAXINE HCL TAB ER 24HR 225 MG (BASE EQUIVALENT) VERAPAMIL HCL CAP ER 24HR 120 MG VERAPAMIL HCL CAP ER 24HR 180 MG VERAPAMIL HCL CAP ER 24HR 240 MG VERAPAMIL HCL TAB 80 MG

(Continued)

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VERAPAMIL HCL TAB ER 120 MG VERAPAMIL HCL TAB ER 180 MG VERAPAMIL HCL TAB ER 240 MG

ZALEPLON CAP 5 MG ZONISAMIDE CAP 25 MG ZONISAMIDE CAP 50 MG

Tier 4| 30-day supply cost: $50.00 (or less)

ACETAMINOPHEN W/ CODEINE TAB 300-60 MG ACETAZOLAMIDE CAP ER 12HR 500 MG ACYCLOVIR TAB 400 MG ACYCLOVIR TAB 800 MG ADAPALENE GEL 0.1% ALFUZOSIN HCL TAB ER 24HR 10 MG ALISKIREN FUMARATE TAB 150 MG (BASE EQUIVALENT) ALPRAZOLAM TAB ER 24HR 3 MG AMINOCAPROIC ACID TAB 500 MG AMIODARONE HCL TAB 100 MG AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 10-20 MG AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL TAB 5-20 MG AMLODIPINE BESYLATE-VALSARTAN TAB 10-160 MG AMLODIPINE BESYLATE-VALSARTAN TAB 5-160 MG AMLODIPINE BESYLATE-VALSARTAN TAB 5-320 MG AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-160-25 MG AMLODIPINE-VALSARTAN-HYDROCHLOROTHIAZIDE TAB 10-320-25 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 10 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 20 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 25 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 30 MG

AMPHETAMINE-DEXTROAMPHETAMINE CAP ER 24HR 5 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG ARMODAFINIL TAB 50 MG ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT) ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT) ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT) ATOVAQUONE-PROGUANIL HCL TAB 250-100 MG AZATHIOPRINE TAB 50 MG AZELASTINE HCL NASAL SPRAY 0.1% (137 MCG/SPRAY) AZELASTINE HCL NASAL SPRAY 0.15% (205.5 MCG/SPRAY) AZITHROMYCIN TAB 600 MG

B-COMPLEX VITAMIN INJ** BACLOFEN TAB 10 MG BENZONATATE CAP 200 MG BENZPHETAMINE HCL TAB 50 MG BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05% BETHANECHOL CHLORIDE TAB 10 MG BETHANECHOL CHLORIDE TAB 25 MG BIMATOPROST OPHTH SOLN 0.03% BIMATOPROST SOLN 0.03% BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG BRIMONIDINE TARTRATE OPHTH SOLN 0.15% BUPRENORPHINE HCL-NALOXONE HCL SL FILM 12-3 MG (BASE EQUIV) BUPROPION HCL TAB ER 12HR 200 MG BUPROPION HCL TAB ER 24HR 150 MG BUPROPION HCL TAB ER 24HR 300 MG BUSPIRONE HCL TAB 15 MG

CCANDESARTAN CILEXETIL TAB 32 MG CARBIDOPA & LEVODOPA ORALLY DISINTEGRATING TAB 25-100 MG CARVEDILOL TAB 12.5 MG

CARVEDILOL TAB 25 MG CARVEDILOL TAB 3.125 MG CARVEDILOL TAB 6.25 MG CEFPODOXIME PROXETIL TAB 200 MG CEFPROZIL TAB 500 MG CEFUROXIME AXETIL TAB 250 MG CELECOXIB CAP 200 MG CHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDE CAP 5-2.5 MG CHOLESTYRAMINE POWDER 4 GM/DOSE CHOLINE FENOFIBRATE CAP DR 135 MG (FENOFIBRIC ACID EQUIV) CICLOPIROX SHAMPOO 1% CICLOPIROX SOLUTION 8% CILOSTAZOL TAB 100 MG CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV) CLARITHROMYCIN TAB 250 MG CLINDAMYCIN HCL CAP 300 MG CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV) CLINDAMYCIN PHOSPHATE LOTION 1% CLOBETASOL PROPIONATE CREAM 0.05% CLOBETASOL PROPIONATE GEL 0.05% CLOMIPRAMINE HCL CAP 25 MG CLONIDINE TD PATCH WEEKLY 0.1 MG/24HR CLONIDINE TD PATCH WEEKLY 0.2 MG/24HR CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV) CLORAZEPATE DIPOTASSIUM TAB 15 MG CLOTRIMAZOLE W/ BETAMETHASONE LOTION 1-0.05%

DESLORATADINE TAB 5 MG DESMOPRESSIN ACETATE NASAL SPRAY SOLN 0.01% DESMOPRESSIN ACETATE TAB 0.2 MG DEXMETHYLPHENIDATE HCL CAP ER 24 HR 15 MG DEXMETHYLPHENIDATE HCL CAP ER 24 HR 30 MG DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG DICLOFENAC SODIUM TAB ER 24HR 100 MG DILTIAZEM HCL CAP ER 12HR 60 MG DILTIAZEM HCL CAP ER 12HR 90 MG DILTIAZEM HCL COATED BEADS TAB ER 24HR 360 MG

(Continued)

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HDIVALPROEX SODIUM TAB DELAYED RELEASE 500 MG DIVALPROEX SODIUM TAB ER 24 HR 500 MG DOFETILIDE CAP 250 MCG (0.25 MG) DONEPEZIL HYDROCHLORIDE TAB 10 MG DONEPEZIL HYDROCHLORIDE TAB 5 MG DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOL 22.3-6.8 MG/ML PF DOXYCYCLINE HYCLATE CAP 100 MG DOXYCYCLINE HYCLATE TAB 100 MG DRONABINOL CAP 5 MG DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MGDULOXETINE HCL ENTERIC COATED PELLETS CAP 20 MG (BASE EQ) DULOXETINE HCL ENTERIC COATED PELLETS CAP 30 MG (BASE EQ) DULOXETINE HCL ENTERIC COATED PELLETS CAP 40 MG (BASE EQ) DULOXETINE HCL ENTERIC COATED PELLETS CAP 60 MG (BASE EQ) DUTASTERIDE CAP 0.5 MG DUTASTERIDE-TAMSULOSIN HCL CAP 0.5-0.4 MG

ECONAZOLE NITRATE CREAM 1% ENOXAPARIN SODIUM INJ 100 MG/ML ENOXAPARIN SODIUM INJ 40 MG/0.4ML ENOXAPARIN SODIUM INJ 60 MG/0.6ML ENOXAPARIN SODIUM INJ 80 MG/0.8ML EPINASTINE HCL OPHTH SOLN 0.05% EPLERENONE TAB 25 MG ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV) ESCITALOPRAM OXALATE TAB 20 MG (BASE EQUIV) ESCITALOPRAM OXALATE TAB 5 MG (BASE EQUIV) ESOMEPRAZOLE MAGNESIUM CAP DELAYED RELEASE 40 MG (BASE EQ) ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 MG ESTRADIOL TD PATCH TWICE WEEKLY 0.025 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.0375 MG/24HR ESTRADIOL TD PATCH TWICE WEEKLY 0.05 MG/24HR ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR

ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR ESTRADIOL VALERATE IM IN OIL 20 MG/ML ESTRADIOL VALERATE IM IN OIL 40 MG/ML ETHOSUXIMIDE CAP 250 MG ETODOLAC TAB 400 MG

FAMCICLOVIR TAB 250 MG FAMOTIDINE FOR SUSP 40 MG/5ML FAMOTIDINE TAB 20 MG FAMOTIDINE TAB 40 MG FENOFIBRATE MICRONIZED CAP 130 MG FENOFIBRATE TAB 145 MG FENOFIBRATE TAB 160 MG FENTANYL TD PATCH 72HR 25 MCG/HR FLECAINIDE ACETATE TAB 100 MG FLECAINIDE ACETATE TAB 50 MG FLUCONAZOLE FOR SUSP 40 MG/ML FLUOCINOLONE ACETONIDE CREAM 0.01% FLUOCINOLONE ACETONIDE OIL 0.01% (BODY OIL) FLUOCINOLONE ACETONIDE SOLN 0.01% FLUOXETINE HCL CAP 40 MG FLUOXETINE HCL TAB 20 MG FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG

GGABAPENTIN CAP 400 MG GABAPENTIN TAB 600 MG GALANTAMINE HYDROBROMIDE TAB 12 MG GATIFLOXACIN OPHTH SOLN 0.5% GEMFIBROZIL TAB 600 MG GLIPIZIDE-METFORMIN HCL TAB 5-500 MG GLYCOPYRROLATE TAB 2 MG

HALOPERIDOL TAB 20 MG HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML HYDROCODONE-ACETAMINOPHEN TAB 10-300 MG HYDROCODONE-IBUPROFEN TAB 7.5-200 MG HYDROCORTISONE ACETATE SUPPOS 25 MG HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 1-1% HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL CREAM 2.5-1% HYDROCORTISONE BUTYRATE SOLN 0.1% HYDROMORPHONE HCL LIQD 1 MG/ML HYDROMORPHONE HCL TAB 8 MG HYDROQUINONE CREAM 4% HYDROXYCHLOROQUINE SULFATE TAB 200 MG

IIMIQUIMOD CREAM 5% IPRATROPIUM BROMIDE NASAL SOLN 0.03% (21 MCG/SPRAY) IRON COMBINATION CAP*** ITRACONAZOLE CAP 100 MG

LLAMOTRIGINE TAB 100 MG LAMOTRIGINE TAB 150 MG LAMOTRIGINE TAB 200 MG LANSOPRAZOLE CAP DELAYED RELEASE 15 MG LANSOPRAZOLE CAP DELAYED RELEASE 30 MG LATANOPROST OPHTH SOLN 0.005% LEFLUNOMIDE TAB 10 MG LEUCOVORIN CALCIUM TAB 25 MG LEVALBUTEROL HCL SOLN NEBU 0.63 MG/3ML (BASE EQUIV) LEVALBUTEROL HCL SOLN NEBU 1.25 MG/3ML (BASE EQUIV) LEVETIRACETAM TAB 250 MG LEVETIRACETAM TAB 500 MG LEVETIRACETAM TAB 750 MG LEVOFLOXACIN TAB 500 MG

(Continued)

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LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)LIDOCAINE HCL CREAM 3% LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG LOVASTATIN TAB 40 MG

MEDROXYPROGESTERONE ACETATE IM SUSP PREFILLED SYR 150 MG/ML MEGESTROL ACETATE SUSP 40 MG/ML MELOXICAM TAB 15 MG MEMANTINE HCL CAP ER 24HR 28 MG METAXALONE TAB 800 MG METHOCARBAMOL TAB 750 MG METHYLERGONOVINE MALEATE TAB 0.2 MG METHYLPHENIDATE HCL CAP ER 10 MG (CD) METHYLPHENIDATE HCL CAP ER 20 MG (CD) METHYLPHENIDATE HCL CAP ER 30 MG (CD) METHYLPHENIDATE HCL TAB ER 10 MG MIDODRINE HCL TAB 5 MG MINOCYCLINE HCL CAP 100 MG MOMETASONE FUROATE NASAL SUSP 50 MCG/ACT MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV) MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV) MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV) MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV) MORPHINE SULFATE CAP ER 24HR 10 MG MORPHINE SULFATE TAB ER 15 MG MOXIFLOXACIN HCL OPHTH SOLN 0.5% (BASE EQUIV)

NABUMETONE TAB 750 MG NADOLOL TAB 40 MG NALTREXONE HCL TAB 50 MG NAPROXEN TAB EC 500 MG NARATRIPTAN HCL TAB 1 MG (BASE EQUIV) NATEGLINIDE TAB 120 MG

NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1% NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1% NIACIN TAB ER 1000 MG (ANTIHYPERLIPIDEMIC) NIACIN TAB ER 500 MG (ANTIHYPERLIPIDEMIC) NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY) NIZATIDINE CAP 150 MG NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCGNORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TAB 1 MG-20 MCG (24)NYSTATIN TAB 500000 UNIT NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-% NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%

OFLOXACIN OTIC SOLN 0.3% OLANZAPINE ORALLY DISINTEGRATING TAB 5 MG OLMESARTAN MEDOXOMIL TAB 20 MG OLMESARTAN MEDOXOMIL TAB 5 MG OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 20-5-12.5 MG OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-10-25 MG OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-5-12.5 MG OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE TAB 40-5-25 MG OLOPATADINE HCL OPHTH SOLN 0.1% (BASE EQUIVALENT) OLOPATADINE HCL OPHTH SOLN 0.2% (BASE EQUIVALENT) OMEPRAZOLE CAP DELAYED RELEASE 10 MG OMEPRAZOLE CAP DELAYED RELEASE 20 MG OMEPRAZOLE CAP DELAYED RELEASE 40 MG ONDANSETRON HCL ORAL SOLN 4 MG/5ML ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)

OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV) OSELTAMIVIR PHOSPHATE FOR SUSP 6 MG/ML (BASE EQUIV) OXCARBAZEPINE TAB 300 MG OXYBUTYNIN CHLORIDE TAB ER 24HR 10 MG OXYCODONE HCL SOLN 5 MG/5ML OXYCODONE W/ ACETAMINOPHEN TAB 7.5-325 MG

PALIPERIDONE TAB ER 24HR 9 MG PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV) PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV) PAROXETINE HCL TAB ER 24HR 25 MG PAROXETINE HCL TAB ER 24HR 37.5 MG PERMETHRIN CREAM 5% PINDOLOL TAB 5 MG PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV) PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 MG PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 MG PIROXICAM CAP 20 MG POLYETHYLENE GLYCOL 3350 ORAL POWDER POTASSIUM CITRATE TAB ER 15 MEQ (1620 MG) PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG PRAVASTATIN SODIUM TAB 10 MG PRAVASTATIN SODIUM TAB 40 MG PRAVASTATIN SODIUM TAB 80 MG PROPAFENONE HCL TAB 225 MG PROPYLTHIOURACIL TAB 50 MG

QUETIAPINE FUMARATE TAB 50 MG QUETIAPINE FUMARATE TAB ER 24HR 50 MG

(Continued)

R

V

S

Z

RALOXIFENE HCL TAB 60 MG RANITIDINE HCL TAB 150 MG RANOLAZINE TAB ER 12HR 500 MG REPAGLINIDE TAB 0.5 MG REPAGLINIDE TAB 1 MG RISPERIDONE ORALLY DISINTEGRATING TAB 3 MG RISPERIDONE TAB 0.5 MG RISPERIDONE TAB 1 MG RISPERIDONE TAB 2 MG RISPERIDONE TAB 3 MG RIVASTIGMINE TARTRATE CAP 1.5 MG (BASE EQUIVALENT) RIVASTIGMINE TARTRATE CAP 4.5 MG (BASE EQUIVALENT) RIVASTIGMINE TARTRATE CAP 6 MG (BASE EQUIVALENT) ROPINIROLE HYDROCHLORIDE TAB ER 24HR 8 MG (BASE EQUIVALENT)

SEVELAMER CARBONATE TAB 800 MG SIMVASTATIN TAB 20 MG SIMVASTATIN TAB 40 MG SIMVASTATIN TAB 80 MG SOTALOL HCL (AFIB/AFL) TAB 80 MG SOTALOL HCL TAB 120 MG SOTALOL HCL TAB 160 MG SOTALOL HCL TAB 80 MG SULFACETAMIDE SODIUM W/ SULFUR WASH 9-4.5% SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 6 MG/0.5ML SUMATRIPTAN SUCCINATE TAB 25 MG

TACROLIMUS CAP 0.5 MG TADALAFIL TAB 10 MG TAMSULOSIN HCL CAP 0.4 MG TELMISARTAN TAB 20 MG

TELMISARTAN TAB 40 MG TELMISARTAN TAB 80 MG TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG TELMISARTAN-HYDROCHLOROTHIAZIDE TAB 80-25 MG TETRACAINE HCL OPHTH SOLN 0.5% TETRACYCLINE HCL CAP 500 MG TINIDAZOLE TAB 500 MG TIZANIDINE HCL CAP 4 MG (BASE EQUIVALENT) TIZANIDINE HCL TAB 4 MG (BASE EQUIVALENT) TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1% TOLTERODINE TARTRATE CAP ER 24HR 4 MG TOLTERODINE TARTRATE TAB 2 MG TOPIRAMATE TAB 25 MG TRAMADOL HCL TAB ER 24HR 100 MG TRAMADOL HCL TAB ER 24HR 200 MG TRAMADOL HCL TAB ER 24HR BIPHASIC RELEASE 200 MG TRAZODONE HCL TAB 300 MG TROSPIUM CHLORIDE TAB 20 MG

UUREA CREAM 40%

VALACYCLOVIR HCL TAB 500 MG VALSARTAN TAB 160 MG VALSARTAN TAB 320 MG VALSARTAN TAB 80 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG VARDENAFIL HCL ORALLY DISINTEGRATING TAB 10 MG VENLAFAXINE HCL CAP ER 24HR 150 MG (BASE EQUIVALENT) VENLAFAXINE HCL CAP ER 24HR 75 MG (BASE EQUIVALENT)

VENLAFAXINE HCL TAB 100 MG (BASE EQUIVALENT) VENLAFAXINE HCL TAB 75 MG (BASE EQUIVALENT) VENLAFAXINE HCL TAB ER 24HR 150 MG (BASE EQUIVALENT)

ZAFIRLUKAST TAB 20 MG ZALEPLON CAP 10 MG ZIPRASIDONE HCL CAP 40 MG ZOLMITRIPTAN TAB 2.5 MG ZOLMITRIPTAN TAB 5 MG ZOLPIDEM TARTRATE TAB 10 MG ZOLPIDEM TARTRATE TAB 5 MG ZOLPIDEM TARTRATE TAB ER 6.25 MG ZONISAMIDE CAP 100 MG

Please note this list is subject to change.

Always refer to your benefit plan materials to determine your coverage for medications and cost-share. Some medications listed on the PDL may not be covered under your specific benefit. Where differences are noted, the benefit plan documents will govern.

All brand-name medications are trademarks or registered trademarks of their respective owners.

The age limits listed within this document are based on U.S. Preventive Services Task Force Recommendations; coverage for additional populations may also apply as required.

The pricing and inclusion of any prescription drug within this preferred drug list is subject to change and is not guaranteed. While we strive to maintain up to date pricing, drug manufacturers and pharmacies may alter pricing at any time creating the opportunity for an outdated price to be displayed on this preferred drug list before price changes can be updated on this preferred drug list.

2020 NBFSA, LLC All Rights Reserved THIS DOCUMENT LIST IS EFFECTIVE 1/1/2020 – 12/31/2020. THIS LIST IS SUBJECT TO CHANGE.