2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

Medicare HMO Blue SM ValueRx (HMO)Medicare HMO Blue SM PlusRx (HMO)2013 FormularyList of Covered DrugsPLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THESE PLANS.Note to existing members: This formulary has changed sincelast year. Please review this document to make sure it stillcontains the drugs you take.Blue Cross Blue Shield of Massachusetts is an IndependentLicensee of the Blue Cross and Blue Shield Association.H2261_1259 Final CMS Accepted 0820201213575 Version 1513577 Version 15Beneficiaries must use network pharmacies to access their prescriptiondrug benefit. Benefits, formulary, pharmacy network, premium and/orcopayments/coinsurance may change on January 1, 2014.Blue Cross Blue Shield of Massachusetts is a Medicare Advantageorganization with a Medicare contract.This material may be available in an alternate format or language.Please call Member Service at 1-800-200-4255, as follows: fromFebruary 15 through September 30, 8:00 a.m. to 8:00 p.m. ET,Monday through Friday, and from October 1 through February 14,8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY users shouldcall 1-800-522-1254.Effective August 1, 2013

What is the Medicare HMO Blue ValueRx andMedicare HMO Blue PlusRx Formulary?A formulary is a list of covered drugs selected by MedicareHMO Blue ValueRx and Medicare HMO Blue PlusRx inconsultation with a team of health care providers, whichrepresents the prescription therapies believed to be anecessary part of a quality treatment program. MedicareHMO Blue ValueRx and Medicare HMO Blue PlusRx willgenerally cover the drugs listed in our formulary as long asthe drug is medically necessary, the prescription is filled ata Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx network pharmacy, and other plan rules are followed.For more information on how to fill your prescriptions, pleasereview your Evidence of Coverage.Can the Formulary change?Generally, if you are taking a drug on our 2013 formularythat was covered at the beginning of the year, we will notdiscontinue or reduce coverage of the drug during the 2013coverage year except when a new, less expensive genericdrug becomes available or when new adverse informationabout the safety or effectiveness of a drug is released.Other types of formulary changes, such as removing adrug from our formulary, will not affect members who arecurrently taking the drug. It will remain available at the samecost-sharing for those members taking it for the remainderof the coverage year. We feel it is important that you havecontinued access for the remainder of the coverage year tothe formulary drugs that were available when you choseour plan, except for cases in which you can save additionalmoney or we can ensure your safety.If we remove drugs from our formulary, or add priorauthorization, quantity limits and/or step therapy restrictionson a drug, we must notify affected members of the changeat least 60 days before the change becomes effective, or atthe time the member requests a refill of the drug, at whichtime the member will receive a 60-day supply of the drug.If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removesthe drug from the market, we will immediately remove thedrug from our formulary and provide notice to members whotake the drug. The enclosed formulary is current as ofAugust 1, 2013. To get updated information about the drugscovered by Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx please visit our Web site atwww.bluecrossma.com/medicare or call Member Serviceat 1-800-200-4255, as follows: from February 15 throughSeptember 30, 8:00 a.m. to 8:00 p.m. ET, Monday throughFriday, and from October 1 through February 14, 8:00 a.m. to8:00 p.m. ET, seven days a week. TTY users shouldcall 1-800-522-1254.If we have a mid-year non-maintenance formularychange, we will provide a notice in the monthlyExplanation of Benefits and on our website,www.bluecrossma.com/medicare. You may ask for a copyof the most recent formulary by calling Member Service at1-800-200-4255. TTY users should call 1-800-522-1254.1

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 categoriesdepending on the type of medical conditions that theyare used to treat. For example, drugs used to treat a heartcondition are listed under the category, “CardiovascularAgents.” If you know what your drug is used for, look forthe 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 tolook under, you should look for your drug in the Index thatbegins on page 96. The Index provides an alphabetical listof all of the drugs included in this document. Both brandname 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 coverageinformation. Turn to the page listed in the Index and findthe name of your drug in the first column of the list.What are generic drugs?Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx cover both brand name drugs and generic drugs.A generic drug is approved by the FDA as having the sameactive 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 requirementsor limits on coverage. These requirements and limitsmay include:Prior Authorization (PA): Medicare HMO Blue ValueRxand Medicare HMO Blue PlusRx require you to get priorauthorization for certain drugs. This means that you willneed to get approval from Medicare HMO Blue ValueRxand Medicare HMO Blue PlusRx plan before you fill yourprescriptions. If you don’t get approval, your MedicareAdvantage plan may not cover the drug.Quantity Limits (QL): For certain drugs, Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx limits theamount of the drug that the plans will cover. For example,Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx provide up to 34 tablets per 30 days for a prescriptionof Omeprazole 10 mg capsule.Step Therapy (ST): In some cases, Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx require you tofirst try certain drugs to treat your medical condition beforewe will cover another drug for that condition. For example,if Drug A and Drug B both treat your medical condition,Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx may not cover Drug B unless you try Drug A first.If Drug A does not work for you, Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx will thencover Drug B.You can find out if your drug has any additional requirementsor limits by looking in the formulary that begins onpage 7. You can also get more information about therestrictions applied to specific covered drugs by visiting ourWeb site at www.bluecrossma.com/medicare.2

You can ask your Medicare Advantage plan to make anexception to these restrictions or limits. See the section,“How do I request an exception to the Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx formulary?” onpage 3 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 firstcontact Member Services and confirm that your drug is notcovered. If you learn that Medicare HMO Blue ValueRx andMedicare HMO Blue PlusRx do not cover your drug, youhave two options:• You can ask Member Services for a list of similar drugsthat are covered by Medicare HMO Blue ValueRx andMedicare HMO Blue PlusRx. When you receive the list,show it to your doctor and ask him or her to prescribea similar drug that is covered by Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx.• You can ask Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx to make an exception and coveryour drug. See below for information about how to requestan exception.How do I request an exception to the Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx Formulary?You can ask Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx to make an exception to our coveragerules. There are several types of exceptions that you canask us to make.• You can ask us to cover your drug even if it is not onour formulary.• You can ask us to waive coverage restrictions or limits onyour drug. For example, for certain drugs, Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx limit theamount of the drug that we will cover. If your drug hasa quantity limit, you can ask us to waive the limit andcover more.• You can ask us to provide a higher level of coverage foryour drug. This would lower the amount you must pay foryour drug. If your drug is contained in our non-preferredbrand tier, you can ask us to cover it at the cost-sharingamount that applies to drugs in the preferred brand tierinstead. Please note, if we grant your request to cover adrug that is not on our formulary, you may not ask us toprovide a higher level of coverage for the drug. Also,you may not ask us to provide a higher level of coveragefor drugs that are on the Tier 5 Specialty tier.Generally, Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx will only approve your request for anexception if the alternative drugs included on the plan’sformulary, or the lower-tiered drug or additional utilizationrestrictions would not be as effective in treating your conditionand/or would cause you to have adverse medical effects.You should contact us to ask us for an initial coveragedecision for a formulary, tiering or utilization restrictionexception. When you are requesting a formulary, tieringor utilization restriction exception you should submit astatement from your physician supporting your request.Generally, we must make our decision within 72 hours ofgetting your prescriber’s or prescribing physician’s supportingstatement. You can request an expedited (fast) exception ifyou or your doctor believe that your health could be seriouslyharmed by waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give you a decisionno later than 24 hours after we get your prescriber’s orprescribing physician’s supporting statement.page 3 3

What do I do before I can talk to my doctor aboutchanging my drugs or requesting an exception?As a new or continuing member in our plan you may betaking drugs that are not on our formulary. Or, you maybe taking a drug that is on our formulary but your abilityto get it is limited. For example, you may need a priorauthorization from us before you can fill your prescription.You should talk to your doctor to decide if you should switchto an appropriate drug that we cover or request a formularyexception so that we will cover the drug you take. While youtalk to your doctor to determine the right course of action foryou, we may cover your drug in certain cases during the first90 days you are a member of our plan.For each of your drugs that is not on our formulary or if yourability to get your drugs is limited, we will cover a temporary30-day supply (unless you have a prescription written forfewer days) when you go to a network pharmacy. After yourfirst 30-day supply, we will not pay for these drugs, even ifyou have been a member of the plan less than 90 days.If you are a resident of a long-term care facility, we willallow you to refill your prescription until we have providedyou with at least a 91-day supply and may be up to a 98 daytransition supply, consistent with the dispensing increment,(unless you have a prescription written for fewer days). Wewill cover more than one refill of these drugs for the first 90days you are a member of our plan. If you need a drug thatis not on our formulary or if your ability to get your drugs islimited, but you are past the first 90 days of membership inour plan, we will cover a 31-day emergency supply of thatdrug (unless you have a prescription for fewer days) whileyou pursue a formulary exception.For more informationFor more detailed information about your Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx prescriptiondrug coverage, please review your Evidence of Coverage andother plan materials.If you have questions about Medicare HMO Blue ValueRxand Medicare HMO Blue PlusRx please call MemberServices at 1-800-200-4255, as follows: from February 15through October 14, 8:00 a.m. to 8:00 p.m. ET, Mondaythrough Friday, and from October 15 through February 14,8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY usersshould call 1-800-522-1254. Or, visitwww.bluecrossma.com/medicare.If you have general questions about Medicare prescriptiondrug coverage, please call Medicare at 1-800-MEDICARE(1-800-633-4227) 24 hours a day/7 days a week.TTY/TDD users should call 1-877-486-2048. Or, visitwww.medicare.gov.Medicare HMO Blue ValueRx andMedicare HMO Blue PlusRx FormularyThe formulary that begins on page 7 provides coverageinformation about some of the drugs covered by MedicareHMO Blue ValueRx and Medicare HMO Blue PlusRx.If you have trouble finding your drug in the list, turn to theIndex that begins on page 96.The first column of the chart lists the drug name. Brandnamedrugs are capitalized (e.g., AMOXIL ®´) and genericdrugs are listed in lower-case italics (e.g., amoxicillin).4

The information in the Requirements/Limits columntells you if Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx have any special requirements forcoverage of your drug.The abbreviations you may see in the drug listing include:Quality Care Dosing (QCD): To help ensure thatthe quantity and dosage of your medications remainsconsistent with manufacturer, clinical, and Food and DrugAdministration (FDA) recommendations, we maintain a listof medications subject to QCD. When you fill a prescriptionfor a medication subject to QCD, your prescription isreviewed for:• Dose Consolidation. Dose consolidation checks to seewhether you’re taking two or more daily doses of medicinethat could be replaced with one daily dose providing thesame total amount of medication.• Recommended Monthly Dosing Level. This process checksto see that your monthly dosage of medication is consistentwith both the manufacturer’s and the FDA’s monthlydosing recommendations and clinical information.Your doctor can also apply for an exception to QCDguidelines when medically necessaryNo Mail Order (NMO): These prescription drugs are notavailable through mail-order.Home Infusion Therapy (HIT): These prescription drugsmay be covered under our medical benefit.Medical Benefit (MB): These drugs and supplies are coveredunder your plan’s medical benefit and are available throughnetwork retail pharmacies or mail-order service.*Limited Pharmacy Availability (LPA): These prescriptionsmay be available only at certain pharmacies.How much will I pay for my Medicare Advantage plan’scovered drugs?Your Medicare prescription drug costs:The amount you pay depends on which drug tier yourdrug is in under our plan. You can find out which drug tieryour drug is in by looking in the formulary included in thisbooklet. See the next page for the copayment/co-insuranceamount for each type of drug.If you qualify for extra help with your drug costs, your costsfor your drugs may be different than those described on thenext page. Please refer to the plan Summary of Benefits oryour Evidence of Coverage, or call Member Service to findout what your costs are.Your costs for drugs and supplies covered under your plan’smedical benefit:You will find some drugs and supplies listed in the formularydrug list with a “MB” note in the tier column. These drugsand supplies covered under your plan’s medical benefit areavailable through network retail pharmacies or mail-orderservice. However, they do not qualify for exception requests,extra help on drug costs, transition fills, or accumulate towardyour total out of pocket costs to bring you through thecoverage gap faster like drugs covered under your Medicareprescription drug benefit.You pay nothing for these drugs and supplies covered underyour plan’s Original Medicare medical benefit.* This formulary booklet lists certain brand test strips;however all other brands of test strips are also covered.page 5 5

Your Medicare Prescription Drug CostsMedicare HMO Blue ValueRxMedicare HMO Blue PlusRxDrug CoverageYou pay:Annual DeductibleInitial Coverage$0 for Tiers 1 and 2$220 for Tiers 3, 4 and 5$0 for Tiers 1 and 2$150 for Tiers 3, 4 & 5You pay the following until total yearly drug costs reach $2,970 for:30-day supplyat a networkretail pharmacy90-day supplyat networkretail pharmacy 190-day supplythrough networkmail-order pharmacy30-day supplyat a networkretail pharmacy90-day supplyat networkretail pharmacy 190-day supplythrough networkmail-order pharmacyTier 1: Preferred Generic drugs $6 $18 $6 $6 $18 $6Tier 2: Non-Preferred Generic drugs $12 $36 $24 $12 $36 $24Tier 3: Preferred Brand drugs $45 $135 $90 $45 $135 $90Tier 4: Non-Preferred Brand drugs $90 $270 $180 $90 $270 $180Tier 5: Specialty Tier drugs 27% 27% 27% 30% 30% 30%Coverage GapAfter your total yearly drug costs reach $2,970 and untilyour yearly out-of-pocket drug costs reach $4,750 you pay no more than:79% of the cost of generic drugs and 47.5% of the negotiated price(excluding dispensing and vaccine administration fees) for brand name drugs.Catastrophic CoverageAfter your yearly out-of-pocket drug costs reach $4,750 you pay the greater of:Generic (including brand drugstreated as generic)$2.65 or 5%All other drugs 2 $6.60 or 5%1. Available at retail pharmacies that have agreed to allow members to fill 90-daysupplies of their prescriptions.2. All covered drugs are on the formulary/drug list.6

Anesthetics: Local Anestheticsbupivacaine hcl injection Tier 2bupivacaine hcl-epinephrine Tier 2bupivacaine-dextrose Tier 2chloroprocaine hcl Tier 2droperidol injection Tier 2ketamine hcl Tier 2lidocaine hcl injectionTier 2 H I Tlidocaine hcl-dextroseTier 2 H I Tlidocaine hcl-epinephrine Tier 2Anesthetics: Topical Anestheticslidocaine hcl cream, -oint, -dental, -gel, Tier 2-lotionlidocaine hcl viscous Tier 2lidocaine-prilocaine Tier 2LIDODERM Tier 3pre-attached lta kit Tier 2Antiinfectives: AminoglycosidesamikacinTier 2 H I TgentamicinTier 2 H I Tiso gentamicinTier 2 H I Tkanamycin sulfate injectionTier 2 H I Tneomycin sulfate tablet Tier 2TOBITier 5 P ATOBI PODHALER Tier 5tobramycinTier 2 H I TAntiinfectives: AnthelminticsALBENZA Tier 3STROMECTOL Tier 3Antiinfectives: Specialized IndicationsDAPSONE TABLET Tier 3metronidazole capsule, -tablet Tier 2metronidazole injectionTier 2 H I Tparomomycin sulfate capsule Tier 2tinidazole tablet Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 7

Antiinfectives: Antiretrovirals and Protease Inhabacavir Tier 2APTIVUS Tier 5ATRIPLA Tier 5COMBIVIR Tier 5COMPLERA Tier 5CRIXIVAN Tier 3didanosine Tier 2EDURANT Tier 5EMTRIVA Tier 3EPIVIR SOLUTION Tier 3EPZICOM Tier 5FUZEON Tier 5INCIVEKTier 5 P AINTELENCE 100 MG TABLET, -200 Tier 5MG TABLETINTELENCE 25 MG TABLET Tier 3INVIRASE CAPSULE Tier 3INVIRASE TABLET Tier 5ISENTRESS Tier 5KALETRA 100-25 MG TABLET Tier 3KALETRA SOLUTION, -200-50 MG Tier 5TABLETlamivudine Tier 2lamivudine-zidovudine Tier 2LEXIVA ORAL SUSP Tier 3LEXIVA TABLET Tier 5Antiinfectives: Antiretrovirals and Protease Inh (continued)nevirapine Tier 2NORVIR Tier 3PREZISTA 150 MG TABLET, -400 MG Tier 5TABLET, -600 MG TABLETPREZISTA 75 MG TABLET, -800MG Tier 3TABLET, -100MG SUSPRESCRIPTOR Tier 3RETROVIR INJECTIONTier 3 H I TREYATAZ 100 MG CAPSULE Tier 3REYATAZ 150 MG CAPSULE, -200 MG Tier 5CAPSULE, -300 MG CAPSULESELZENTRY Tier 5stavudine Tier 2STRIBILD Tier 5SUSTIVA Tier 3TRIZIVIR Tier 5TRUVADA Tier 5VICTRELISTier 5 P AVIDEX Tier 3VIRACEPT POWDER, -250 MG Tier 3TABLETVIRACEPT 625 MG TABLET Tier 5VIRAMUNE ORAL SUSP Tier 3VIRAMUNE XR Tier 3VIREAD Tier 5ZIAGEN SOLUTION Tier 38Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Antiinfectives: Antiretrovirals and Protease Inh (continued)zidovudine Tier 2Antiinfectives: Antituberculosis DrugsCAPASTAT SULFATETier 3 H I Tethambutol hcl Tier 2isonarif Tier 2isoniazid injection, -syrup, -tablet Tier 2MYCOBUTIN Tier 3PASER Tier 3PRIFTIN Tier 3pyrazinamide Tier 2rifampin capsule Tier 2rifampin injectionTier 2 H I TSEROMYCIN Tier 3TRECATOR Tier 3Antiinfectives: Cephalosporinscefaclor Tier 2cefaclor er Tier 2cefadroxil Tier 2cefazolinTier 2 H I Tcefdinir Tier 2cefepimecefotaximecefotetancefoxitinTier 2 H I TTier 2 H I TTier 2 H I TTier 2 H I Tcefpodoxime proxetil Tier 2cefprozil Tier 2ceftazidimeceftriaxoneTier 2 H I TTier 2 H I Tcefuroxime Tier 2cefuroxime axetil Tier 2cefuroxime sodiumTier 2 H I Tcephalexin Tier 2SUPRAX Tier 3Antiinfectives: Erythromycinsery-tab Tier 2ERYTHROCIN VIAL FOR INJECTION Tier 3 H I Terythrocin stearate Tier 2erythromycin e.c. cap, -tablet Tier 2erythromycin ethylsuccinate tablet Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 9

Antiinfectives: Oral Antifungal Drugsclotrimazole lozenge Tier 2fluconazole 150 mg tablet Tier 2 Q C D (5/30)fluconazole suspension, -50 mg tablet, Tier 2-100 mg tablet, -200 mg tabletflucytosine capsule Tier 5griseofulvin micro tablet Tier 2griseofulvin oral susp Tier 2griseofulvin ultra tablet Tier 2itraconazole capsule Tier 2 Q C D (120/30)ketoconazole tablet Tier 2LAMISIL 125 MG GRANULES Tier 4 Q C D (68/30)PACKETLAMISIL 187.5 MG GRANULES PACK Tier 4 Q C D (34/30)NOXAFIL Tier 5nystatin Tier 2terbinafine hcl tablet Tier 2 Q C D (34/30)VFEND SUSPENSION Tier 5voriconazole 200 mg tablet Tier 5voriconazole 50 mg tablet Tier 2Antiinfectives: Other Antiinfective DrugsALINIA Tier 3AZACTAM-ISO-OSMOT 1 GM/50 ML Tier 3 H I TAZACTAM-ISO-OSMOT 2 GM/50 ML Tier 5 H I Taztreonam vialTier 2 H I Tbaciim Tier 2bacitracin injection Tier 2CAYSTONTier 5 L P A, N M Ochloramphenicol sod succinate Tier 2 H I Tclindamycin-d5w Tier 2clindamycin injectionTier 2 H I Tclindamycin hcl capsule Tier 2clindamycin palmitate hcl Tier 2colistimethate 150 mg vialTier 2 H I TCUBICINTier 5 H I TDIFICID Tier 5DORIBAX VIALTier 3 H I Timipenem-cilastatin sodiumTier 2 H I TINVANZ VIALTier 3 H I TKETEK Tier 3MEPRON Tier 5meropenem vialTier 2 H I TNEBUPENTTier 3 P Apolymyxin b sulfate injectionTier 2 H I TTYGACILTier 3 H I Tvancomycin vialTier 2 H I T10Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Antiinfectives: Other Antiinfective Drugs (continued)vancomycin hcl capsule Tier 5VANCOMYCIN-D5WTier 3 H I TVIBATIV 250 MG VIALTier 3 H I TVIBATIV 750 MG VIALTier 5 H I TZYVOX ORAL SUSP, -TABLET Tier 5ZYVOX IV SOLUTIONTier 5 H I TAntiinfectives: Other Antiviral Drugsacyclovir Tier 2acyclovir injectionTier 2 H I Tacyclovir ointment Tier 2amantadine Tier 2BARACLUDE SOLUTION Tier 3BARACLUDE TABLET Tier 5cidofovir vial Tier 2DENAVIR Tier 3EPIVIR HBV Tier 3famciclovir 125 mg tablet, -500 mg Tier 2 Q C D (21/30)tabletfamciclovir 250 mg tablet Tier 2 Q C D (68/30)foscarnet sodiumTier 2 H I Tganciclovir injectionTier 2 H I THEPSERA Tier 5RELENZA Tier 3 Q C D (60inhalations/180), N M Oribapak 200-400 mg dosepack Tier 2ribapak 400-400 mg dosepack, -400- Tier 5600 mg, -600-400 mg, -600-600 mgribasphere 600 mg tablet Tier 5ribasphere capsule, -200 mg tablet, Tier 2-400 mg tabletribavirin capsule, -tablet Tier 2rimantadine hcl Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 11

Antiinfectives: Other Antiviral Drugs (continued)TAMIFLU 30 MG GELCAP Tier 3 Q C D (84/180),N M OTAMIFLU 45 MG GELCAP, -75 MGGELCAPTier 3 Q C D (42/180),N M OTAMIFLU SUSPENSION Tier 3 Q C D (263ml/180), N M OTYZEKA Tier 5valacyclovir Tier 2 Q C D (34/30)VALCYTE Tier 5ZOVIRAX CREAM, -OINT Tier 3Antiinfectives: Other Macrolidesazithromycin injectionTier 2 H I Tazithromycin packet, -suspension, -tablet Tier 2clarithromycin er Tier 2clarithromycin suspension, -tablet Tier 2Antiinfectives: Other Topical Antifungalsciclodan Tier 2ciclopirox Tier 2clotrimazole Tier 2econazole nitrate Tier 2ketoconazole Tier 2ketodan foam Tier 2LAMISIL SOLUTION Tier 3nyamyc Tier 2nystatin Tier 2nystop Tier 2pedi-dri Tier 2Antiinfectives: Parenteral Antifungalsamphotericin b injectionTier 2 H I TCANCIDASTier 5 H I TfluconazoleTier 2 H I TMYCAMINETier 5 H I Tvoriconazole Tier 212Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Antiinfectives: Penicillinsamox tr-potassium clavulanate Tier 2amoxicillin Tier 2amoxicillin-clavulanate er Tier 2ampicillin injectionTier 2 H I Tampicillin trihydrate Tier 2ampicillin-sulbactam injectionTier 2 H I Tdicloxacillin sodium Tier 2nafcillin 1 gm add-van vialTier 2 H I Tnafcillin 1 gm vialTier 2 H I Tnafcillin 1 gm/ 50 ml injTier 5 H I Tnafcillin 10 gm bulk vial, -10 gm vial Tier 5 H I Tnafcillin 2 gm add-vant vial, -2 gm vial Tier 5 H I Tnafcillin 2 gm/ 100 ml injTier 5 H I Toxacillin 1 gm vialTier 2 H I Toxacillin 1 gm/ 50 ml injTier 2 H I Toxacillin 10 gm vialTier 5 H I Toxacillin 2 gm add-vantage vl, -2 gm vial Tier 5 H I Toxacillin 2 gm/ 50 ml injTier 5 H I Tpenicillin g k 5 million unitTier 2 H I Tpenicillin g procaineTier 2 H I Tpenicillin g sodiumTier 2 H I Tpenicillin gk 20 million unitTier 2 H I Tpenicillin v potassium Tier 2piperacil-tazobact injectionTier 2 H I TAntiinfectives: Plasmodicidesatovaquone-proguanil hcl Tier 2chloroquine phosphate tablet Tier 2COARTEM Tier 3DARAPRIM Tier 3hydroxychloroquine sulfate tablet Tier 2mefloquine hcl Tier 2PRIMAQUINE Tier 4QUALAQUIN Tier 4 Q C D (42/30),N M Oquinine sulfate 324mg capsule Tier 2 Q C D (42/30),N M OAntiinfectives: Quinolonesciprofloxacin injectionTier 2 H I Tciprofloxacin-d5w injectionTier 2 H I Tciprofloxacin er Tier 2ciprofloxacin tablet Tier 2levofloxacin injectionTier 2 H I Tlevofloxacin solution, -tablet Tier 2levofloxacin-d5w injectionTier 2 H I Tofloxacin tablet Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 13

Antiinfectives: Sulfonamideserythromycin-sulfisoxazole Tier 2sulfadiazine tablet Tier 2sulfamethoxazole-trimethoprim injectionsulfamethoxazole-trimethoprim oralsusp, -tabletAntiinfectives: TetracyclinesTier 2 H I TTier 2demeclocycline hcl tablet Tier 2doxycycline hyclate capsule, -e.c. cap, Tier 2-e.c. tab, -100 mg tabdoxycycline hyclate injectionTier 2 H I Tdoxycycline monohydrate Tier 2minocycline hcl capsule, -tablet, -tablet Tier 2sustained actiontetracycline hcl capsule Tier 2Antiinfectives: Topical Antibacterial Drugsgentamicin sulfate cream, -0.1% Tier 2ointmentmafenide acetate Tier 2mupirocin cream Tier 2mupirocin oint Tier 2silver sulfadiazine cream Tier 2ssd Tier 2SULFAMYLON Tier 3thermazene Tier 2Antiinfectives: Topical Antifungal-Corticosteroid Comb.clotrimazole-betamethasone Tier 2nystatin-triamcinolone Tier 2Antiinfectives: Urinary Antiinfectivesmethenamine hippurate Tier 2methenamine mandelate e.c. tab, -tablet Tier 2nitrofurantoin macrocrystal capsule Tier 2nitrofurantoin mono-macro Tier 2nitrofurantoin oral susp Tier 2trimethoprim Tier 2urogesic-blue Tier 214Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Antiinfectives: Vaginal Antifungalsmiconazole 3 Tier 2nystatin vaginal products Tier 2terconazole Tier 2Antineoplastic/Immunosuppressant Drugsadriamycin injectionTier 2 H I Tadrucil Tier 2AFINITOR Tier 5ALIMTATier 5 H I TALKERAN TABLET M BamifostineTier 5 H I Tanagrelide hcl Tier 2anastrozole tablet Tier 2ARRANONTier 5 H I TARZERRATier 5 H I T, N M OAVASTINTier 5 H I Tazathioprine sodiumTier 2 P A, H I Tazathioprine tabletTier 2 P ABENLYSTA 120 MG VIALTier 3 H I TBENLYSTA 400 MG VIALTier 5 H I Tbicalutamide Tier 2BICNUTier 3 H I Tbleomycin sulfate injectionTier 2 H I TBOSULIF TABLET Tier 5BUSULFEXTier 5 H I Tcalcium folinate injection Tier 2CAMPATHTier 5 H I TCAPRELSATier 5 L P A, N M OcarboplatinTier 2 H I TCEENU Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 15

Antineoplastic/Immunosuppressant Drugs (continued)CELLCEPT INJECTIONTier 3 P A, H I TCELLCEPT ORAL SUSPTier 5 P AcerubidineTier 2 H I TcisplatinTier 2 H I TcladribineTier 5 H I TCLOLARTier 5 H I TCOMETRIQ Tier 5cyclophosphamide injectionTier 2 H I Tcyclophosphamide tablet Tier 2cyclosporine 50 mg/ml ampTier 2 P A, H I Tcyclosporine capsule, -50 mg/ml vial, Tier 2 P A-solutioncyclosporine modifiedTier 2 P AcytarabineTier 2 H I TdacarbazineTier 2 H I TDACOGENTier 5 H I TdaunorubicinTier 2 H I TDEPOCYT Tier 3dexrazoxaneTier 5 H I TDOCEFREZTier 5 H I Tdocetaxel 160 mg/16 ml vial, -20 mg/2 Tier 5 H I Tml vial, -20 mg/0.5 ml vial, -80 mg/2ml vialdocetaxel 20 mg/ml vialTier 2 H I Tdocetaxel 80 mg/8 ml vial, -80 mg/4 ml Tier 5 H I TvialAntineoplastic/Immunosuppressant Drugs (continued)DOXILTier 5 H I TdoxorubicinTier 2 H I TELIGARD Tier 3ELITEKTier 5 H I TELSPARTier 3 H I TEMCYT Tier 3ENBREL 25 MG KIT Tier 5 Q C D (16/30),P AENBREL 25 MG/0.5 ML SYRINGE, Tier 5 P A-50 MG/ML SURECLICK SYRENBREL 50 MG/ML SYRINGE Tier 5 Q C D (8/30), P AepirubicinTier 2 H I TERBITUXTier 5 H I TERIVEDGE Tier 5ETOPOPHOSTier 5 H I Tetoposide injectionTier 2 H I Texemestane Tier 2FARESTON Tier 3FASLODEX Tier 5FIRMAGON Tier 3floxuridine Tier 2fludarabine 50mg vialTier 2 H I Tfludarabine 50 mg/2 ml vial Tier 5fluorouracilTier 2 H I Tflutamide Tier 2FOLOTYNTier 5 H I T, N M O16Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Antineoplastic/Immunosuppressant Drugs (continued)FUSILEVTier 3 H I Tgemcitabine 1 gram/26.3 ml vl Tier 5 H I Tgemcitabine 200 mg/5.26 ml vl, -200 Tier 2 H I Tmg vialgemcitabine hcl 1 gram vial, -2 Tier 5 H I Tgram/52.6 ml vl, -2 gram vialgengrafTier 2 P AGLEEVEC Tier 5HALAVENTier 5 H I Thecoria 0.5 mg capsule, -1 mg capsule Tier 2 P Ahecoria 5 mg capsuleTier 5 P AHERCEPTINTier 5 H I THEXALEN Tier 5HUMIRA 20 MG/0.4 ML SYRINGE Tier 5 P AHUMIRA 40 MG/0.8 ML PEN, -40MG/0.8 ML SYRINGE, -CROHN’SSTARTER PACK, -PSORIASISSTARTER PACKTier 5 Q C D (6syringes/30),P AHYCAMTIN CAPSULE M Bhydroxyurea capsule Tier 2ICLUSIG Tier 5idarubicin hclTier 5 H I Tifosfamide 1 gm vialTier 2 H I Tifosfamide 1 gm/ 20 ml vial, -3 gm vial, Tier 5 H I T-3 gm/ 60 ml vialifosfamide-mesnaTier 5 H I TINLYTA Tier 5Antineoplastic/Immunosuppressant Drugs (continued)IRESSAirinotecan hclISTODAXIXEMPRATier 5 N M OTier 2 H I TTier 5 H I TTier 3 H I TJAKAFI Tier 5JEVTANATier 5 H I TKADCYLA Tier 5leflunomide Tier 2 Q C D (34/30)letrozole Tier 2leucovorin calcium injectionTier 2 H I Tleucovorin calcium tablet Tier 2LEUKERAN Tier 3LIPODOX Tier 5LIPODOX 50 Tier 5LUPRON DEPOT 45 MG 6MO KIT Tier 5LYSODREN Tier 3MATULANETier 5 N M Omegestrol acetate oral susp, -tablet Tier 2melphalan hclTier 2 H I Tmercaptopurine tablet Tier 2mesnaTier 2 H I TMESNEX TABLET Tier 5methotrexate injectionTier 2 P A, H I Tmethotrexate tabletTier 2 P AmitomycinTier 2 H I TQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 17

Antineoplastic/Immunosuppressant Drugs (continued)mitoxantroneMUSTARGENmycophenolate mofetilMYFORTICTier 2 H I TTier 3 H I TTier 2 P ATier 3 P AMYLERAN M BNEXAVARTier 5 L P A, N M ONILANDRON Tier 3NULOJIXTier 5 P A, H I Toctreotide acet 200 mcg/ml vl, -acet Tier 5500 mcg/ml amp, -acet 500 mcg/mlsyr, -acet 500 mcg/ml vl, -1,000 mcg/ml vialoctreotide acet 50 mcg/ml amp, -acet Tier 250 mcg/ml syr, -acet 50 mcg/ml vial,-acet 100 mcg/ml amp, -acet 100mcg/ml syr, -acet 100 mcg/ml vlONCASPAR Tier 5ONTAKTier 5 H I TORENCIA 125 MG/ML SYRINGE Tier 5 P AORENCIA 250 MG VIALTier 5 P A, H I Toxaliplatin 100 mg vialTier 2 H I Toxaliplatin 100 mg/20 ml vialTier 5 H I Toxaliplatin 50 mg/10 ml vialTier 5 H I Tpaclitaxel 100 mg/16.7 ml vial, -30mg/5 ml vialpaclitaxel 300 mg/50 ml vialpentostatinTier 5 H I TTier 2 H I TTier 2 H I TAntineoplastic/Immunosuppressant Drugs (continued)PERJETA Tier 5POMALYST Tier 5PROGRAF INJECTIONTier 3 P A, H I TQUADRAMET Tier 5RAPAMUNE 2 MG TABLETTier 5 P ARAPAMUNE SOLUTION, -0.5 MG Tier 3 P ATABLET, -1 MG TABLETREMICADETier 5 P A, H I TREVLIMIDTier 5 L P A, N M ORITUXANTier 5 P A, H I TSANDOSTATIN LAR Tier 5SIMULECTTier 3 P A, H I TSOLTAMOX Tier 4SOMATULINE DEPOT Tier 5SPRYCEL Tier 5STIVARGA Tier 5SUTENT Tier 5SYNRIBO Tier 5TABLOID Tier 3tacrolimus 0.5 mg capsule, -1 mg Tier 2 P Acapsuletacrolimus 5 mg capsuleTier 5 P Atamoxifen citrate tablet Tier 2TARCEVA Tier 5TARGRETIN Tier 5TASIGNA Tier 518Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Antineoplastic/Immunosuppressant Drugs (continued)TEMODAR CAPSULE M BTEMODAR INJECTION Tier 3THERACYS Tier 3thiotepa injectionTier 2 H I TtoposarTier 2 H I Ttopotecan hclTier 5 H I TTORISELTier 5 H I TTREANDA 100 MG VIALTier 3 H I TTREANDA 25 MG VIAL Tier 5TRELSTAR Tier 5TRELSTAR DEPOT Tier 5TRELSTAR LA Tier 5tretinoin capsule Tier 5TRISENOXTier 3 H I TTYKERB Tier 5TYSABRITier 5 L P A, H I T, N M OUVADEX Tier 3VALSTAR Tier 3VANDETANIBTier 5 N M OVANTAS Tier 3VECTIBIXTier 5 H I TVELCADETier 5 H I TVIDAZA Tier 5vinblastineTier 2 H I Tvincasar pfs Tier 2vincristineTier 2 H I TAntineoplastic/Immunosuppressant Drugs (continued)vinorelbineTier 2 H I TVORAXAZE Tier 5VOTRIENT Tier 5VUMON Tier 5XALKORI Tier 5XELODA M BXTANDI Tier 5YERVOYTier 5 H I T, N M OZALTRAP Tier 5ZANOSARTier 5 H I TZELBORAF Tier 5ZOLADEX Tier 3ZOLINZA Tier 5ZORTRESS 0.25 MG TABLET Tier 3ZORTRESS 0.5 MG TABLET, -0.75 MG Tier 5TABLETZYTIGA Tier 5Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 19

Autonomic and CNS Medications: AnalgesicsbuprenorphineTier 2 H I Tbutorphanol tartrate injectionTier 2 H I TnalbuphineTier 2 H I Tpentazocine-acetaminophen Tier 2pentazocine-naloxone hcl Tier 2sufenta Tier 2sufentanil citrate injection Tier 2tramadol hcl Tier 2tramadol hcl er Tier 2tramadol hcl-acetaminophen Tier 2Autonomic and CNS Medications:Antiparkinson Anticholinergic Drugsbenztropine injectionTier 2 H I Tbenztropine tablet Tier 1trihexyphenidyl hcl elix Tier 2trihexyphenidyl hcl tablet Tier 1Autonomic and CNS Medications:Antidementia DrugsARICEPT 23 MG TABLET Tier 3donepezil hcl Tier 2EXELON ADH. PATCH, -SOLUTION Tier 3galantamine hbr Tier 2NAMENDA Tier 3rivastigmine Tier 220Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Autonomic and CNS Medications:Antipsychotic DrugsABILIFY 20 MG TABLET, -30 MG Tier 5TABLET, -300 MG ER INJECTIONABILIFY DISCMELT Tier 4ABILIFY INJECTION, -SOLUTION, -2 Tier 3MG TABLET, -5 MG TABLET, -10 MGTABLET, -15 MG TABLETchlorpromazine hcl injectionTier 2 H I Tchlorpromazine hcl tablet Tier 2clozapine Tier 2FANAPT Tier 4FAZACLO Tier 4fluphenazine decanoate injection Tier 2fluphenazine hcl Tier 2GEODON INJECTION Tier 3haloperidol decanoate Tier 2haloperidol decanoate 100 Tier 2haloperidol injection Tier 2haloperidol lactate Tier 2haloperidol tablet Tier 1INVEGA Tier 4INVEGA SUSTENNA 117 MG PREF Tier 5SY, -156 MG PREF SY, -234 MGPREF SYINVEGA SUSTENNA 39 MG PREF Tier 4SYR, -78 MG PREF SYRAutonomic and CNS Medications:Antipsychotic Drugs (continued)LATUDA Tier 4loxapine Tier 2olanzapine 20 mg tablet Tier 5olanzapine injection, -2.5 mg tablet, Tier 2-5 mg tablet, -7.5 mg tablet, -10 mgtablet, -15 mg tabletolanzapine odt Tier 2olanzapine-fluoxetine hcl Tier 2 Q C D (34/30)ORAP Tier 3perphenazine Tier 2quetiapine fumarate Tier 2RISPERDAL CONSTA 12.5 MG SYR, Tier 3-25 MG SYRRISPERDAL CONSTA 37.5 MG SYR, Tier 5-50 MG SYRrisperidone Tier 2risperidone m-tab Tier 2risperidone odt Tier 2SAPHRIS Tier 4SEROQUEL XR Tier 3thioridazine hcl Tier 2thiothixene Tier 1trifluoperazine hcl Tier 2ziprasidone hcl Tier 2ZYPREXA RELPREVV Tier 4Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 21

Autonomic and CNS Medications:Antivertigo and Antiemetic Drugscompro Tier 2dimenhydrinate injection Tier 2dronabinol 10 mg capsule Tier 5dronabinol 2.5 mg capsule, -5 mg Tier 2capsuleEMEND 40 MG CAPSULE, -125 MG Tier 3 Q C D (1/1)CAPSULEEMEND 80 MG CAPSULE Tier 3 Q C D (2/1)EMEND INJECTION Tier 3EMEND TRIFOLD PACK Tier 3 Q C D (3/1)granisetron hcl 0.1 mg/ml vial, -4 mg/4 Tier 2 H I Tml vialgranisetron hcl 1 mg/ml vial Tier 2granisetron hcl tablet Tier 2 Q C D (4/3)granisolTier 2 Q C D (30 ml/3)meclizine hcl tablet Tier 2ondansetron 40 mg/20 ml vial, -4 mg/2 Tier 2ml syr, -4 mg/2 ml ampuleondansetron hcl 24 mg tablet Tier 2 Q C D (2/1)ondansetron hcl 4 mg tablet, -8 mg Tier 2 Q C D (12/1)tabletondansetron hcl 4 mg/2 ml vial Tier 2 H I Tondansetron hcl in dextrose Tier 2ondansetron hcl solutionTier 2 Q C D (150 ml/1)ondansetron in sodium chloride Tier 2Autonomic and CNS Medications: Antivertigoand Antiemetic Drugs (continued)ondansetron odt Tier 2 Q C D (12/1)phenadoz Tier 2prochlorperazine edisylate injection Tier 2prochlorperazine maleate rectal Tier 2prochlorperazine maleate tablet Tier 1promethazine hcl rectal Tier 2promethegan Tier 2TRANSDERM-SCOP Tier 4trimethobenzamide hcl capsule,-injectionTier 222Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Autonomic and CNS Medications: Class II Narcoticsalfentanil hydrochloride Tier 2codeine phosphate injection Tier 2codeine sulfate Tier 2diskets Tier 2duramorph 0.5mg/ml ampul, -1mg/ml Tier 2 H I Tampulduramorph 5mg/10ml ampul,Tier 2 H I T-10mg/10ml ampulendocet Tier 2endodan Tier 2fentanyl Tier 2 Q C D (15/30)fentanyl 0.05 mg/ml ampul, -0.05 mg/ml Tier 2syringe, -0.05 mg/ml vial, -1 mg/20 mlvial, -100 mcg/2 ml vial, -250 mcg/5ml vialfentanyl 2,500 mcg/50 ml vial Tier 2fentanyl citrate lozenge Tier 5 Q C D (120/30),P Ahydromorphone hcl injection, -rectal, Tier 2-solution, -tabletlevorphanol tartrate tablet Tier 2meperidine hcl injection, -solution, Tier 2-tabletmeperitab Tier 2methadone hcl injectionTier 2 H I Tmethadone hcl solution, -tablet Tier 2methadone intensol Tier 2Autonomic and CNS Medications:Class II Narcotics (continued)methadose Tier 2morphine sulfate er capsule sustained Tier 2 Q C D (90/30)actionmorphine sulfate er tablet sustained Tier 2 Q C D (120/30)actionmorphine sulfate in dextrose Tier 2morphine sulfate injection, -rectal, Tier 2-solution, -tabletOPIUM TINCTURE Tier 3oxycodone concentrate Tier 2oxycodone hcl Tier 2oxycodone hcl-acetaminophen Tier 2oxycodone hcl-aspirin Tier 2oxycodone hcl-ibuprofen Tier 2oxycodone-acetaminophen Tier 2OXYCONTIN 10 MG TABLET, -15 MG Tier 3 Q C D (90/30)TABLET, -20 MG TABLET, -30 MGTABLET, -40 MG TABLETOXYCONTIN 60 MG TABLET Tier 3 Q C D (120/30)OXYCONTIN 80 MG TABLET Tier 5 Q C D (120/30)oxymorphone hcl tablet Tier 2oxymorphone hcl er tablet Tier 2 Q C D (90/30)ROXICET SOLUTION Tier 3roxicet tablet Tier 2sublimaze Tier 224Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Autonomic and CNS Medications: CNSStimulant Drugs (continued)modafinil tabletTier 2 P AAutonomic and CNS Medications: Drugsto Prevent and Treat Headachesascomp with codeine Tier 2butalb-caff-acetaminoph-codein Tier 2butalbital compound-codeine Tier 2butorphanol tartrate aerosolTier 2 Q C D (5 ml/30)dihydroergotamine mesylate injection Tier 2migergot Tier 2naratriptan hcl Tier 2 Q C D (9/30)rizatriptan Tier 2 Q C D (18/30)sumatriptan 4 mg/0.5 ml cart, -4 mg/0.5ml inject, -4 mg/0.5 ml kit, -4 mg/0.5ml refill, -4 mg/0.5 ml vial, -6 mg/0.5ml refill, -6 mg/0.5 ml syrngsumatriptan 6 mg/0.5 ml inject, -6mg/0.5 ml vialTier 2Tier 2 Q C D (4vials/30)sumatriptan succinate tablet Tier 2 Q C D (9/30)ZOMIG NASAL DROPS/SPRAYS Tier 3 Q C D (6 nasalsprayers/30)Autonomic and CNS Medications: HydantoinsDILANTIN 30 MG CAPSULE Tier 3fosphenytoinTier 2 H I TPEGANONE Tier 3phenytoin injectionTier 2 H I Tphenytoin oral susp Tier 2phenytoin sodium extended Tier 2phenytoin tablet chew Tier 2Autonomic and CNS Medications: MAO InhibitorsEMSAM Tier 4MARPLAN Tier 3phenelzine sulfate tablet Tier 2tranylcypromine sulfate Tier 226Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Autonomic and CNS Medications:Other AnticonvulsantsBANZEL 400 MG TABLET Tier 5BANZEL ORAL SUSP, -200 MG Tier 3TABLETclonazepam tabletTier 2 P Adiazepam rectalTier 2 P Afelbamate Tier 2gabapentin capsule, -tablet Tier 1gabapentin solution Tier 2GABITRIL 12 MG TABLET -16 MG Tier 3TABLETHORIZANT Tier 4lamotrigine Tier 2lamotrigine er Tier 2levetiracetam injectionTier 2 H I Tlevetiracetam solution, -tablet, -tablet Tier 2sustained actionLYRICATier 4 P AONFITier 4 P Aphenobarbital elix, -tablet Tier 2POTIGA Tier 3primidone tablet Tier 2SABRILTier 5 L P A, N M Otiagabine tablet Tier 2topiragen Tier 2topiramate sprinkle, -tablet Tier 2Autonomic and CNS Medications: OtherAnticonvulsants (continued)VIMPAT INJECTIONTier 3 H I TVIMPAT SOLUTION, -TABLET Tier 3zonisamide Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 27

Autonomic and CNS Medications:Other Antidepressantsbudeprion sr Tier 2 Q C D (68/30)bupropion hcl sr Tier 2 Q C D (68/30)bupropion hcl tablet Tier 2bupropion xl Tier 2 Q C D (34/30)chlordiazepoxide-amitriptyline Tier 2CYMBALTA 20 MG CAPSULE, -60 MGCAPSULETier 4 Q C D (68/30),S TCYMBALTA 30 MG CAPSULE Tier 4 Q C D (34/30),S TDESVENLAFAXINE ER Tier 4FORFIVO XL TABLET Tier 4maprotiline hcl Tier 2mirtazapine 15 mg tablet Tier 2 Q C D (51/30)mirtazapine 7.5 mg tablet, -15 mg odt, Tier 2 Q C D (34/30)-30 mg odt, -30 mg tablet, -45 mg odt,-45 mg tabletnefazodone hcl Tier 2perphenazine-amitriptyline Tier 2PRISTIQ ER Tier 4 Q C D (34/30),S TSAVELLA Tier 3trazodone hcl tablet Tier 1venlafaxine hcl Tier 2venlafaxine hcl er 150 mg cap, -150 mgtabTier 2 Q C D (68/30)Autonomic and CNS Medications: OtherAntidepressants (continued)VENLAFAXINE HCL ER 225 MG TAB Tier 4 Q C D (34/30)(BRAND)venlafaxine hcl er 225 mg tab (generic) Tier 2 Q C D (34/30)venlafaxine hcl er 37.5 mg cap, -75 mgcap, -37.5 mg tab, -75 mg tabAutonomic and CNS Medications:Other Antiparkinson DrugsTier 2 Q C D (34/30)APOKYNTier 5 L P A, N M OAZILECT Tier 3bromocriptine mesylate capsule, -tablet Tier 2carbidopa-levodopa Tier 2carbidopa-levodopa-entacapone Tier 2COMTAN Tier 4entacapone Tier 2LODOSYN Tier 3pramipexole dihydrochloride Tier 2ropinirole hcl Tier 2selegiline hcl capsule, -tablet Tier 2TASMAR Tier 5ZELAPAR Tier 428Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Autonomic and CNS Medications:Other CNS/Autonomic Drugsatropine sulfate injection Tier 2CAMPRAL Tier 3depade Tier 2disulfiram Tier 2flumazenil Tier 2guanidine hcl Tier 2INTUNIV Tier 4lithium Tier 2lithium carbonate capsule, -tablet, -tablet Tier 1sustained actionMESTINON SYRUP, -TABLETTier 3SUSTAINED ACTIONnaloxone hcl injection Tier 2naltrexone hcl tablet Tier 2neostigmine methylsulfate injection Tier 2NUEDEXTATier 3 P Aphysostigmine salicylate injection Tier 2PROSTIGMIN Tier 3pyridostigmine bromide tablet Tier 2STRATTERA 10 MG CAPSULE, -18MG CAPSULE, -25 MG CAPSULE,-80 MG CAPSULE, -100 MGCAPSULESTRATTERA 40 MG CAPSULE, -60MG CAPSULETier 3 Q C D (34/30),P ATier 3 Q C D (68/30),P AAutonomic and CNS Medications: OtherCNS/Autonomic Drugs (continued)XENAZINEXYREMTier 5 L P A, N M OTier 5 L P A, N M OAutonomic and CNS Medications: Secondary Aminesamoxapine Tier 2desipramine hcl tablet Tier 2nortriptyline hcl capsule, -solution Tier 2protriptyline hcl Tier 2Autonomic and CNS Medications:Sedative/Hypnotic Drugsestazolamflurazepam hcltemazepamtriazolamTier 2 P ATier 2 P ATier 2 P ATier 2 P Azaleplon Tier 2 Q C D (30/30)zolpidem tartrate Tier 2 Q C D (30/30)zolpidem tartrate er Tier 2 Q C D (30/30)Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 29

Autonomic and CNS Medications: SelectiveSerotonin Reuptake Inhibitorscitalopram hbr solution Tier 2citalopram hbr tablet Tier 1 Q C D (51/30)escitalopram oxalate solution Tier 2escitalopram oxalate tablet Tier 2 Q C D (51/30)fluoxetine dr Tier 2 Q C D (5/30)fluoxetine hcl 10 mg capsule, -20 mg Tier 2 Q C D (34/30)capsulefluoxetine hcl 10 mg tablet Tier 2 Q C D (51/30)fluoxetine hcl 20 mg tablet Tier 2 Q C D (120/30)fluoxetine hcl 40 mg capsule Tier 2 Q C D (68/30)fluoxetine hcl solution Tier 2fluvoxamine maleate 100 mg tab Tier 2 Q C D (102/30)fluvoxamine maleate 25 mg tab Tier 2 Q C D (51/30)fluvoxamine maleate 50 mg tab Tier 2 Q C D (68/30)paroxetine cr 12.5 mg tablet, -cr 37.5 Tier 2 Q C D (68/30)mg tablet, -er 37.5 mg tabletparoxetine cr 25 mg tablet Tier 2 Q C D (102/30)paroxetine hcl 10 mg tablet, -40 mg Tier 1 Q C D (51/30)tabletparoxetine hcl 20 mg tablet, -30 mg Tier 1 Q C D (68/30)tabletPAXIL ORAL SUSP Tier 4sertraline hcl 100 mg tablet Tier 1 Q C D (68/30)sertraline hcl 25 mg tablet, -50 mgtabletTier 1 Q C D (51/30)Autonomic and CNS Medications: SelectiveSerotonin Reuptake Inhibitors (continued)sertraline hcl solution Tier 2VIIBRYD 10 MG TABLET, -20 MGTABLET, -40 MG TABLETTier 4 Q C D (34/30),S TVIIBRYD TITRATION PACK Tier 4 Q C D (30/30),S TAutonomic and CNS Medications:Smoking Cessation Productsbuproban Tier 2CHANTIX Tier 3 Q C D (408/365)NICOTROL Tier 3NICOTROL NS Tier 3 Q C D (160/30)Autonomic and CNS Medications: SuccinimidesCELONTIN Tier 3ethosuximide capsule, -syrup Tier 2Autonomic and CNS Medications: Tertiary Aminesamitriptyline hcl tablet Tier 2clomipramine hcl capsule Tier 2doxepin hcl capsule, -solution Tier 2imipramine hcl tablet Tier 2imipramine pamoate Tier 2trimipramine maleate capsule Tier 230Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Autonomic and CNS Medications:Valproic Acid and Derivativesdivalproex sodium Tier 2divalproex sodium er Tier 2valproate sodium injectionTier 2 H I Tvalproic acid capsule, -syrup Tier 2Cardiovascular Medications: AngiotensinII Receptor AntagonistsDIOVANTier 3 S Teprosartan mesylate Tier 2irbesartan Tier 2losartan potassium Tier 2Cardiovascular Medications: AngiotensinConverting Enzyme Inhibitorsbenazepril hcl tablet Tier 1captopril tablet Tier 1enalapril maleate tablet Tier 1enalaprilat Tier 2fosinopril sodium Tier 2lisinopril tablet Tier 1moexipril hcl Tier 2perindopril erbumine Tier 2quinapril hcl Tier 1ramipril Tier 1trandolapril Tier 2Cardiovascular Medications: Antidysrhythmic Drugsdisopyramide phosphate Tier 2flecainide acetate Tier 2mexiletine hcl capsule Tier 2procainamide hcl injectionTier 2 H I Tpropafenone hcl Tier 2quinidine gluconate injectionquinidine gluconate tablet sustainedactionquinidine sulfate tablet, -tablet sustainedactionTier 2 H I TTier 2Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 31

Cardiovascular Medications: Beta-Adrenergic Antagonist Drugsacebutolol hcl capsule Tier 2atenolol tablet Tier 1betaxolol hcl tablet Tier 2bisoprolol fumarate Tier 2carvedilol Tier 1labetalol hcl tablet Tier 2labetalol hcl injectionTier 2 H I Tmetoprolol succinate Tier 2metoprolol tartrate injectionTier 2 H I Tmetoprolol tartrate tablet Tier 1nadolol tablet Tier 1pindolol Tier 2propranolol hcl capsule sustained Tier 1action, -tabletpropranolol hcl injectionTier 2 H I Tpropranolol hcl solution Tier 2timolol maleate tablet Tier 1Cardiovascular Medications: Calcium Antagonistsafeditab cr Tier 2amlodipine besylate 10 mg tab Tier 1 Q C D (34/30)amlodipine besylate 2.5 mg tab, -5 mg Tier 1 Q C D (51/30)tabcartia xt Tier 2dilt-cd Tier 2diltiazem 125 mg/25 ml vial, -50 mg/10 Tier 2ml vialdiltiazem 24hr cd Tier 2diltiazem 24hr er Tier 2diltiazem injectionTier 2 H I Tdiltiazem er Tier 2diltiazem hcl tablet Tier 1dilt-xr Tier 2diltzac er Tier 2felodipine er Tier 2isradipine Tier 2matzim la Tier 2nicardipine injectionTier 2 H I Tnicardipine hcl capsule Tier 2nifediac cc Tier 2nifedical xl Tier 2nifedipine capsule Tier 2nifedipine er Tier 2nimodipine Tier 232Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Cardiovascular Medications: CalciumAntagonists (continued)nisoldipine Tier 2taztia xt Tier 2verapamil injectionTier 2 H I Tverapamil er 120 mg tablet, -180 mg Tier 1tablet, -240 mg tabletverapamil er pm Tier 2verapamil hcl capsule sustained action,-tablet, -er 120 mg tablet, -er 240 mgtabletTier 1Cardiovascular Medications: CentrallyActing Antihypertensivesclonidine Tier 2 Q C D (5/30)clonidine hcl injection Tier 2clonidine hcl tablet Tier 1guanfacine hcl Tier 1methyldopa Tier 1methyldopate hclCardiovascular Medications: Drugsfor PheochromocytomaTier 2 H I TDEMSER Tier 3DIBENZYLINE Tier 3Cardiovascular Medications: HMG-COA Reductase Inhibitorsamlodipine-atorvastatin Tier 2atorvastatin calcium Tier 2 Q C D (34/30)CRESTOR Tier 3 Q C D (34/30),S Tfluvastatin sodium 20 mg cap Tier 2 Q C D (34/30)fluvastatin sodium 40 mg cap Tier 2 Q C D (68/30)lovastatin 10 mg tablet Tier 1 Q C D (34/30)lovastatin 20 mg tablet, -40 mg tablet Tier 1 Q C D (68/30)pravastatin sodium Tier 1 Q C D (34/30)simvastatin tablet Tier 1 Q C D (34/30)Cardiovascular Medications: Hypolipoproteinemicscholestyramine Tier 2cholestyramine light Tier 2colestipol hcl Tier 2fenofibrate Tier 2gemfibrozil tablet Tier 2LOVAZA Tier 4NIASPAN Tier 3prevalite Tier 2WELCHOL Tier 4ZETIA Tier 3 Q C D (34/30),S TQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 33

Cardiovascular Medications: Loop Diureticsbumetanide injectionTier 2 H I Tbumetanide tablet Tier 2furosemide solution Tier 2furosemide injectionTier 2 H I Tfurosemide tablet Tier 1torsemide injectionTier 2 H I Ttorsemide tablet Tier 2Cardiovascular Medications: Nitratesisoditrate Tier 2isosorbide dinitrate Tier 2isosorbide mononitrate Tier 1isosorbide mononitrate er Tier 1nitro-bid Tier 2nitroglycerin in d5w Tier 2nitroglycerin injectionTier 2 H I Tnitroglycerin patch Tier 2NITROSTAT Tier 3Cardiovascular Medications: Other Antiarrhythmicsadenosine injection Tier 2amiodarone injectionTier 2 H I Tamiodarone tablet Tier 2ibutilide fumarate Tier 2MULTAQ Tier 4pacerone Tier 2sorine Tier 2sotalol Tier 2sotalol af Tier 2TIKOSYN Tier 334Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Cardiovascular Medications: Other Antihypertensivesamlodipine besylate-benazepril Tier 2atenolol-chlorthalidone Tier 1benazepril-hydrochlorothiazide Tier 1bisoprolol-hydrochlorothiazide Tier 1candesartan- hctz Tier 2captopril-hydrochlorothiazide Tier 1enalapril-hydrochlorothiazide Tier 1EXFORGETier 4 S TEXFORGE HCTTier 4 S Tfosinopril-hydrochlorothiazide Tier 2irbesartan-hydrochlorothiazide Tier 2lisinopril-hydrochlorothiazide Tier 1losartan-hydrochlorothiazide Tier 2methyldopa-hydrochlorothiazide Tier 2metoprolol-hydrochlorothiazide Tier 2moexipril-hydrochlorothiazide Tier 2nadolol-bendroflumethiazide Tier 2propranolol-hydrochlorothiazid Tier 1quinapril-hydrochlorothiazide Tier 2reserpine tablet Tier 2TEKAMLO Tier 4TEKTURNA Tier 4TEKTURNA HCT Tier 4valsartan-hctz Tier 2Cardiovascular Medications: OtherCardiovascular Drugsalprostadil injection Tier 2digoxin injectionTier 2 H I Tdigoxin solution Tier 2digoxin tablet Tier 1dobutamine hcl Tier 2dobutamine hcl in dextrose Tier 2dopamine hcl in 5% dextrose Tier 2dopamine hcl injection Tier 2kalexate Tier 2kionex oral susp Tier 2LANOXIN TABLET Tier 4midodrine hcl Tier 2milrinone in 5% dextrose Tier 2milrinone lactate Tier 2norepinephrine bitartrate Tier 2pentoxifylline tablet sustained action Tier 2RANEXA Tier 3sodium polystyrene sulfonate Tier 2sps Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 35

Cardiovascular Medications: OtherVasodilating DrugsADCIRCATier 5 P Aepoprostenol sodium Tier 2LETAIRISTier 5 L P A, N M OREMODULINTier 5 L P A, H I T, N M OREVATIO INJECTIONTier 5 P A, H I Tsildenafil tabletTier 2 P ATRACLEERTier 5 L P A, N M OTYVASO M BveletriTier 2 N M OVENTAVIS M B N M OCardiovascular Medications:Potassium Sparing Diureticsamiloride hcl tablet Tier 2amiloride-hydrochlorothiazide Tier 1eplerenone Tier 2spironolactone tablet Tier 1spironolactone-hctz Tier 1triamterene-hctz Tier 1triamterene-hydrochlorothiazid Tier 1Cardiovascular Medications: Thiazideand Related Drugschlorothiazide Tier 2chlorothiazide sodiumTier 5 H I Tchlorthalidone Tier 1hydrochlorothiazide capsule, -tablet Tier 1indapamide Tier 1methyclothiazide Tier 2metolazone Tier 2Cardiovascular Medications:Vasodilator Antihypertensivesdoxazosin mesylate 1 mg tab Tier 1 Q C D (34/30)doxazosin mesylate 2 mg tab, -4 mg tab, Tier 1 Q C D (68/30)-8 mg tabhydralazine hcl injectionTier 2 H I Thydralazine hcl tablet Tier 2minoxidil tablet Tier 2prazosin hcl Tier 1terazosin 1 mg capsule, -5 mg capsule Tier 1 Q C D (34/30)terazosin 2 mg capsule, -10 mg capsule Tier 1 Q C D (68/30)36Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Dermatological Medications: Antiacne Drugsadapalene Tier 2bp 10-1 Tier 2clenia emulsion Tier 2clinda-benzoyl perox 1-5% gel Tier 2clindacin p Tier 2clindamycin phos-benzoyl perox Tier 2clindamycin phosphate foam (noncontraceptive),-gel, -lotion, -soln, top,Tier 2-swabs, applicatorsclindamycin-benzoyl perox gel Tier 2ery Tier 2erythromycin gel, -soln, top, -swabs, Tier 2applicatorserythromycin-benzoyl peroxide Tier 2metronidazole cream, -gel, -lotion Tier 2prascion Tier 2prascion fc Tier 2rosadan cream, -gel Tier 2sodium sulfacetamide pad, medicatedpadsodium sulfacetamide-sulfur cream,-sulf-sulfur cleanser, -sulfacetamidesulfur8-4% suspTier 2Tier 2Dermatological Medications: Antiacne Drugs (continued)sodium sulfacetamide-sulfur foam Tier 2(non-contraceptive), -lotion, -sulfacetsulfurwash, -sulf-sulfur cleanser, -pad,medicated pad, -sod.sulfacet-sulfursuspsulfacetamide sodium-sulfur Tier 2sulfacleanse 8-4 Tier 2tretinoin cream, -gelTier 2 P Avitazol Tier 2Dermatological Medications: Antipsoriasisand Antieczema Drugscalcipotriene Tier 2CALCITRIOL OINT Tier 4DRITHOCREME HP Tier 3selenium sulfide 2.25% shampoo Tier 2selenium sulfide 2.5% lotion Tier 2sodium sulfacetamide solution Tier 2SORIATANE Tier 5SORIATANE CK Tier 5sulfacetamide sodium lotion Tier 2TAZORAC Tier 4ZITHRANOL-RR Tier 4Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 37

Dermatological Medications: OralDermatological Drugs8-MOP Tier 3amnesteem Tier 2claravis Tier 2myorisan Tier 2sotret Tier 2Dermatological Medications: Scabicidesacticin Tier 2EURAX Tier 3lindane Tier 2malathion Tier 2permethrin cream Tier 2ULESFIA Tier 4Dermatological Medications: TopicalCorticosteroid Drugsalclometasone dipropionate Tier 2amcinonide Tier 2betamethasone dipropionate cream, Tier 2-gel, -lotion, -ointbetamethasone valerate cream, -lotion, Tier 2-oint, -foamclobetasol emollient Tier 2clobetasol propionate cream, -foam Tier 2(non-contraceptive), -gel, -lotion,-oil,shampoo,cleanser, -oint, -soln, topcormax Tier 2desonide cream, -lotion, -oint Tier 2desoximetasone cream, -gel, -oint Tier 2diflorasone diacetate Tier 2fluocinolone acetonide cream,Tier 2-oil,shampoo,cleanser, -oint, -soln, topfluocinonide cream, -gel, -oint, -soln, top Tier 2fluocinonide emollient Tier 2fluocinonide-e Tier 2fluticasone propionate cream, -lotion, Tier 2-ointhalobetasol propionate Tier 2halonate pac Tier 2hydrocortisone 1% cream Tier 238Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Dermatological Medications: TopicalCorticosteroid Drugs (continued)hydrocortisone 1% cream, -plus 1% Tier 2cream, -2.5% cream, -lotion, -oint, -solhydrocortisone butyrate Tier 2hydrocortisone valerate Tier 2lidocaine-hydrocortisone cream, -kit Tier 2mometasone furoate Tier 2prednicarbate Tier 2triamcinolone acetonide cream, -lotion, Tier 2-ointtrianex Tier 2triderm Tier 2Dermatological Medications: TopicalDermatological Drugsammonium lactate cream, -lotion Tier 2CAMPHOR Tier 2CONDYLOX GEL Tier 3ELIDELTier 4 P AFLUOROPLEX Tier 3fluorouracil cream, -soln, top Tier 2hpr plus Tier 2hypercare Tier 2imiquimod cream Tier 2methyl salicylate Tier 2METVIXIA Tier 4PANRETIN Tier 5PICATO Tier 4podofilox Tier 2PROTOPICTier 4 P Aprudoxin Tier 2REGRANEX Tier 3remeven Tier 2salicylic acid soln, top Tier 2SANTYL Tier 3SOLARAZE Tier 3u-kera e urea emollient Tier 2urea 39% cream, -45% lotion, -40%nail film suspTier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 39

Dermatological Medications: TopicalDermatological Drugs (continued)urea 40% cream, -45% cream, -50% Tier 2cream, -foam (non-contraceptive),-gel, -40% lotion, -soln, top, -50%emulsion, -50% topical suspensionx-viate Tier 2ZONALON Tier 3ZYCLARA Tier 3Diagnostic and MiscellaneousMedications: Diagnostic ProductsCHEMET Tier 3EXJADE 125 MG TABLETTier 3 L P A, N M OEXJADE 250 MG TABLET, -500 MG Tier 5 L P A, N M OTABLETFERRIPROX Tier 5METHACHOLINE CHLORIDE Tier 2Diagnostic and MiscellaneousMedications: Miscellaneous DrugsADAGENaminocaproic acid injection, -syrup,-500 mg tabTier 5 L P A, N M OTier 2AMPYRA Tier 5 Q C D (68/30),P A, L P A, N M OAUBAGIO TABLET Tier 5BUPHENYL TABLET Tier 5CARBAGLUTier 5 N M OCOPAXONE Tier 5 Q C D (30/30)CYKLOKAPRONTier 3 H I Tergoloid mesylates tablet Tier 2fomepizoleTier 2 H I TGILENYA Tier 5 Q C D (30/30),P AORFADINTier 5 L P A, N M Osodium phenylbutyrate powder Tier 2THALOMID Tier 5tranexamic acidTier 2 H I Ttranexamic tab Tier 2 Q C D (30/30)40Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Ear-Nose-Throat Medications:Drugs Affecting the Earacetasol hc Tier 2acetic acid otic drops Tier 2acetic acid-aluminum Tier 2antipyrine-benzocaine Tier 2aurodex Tier 2auroguard Tier 2CIPRODEX Tier 3fluocinolone acetonide oil Tier 2hydrocortisone-acetic acid Tier 2neomycin-polymyxin-hc suspensions, Tier 2(not oral)neomycin-polymyxin-hydrocort Tier 2ofloxacin otic drops Tier 2Ear-Nose-Throat Medications:Drugs Affecting the Noseazelastine hcl nasal drops/sprays Tier 2 Q C D (60 ml/30)flunisolide 0.025% sprayTier 2 Q C D (50 ml/30)flunisolide 29 mcg-0.025% spr Tier 2fluticasone propionate nasal inhaledsteroidsipratropium 0.03% sprayipratropium 0.06% spraytriamcinolone acetonide nasal inhaledsteroidsTYZINE Tier 3Ear-Nose-Throat Medications: DrugsAffecting the Throat and Mouthcevimeline hcl Tier 2chlorhexidine gluconate dental/mucous Tier 2membrn productsdoxycycline hyclate 20 mg tab Tier 2periogard Tier 2pilocarpine hcl tablet Tier 2triamcinolone acetonide paste Tier 2Tier 2 Q C D (32gm/30)Tier 2 Q C D (60 ml/30)Tier 2 Q C D (15 ml/30)Tier 2 Q C D (33gm/30)Endocrine Medications: Antithyroid Drugsmethimazole tablet Tier 2propylthiouracil tablet Tier 1Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 41

Endocrine Medications: Glucocorticoid Drugsa-methapred Tier 2baycadron Tier 2betamethasone acetate-sod phos Tier 2cortisone acetate tablet Tier 2dexamethasone elix Tier 2dexamethasone intensol Tier 2dexamethasone sodium phosphate Tier 2 H I Tinjectiondexamethasone tablet Tier 1hydrocortisone tablet Tier 2methylprednisolone injectionTier 2 H I Tmethylprednisolone tab(in convenience Tier 1package), -tabletMILLIPRED DP Tier 3millipred tablet Tier 1prednisolone 15 mg/5 ml soln Tier 2prednisolone 5 mg/5 ml soln, -6.7 mg/5 Tier 2ml soln, -15 mg/5 ml soln, 25mg/5mlsolnprednisone intensol Tier 2prednisone solution Tier 2prednisone tab(in convenience Tier 1package), -tabletRAYOS Tier 4veripred 20 Tier 2Endocrine Medications: Glucose Elevating DrugsGLUCAGEN Tier 3GLUCAGON EMERGENCY KIT Tier 3PROGLYCEM Tier 3Endocrine Medications: Hypoglycemic DrugsBYDUREON Tier 3BYETTA Tier 3SYMLIN Tier 3SYMLINPEN 120 Tier 3SYMLINPEN 60 Tier 3VICTOZA 2-PAKTier 4 S TVICTOZA 3-PAKTier 4 S T42Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Endocrine Medications: InsulinHUMALOG Tier 3HUMALOG MIX 50-50 Tier 3HUMALOG MIX 75-25 Tier 3HUMULIN 70-30 Tier 3HUMULIN N Tier 3HUMULIN R Tier 3LANTUS Tier 3LANTUS SOLOSTAR Tier 3LEVEMIR Tier 3NOVOLIN 70-30 Tier 3NOVOLIN N Tier 3NOVOLIN R Tier 3NOVOLOG Tier 3NOVOLOG MIX 70-30 Tier 3Endocrine Medications: OralHypoglycemics and Combosacarbose Tier 2ACTOS 15 MG TABLET Tier 4 Q C D (51/30),S TACTOS 30 MG TABLET, -45 MGTABLETTier 4 Q C D (34/30),S TAVANDAMET Tier 4 Q C D (68/30),S T, L P A, N M OAVANDIA 2 MG TABLET, -4 MGTABLETTier 4 Q C D (68/30),S T, L P A, N M OAVANDIA 8 MG TABLET Tier 4 Q C D (34/30),S T, L P A, N M Ochlorpropamide Tier 2glimepiride Tier 1glipizide er Tier 2glipizide tablet Tier 1glipizide xl Tier 2glipizide-metformin Tier 2glyburide micronized Tier 2glyburide tablet Tier 1glyburide-metformin hcl Tier 2JANUMETTier 3 S TJANUMET XRTier 3 S TJANUVIATier 3 S TJUVISYNCTier 4 S TKOMBIGLYZE XRTier 3 S TQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 43

Endocrine Medications: Oral Hypoglycemicsand Combos (continued)metformin hcl Tier 1metformin hcl er 500 mg tab, -750 mg Tier 1tabletmetformin hcl er 500 mg tablet, -1,000 Tier 2mg tabnateglinide Tier 2ONGLYZATier 3 S Tpioglitazone hcl 15mg tablet Tier 2 Q C D (51/30),S Tpioglitazone hcl 30mg tablet, -45mg tab Tier 2 Q C D (34/30),S Tpioglitazone-glimepirideTier 2 S Tpioglitazone-metformin Tier 2 Q C D (68/30),S TPRANDIN Tier 3tolazamide Tier 2tolbutamide Tier 2Endocrine Medications: Other Endocrine DrugsALDURAZYMEalendronate sodium 35 mg tab, -70 mgtabTier 5 L P A, H I T, N M OTier 1 Q C D (5/30)alendronate sodium 5 mg tablet, -10 mg Tier 1 Q C D (34/30)tab, -40 mg tabcabergoline Tier 2 Q C D (16/30)calcitonin-salmon Tier 2CEREZYME Tier 5 P A, L P A, H I T,N M Odesmopressin ac nasal drops/sprays, Tier 2-solution, -tabletdesmopressin ac injectionTier 2 H I TELELYSO Tier 5etidronate disodium Tier 2EVISTA Tier 3FABRAZYME 35 MG VIALTier 5 L P A, H I T, N M Ofludrocortisone acetate tablet Tier 2FORTEO Tier 5 Q C D (2.4pens/30), P Afortical Tier 2ibandronate sodium Tier 2 Q C D (1/30)INCRELEXTier 5 P A, L P A, N M OKORLYMTier 5 P AKUVANTier 5 L P A, N M OMIACALCIN INJECTION Tier 4NAGLAZYMETier 5 L P A, H I T, N M O44Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Endocrine Medications: OtherEndocrine Drugs (continued)pamidronateTier 2 H I TPROLIATier 4 P ARECLASTTier 4 H I TSAMSCA Tier 5SENSIPAR 30 MG TABLET Tier 3SENSIPAR 60 MG TABLET, -90 MG Tier 5TABLETSOMAVERTTier 5 L P A, N M OSTIMATE Tier 3XGEVATier 5 P AZAVESCATier 5 L P A, N M Ozoledronic acid Tier 5ZOMETATier 5 H I TEndocrine Medications: Thyroid Supplementslevothroid Tier 1LEVOTHYROXINE 100 MCG VIAL Tier 3levothyroxine 500 mcg vial Tier 2levothyroxine sodium tablet Tier 1levoxyl Tier 1liothyronine sodium injectionTier 2 H I Tliothyronine sodium tablet Tier 2lugol’s solution Tier 2nature-throid Tier 2SYNTHROID Tier 4unithroid Tier 1Gastrointestinal Medications: Antidiarrheal Drugsdiphenoxylate-atropine Tier 2loperamide capsule Tier 2paregoric Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 45

Gastrointestinal Medications: Antispasmodics/Drugs Affect GI MotilityCUVPOSATier 4 N M Odicyclomine hcl capsule, -syrup, -tablet Tier 2glycopyrrolate injection, -tablet Tier 2methscopolamine bromide tablet Tier 2metoclopramide syrup Tier 2metoclopramide injectionTier 2 H I Tmetoclopramide hcl tablet Tier 1propantheline bromide tablet Tier 2Gastrointestinal Medications: Antiulcer Drugscimetidine injectionTier 2 H I Tcimetidine solution, -tablet Tier 2famotidine oral susp Tier 2famotidine injectionTier 2 H I Tfamotidine tablet Tier 1nizatidine Tier 2ranitidine syrup Tier 2ranitidine hcl injectionTier 2 H I Tranitidine hcl capsule, -tablet Tier 1Gastrointestinal Medications: Other Antiulcer Drugsmisoprostol Tier 2sucralfate oral susp, -tablet Tier 2Gastrointestinal Medications: Other GI DrugsAMITIZA Tier 3 Q C D (68/30)APRISO Tier 3ASACOL Tier 3ASACOL HD Tier 3balsalazide disodium Tier 2budesonide ec Tier 5DELZICOL Tier 3gavilyte-c Tier 2gavilyte-g Tier 2gavilyte-n Tier 2hydrocortisone rectal Tier 2lidocaine-hydrocortisone rectal Tier 2LINZESS CAPSULE Tier 3 Q C D (34/30)LOTRONEX Tier 5 Q C D (68/30)mesalamine kit, -rectal Tier 2OSMOPREP Tier 4PANCREAZE Tier 4PANCRELIPASE 5,000 Tier 3peg 3350-electrolyte Tier 2peg-3350 and electrolytes Tier 2peg-3350 with flavor packs Tier 2PENTASA Tier 3polyethylene glycol 3350 Tier 2procto-pak Tier 2proctosol-hc Tier 246Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Gastrointestinal Medications: Other GI Drugs (continued)proctozone-hc Tier 2PYLERA Tier 3RECTIV Tier 4RELISTOR Tier 3SUCRAID Tier 5sulfasalazine dr Tier 2sulfasalazine tablet Tier 2sulfazine Tier 2sulfazine ec Tier 2trilyte with flavor packets Tier 2ursodiol capsule, -tablet Tier 2VISICOL Tier 4ZENPEP Tier 3Immunologicals and Vaccines: GrowthHormones and Related DrugsHUMATROPENUTROPINNUTROPIN AQNUTROPIN AQ NUSPINSAIZENZORBTIVETier 5 P ATier 5 P ATier 5 P ATier 5 P ATier 5 P ATier 5 P A, L P A, N M OGastrointestinal Medications: Proton Pump Inhibitorslansoprazole capsule sustained action Tier 2 Q C D (34/30),S Tomeprazole dr 10 mg capsule, -dr 40 Tier 2 Q C D (34/30)mg capsuleomeprazole dr 20 mg capsule Tier 2 Q C D (68/30)omeprazole-sodium bicarbonate Tier 2 Q C D (34/30),S Tpantoprazole sodium Tier 2 Q C D (34/30),S Tpantoprazole sodium vial Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 47

Immunologicals and VaccinesACTHIB Tier 3ADACEL Tier 3AFLURIA 2011-2012 M BAFLURIA 2011-2012 (PF) M BARANESP 100 MCG/0.5 MLTier 5 Q C D (2/30), P ASYRINGEARANESP 100 MCG/ML VIAL, -200 Tier 5 Q C D (4/30), P AMCG/ML VIAL, -300 MCG/ML VIAL,-500 MCG/1 ML SYRINGEARANESP 150 MCG/0.3 MLSYRINGEARANESP 150 MCG/0.75 ML VIALARANESP 200 MCG/0.4 MLSYRINGETier 5 Q C D (1.2/30),P ATier 5 P ATier 5 Q C D (1.6/30),P AARANESP 25 MCG/0.42 ML SYRING Tier 3 Q C D (1.68/30),P AARANESP 25 MCG/ML VIAL, -40 Tier 3 Q C D (4/30), P AMCG/ML VIAL, -60 MCG/ML VIALARANESP 300 MCG/0.6 MLSYRINGETier 5 Q C D (2.4/30),P AARANESP 40 MCG/0.4 ML SYRINGE Tier 3 Q C D (1.6/30),P AARANESP 60 MCG/0.3 ML SYRINGE Tier 3 Q C D (1.2/30),P ABOOSTRIX Tier 3candin Tier 2CERVARIX Tier 3CINRYZETier 5 H I TImmunologicals and Vaccines (continued)COMVAX Tier 3DAPTACEL Tier 3DECAVAC Tier 3DIPHTHERIA-TETANUS TOXOID Tier 3ENGERIX-B M BEPOGEN 10,000 UNITS/ML VIAL Tier 3 P AEPOGEN 2,000 UNITS/ML VIAL,-3,000 UNITS/ML VIAL, -4,000UNITS/ML VIAL, -20,000 UNITS/2 MLVIAL, -20,000 UNITS/ML VIALTier 3 Q C D (12/30),P AFIRAZYR Tier 5FLUARIX 2011-2012 M BFLULAVAL 2011-2012 M BFLUMIST NASAL 2011-12 VACCINE M BFLUVIRIN 2011-2012 M BFLUZONE 2011-2012 M BFLUZONE 2011-2012 (PF) M BFLUZONE 2012-2013 M BFLUZONE HIGH-DOSE 2011-12 (PF) M BFLUZONE HIGH-DOSE 2012-13 M BFLUZONE INTRADERMAL M BFLUZONE INTRADERMAL 2012-2013 M BFLUZONE PEDI 2012-2013 M BGAMASTAN S-DTier 3 P AGAMMAGARD LIQUIDTier 5 P A, H I TGAMMAGARD S-DTier 5 P A48Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Immunologicals and Vaccines (continued)GAMUNEXTier 5 P A, H I TGAMUNEX-CTier 5 P AGARDASIL Tier 3HAVRIX Tier 3HIBERIX Tier 3IMOVAX RABIES VACCINE Tier 3INFANRIX Tier 3INFLUENZA A (H1N1) 2009 M BIPOL Tier 3IXIARO Tier 3JE-VAX Tier 3KEPIVANCETier 5 L P A, H I T, N M OKINRIX Tier 3MENACTRA Tier 3MENOMUNE-A-C-Y-W-135 Tier 3MENVEO A-C-Y-W-135-DIP Tier 3M-M-R II VACCINE Tier 3MOZOBIL Tier 5NPLATETier 5 N M OOCTAGAMTier 5 P APEDIARIX Tier 3PEDVAXHIB Tier 3PENTACEL Tier 3PNEUMOVAX 23 VIAL M BPREVNAR 13 M BImmunologicals and Vaccines (continued)PROCRIT 2,000 UNITS/ML VIAL,-3,000 UNITS/ML VIAL, -4,000UNITS/ML VIAL, -10,000 UNITS/MLVIALPROCRIT 20,000 UNITS/ML VIAL,-40,000 UNITS/ML VIALPROMACTAPROQUAD Tier 3RABAVERT Tier 3RECOMBIVAX HB M BROTARIX Tier 3ROTATEQ Tier 3TENIVAC Tier 3TETANUS DIPHTHERIA TOXOIDS Tier 3tetanus toxoid adsorbed Tier 2TETANUS-DIPHTERIA-DECAVAC Tier 3TRIHIBIT Tier 3TRIPEDIA Tier 3TWINRIX Tier 3TYPHIM VI Tier 3VAQTA Tier 3VARIVAX VACCINE Tier 3YF-VAX Tier 3ZOSTAVAX Tier 3Tier 3 Q C D (12/30),P ATier 5 Q C D (12/30),P ATier 5 L P A, N M OQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 49

Immunologicals and Vaccines: InterferonsACTIMMUNETier 5 P A, L P A, N M OAVONEXTier 5 Q C D (4 kits/30)AVONEX ADMINISTRATION PACK Tier 5 Q C D (4 kits/30)AVONEX PEN Tier 5BETASERON Tier 5 Q C D (15/30)INFERGEN 15 MCG/0.5 ML VIAL Tier 5 P AINFERGEN 9 MCG/0.3 ML VIAL Tier 5 P AINTRON A 3 MILLION UNIT/ML Tier 3 P APEN, -6 MILLION UNIT/ML VL, -10MILLION UNIT PEN, -10 MILLIONUNIT/ML, -10 MILLION UNITS VIALINTRON A 5 MILLION UNIT/ML Tier 5 P APEN, -18 MILLION UNITS VIAL, -50MILLION UNITS VIALPEGASYS 180 MCG/0.5 ML SYRINGE Tier 5 Q C D (4syringes/30),P APEGASYS 180 MCG/ML VIAL Tier 5 Q C D (4vials/30), P APEGASYS PROCLICK 135 MCG/0.5 Tier 5 Q C D (4/30), P APEGASYS PROCLICK 180 MCG/0.5 Tier 5 Q C D (4/30), P APEGINTRON 50 MCG KITTier 5 Q C D (5 kits/30),P APEGINTRON 80 MCG KIT, -120 MCG Tier 5 P AKIT, -150 MCG KITPEGINTRON REDIPEN Tier 5 Q C D (4pens/30), P AImmunologicals and Vaccines: Interferons (continued)REBIF 22 MCG/0.5 ML SYRINGE, -44 Tier 5 Q C D (7.5 ml/30)MCG/0.5 ML SYRINGEREBIF TITRATION PACK Tier 5 Q C D (4.2syringes/30)SYLATRONTier 5 P ASYLATRON 4-PACKTier 5 P AImmunologicals and Vaccines:Interleukin Recptr AntagonistACTEMRAARCALYSTILARISKINERETTier 5 P ATier 5 L P A, N M OTier 5 P A, L P A, N M OTier 5 P AImmunologicals and Vaccines: InterleukinsNEUMEGA Tier 5PROLEUKINTier 5 P A, H I T50Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Immunologicals and Vaccines: Myeloid StimulantsLEUKINETier 5 H I TNEULASTA Tier 5 Q C D (1.2syringes/30)NEUPOGEN 300 MCG/0.5 ML SYR Tier 5 Q C D (15/30)NEUPOGEN 300 MCG/ML VIAL Tier 5NEUPOGEN 480 MCG/0.8 ML SYR Tier 5 Q C D (24/30)NEUPOGEN 480 MCG/1.6 ML VIAL Tier 5 Q C D (48/30)Medical (Miscellaneous) Supplies: Diabetic Supplies1ST CHOICE SUPER THIN LANCETS M B1ST CHOICE THIN LANCETS M B1ST CHOICE ULTRA THIN LANCETS M B1ST TIER COMFORTOUCH 28G M BLANCT1ST TIER COMFORTOUCH 30G M BLANCT1ST TIER UNIFINE PENTP 5MM 31G Tier 31ST TIER UNIFINE PNTIP 4MM 32G Tier 31ST TIER UNIFINE PNTIP 6MM 31G Tier 31ST TIER UNIFINE PNTIP 8MM 31G Tier 31ST TIER UNIFINE PNTP 12MM 29G Tier 32TEK CONTROL SOLUTION M BACCU-CHEK ACTIVE GLUCOSE SOL M BACCU-CHEK ACTIVE TEST STRIP M B Q C D (300/30)ACCU-CHEK ADVANTAGE KIT M B Q C D (1/365)ACCU-CHEK AVIVA PLUS METER M B Q C D (1/365)ACCU-CHEK AVIVA PLUS TEST STRP M B Q C D (300/30)ACCU-CHEK AVIVA SOLUTION M BACCU-CHEK AVIVA TEST STRIPS M B Q C D (300/30)ACCU-CHEK CMFRT CURVE SOLN M BACCU-CHEK CMFRT CURVE STRIP M B Q C D (300/30)ACCU-CHEK COMFORT CURVE M B Q C D (300/30)STRIPACCU-CHEK COMPACT BLUECONTROLM BQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 51

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ACCU-CHEK COMPACT CARE KIT M B Q C D (1/365)ACCU-CHEK COMPACT DRUM M B Q C D (300/30)STRIPSACCU-CHEK COMPACT PLUS KIT M B Q C D (1/365)ACCU-CHEK COMPACT STRIPS M B Q C D (300/30)ACCU-CHEK COMPACT TEST DRUM M B Q C D (300/30)ACCU-CHEK CONTROL SOLUTION M BACCU-CHEK FASTCLIX LANCETS M BACCU-CHEK III DIABETES KIT M B Q C D (1/365)ACCU-CHEK MULTICLIX LANCET M BACCU-CHEK MULTICLIX LANCET KIT M BACCU-CHEK MULTICLIX LANCETS M BACCU-CHEK NANO SMARTVIEW M B Q C D (1/365)METERACCU-CHEK SAFE-T-PRO 23G M BLANCTACCU-CHEK SAFE-T-PRO LANCETS M BACCU-CHEK SAFE-T-PRO PLUS 23G M BACCU-CHEK SMARTVIEW CONTRL M BSOLACCU-CHEK SMARTVIEW STRIP M B Q C D (300/30)ACCU-CHEK SMARTVIEW TEST M B Q C D (300/30)STRIPACCU-CHEK SOFTCLIX LANCETS M BACCU-CHEK VOICEMATE SYSTEM M B Q C D (1/365)ACCUTREND GLUCOSE CONTROL M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)ACTI-LANCE 23G LANCETS M BACTI-LANCE 28G LANCETS M BACTI-LANCE LITE 28G LANCETS M BACTI-LANCE SPECIAL 17G LANCETS M BACTI-LANCE UNIVERS 23G LANCETS M BACURA CONTROL SOLUTION HIGH M BACURA CONTROL SOLUTION LOW M BACURA CONTROL SOLUTION M BNORMALADVANCE MICRO-DRAW CNTRL M BSOLNADVANCE MICRO-DRAW CONTRL M BSOLNADVANCE NORMAL CONTROL SOLN M BADVANCED TRAVEL LANCETS 28G M BADVOCATE 26G LANCETS M BADVOCATE 30G LANCETS M BADVOCATE CONTROL SOLUTION M BHIGHADVOCATE CONTROL SOLUTION M BLOWADVOCATE INS 0.3 ML 30GX5/16 Tier 3ADVOCATE INS 0.3 ML 31GX5/16 Tier 3ADVOCATE INS 0.5 ML 30GX5/16 Tier 3ADVOCATE INS 0.5 ML 31GX5/16 Tier 3ADVOCATE INS 1 ML 31GX5/16 Tier 352Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ADVOCATE INS SYR 0.3ML 29GX1/2 Tier 3ADVOCATE INS SYR 0.5ML 29GX1/2 Tier 3ADVOCATE INS SYR 1 ML 29GX1/2 Tier 3ADVOCATE INS SYR 1 ML 30GX5/16 Tier 3ADVOCATE PEN NEEDLES 5MM 31G Tier 3ADVOCATE PEN NEEDLES 8MM 31G Tier 3ADVOCATE REDI-CODE+ CTRL M BSOLNAGAMATRIX HIGH CONTROL SOLN M BAGAMATRIX NORM-HI CONTROL M BSOLNAIMSCO INS PEN NDL 29GX1/2 Tier 3AIMSCO INS PEN NDL 31GX3/16 Tier 3AIMSCO INS PEN NDL 31GX5/16 Tier 3AIMSCO INS SYR 0.3 ML 29GX1/2 Tier 3AIMSCO INS SYR 0.3 ML 30GX5/16 Tier 3AIMSCO INS SYR 0.5 ML 28GX1/2 Tier 3AIMSCO INS SYR 0.5 ML 29GX1/2 Tier 3AIMSCO INS SYR 1 ML 28GX1/2 Tier 3AIMSCO INS SYR 1 ML 29GX1/2 Tier 3AIMSCO INS SYR 1 ML 30GX5/16 Tier 3AIMSCO SYRING 0.3 ML 31GX5/16 Tier 3AIMSCO SYRING 0.5 ML 30GX5/16 Tier 3AIMSCO SYRING 0.5 ML 31GX5/16 Tier 3AIMSCO ULTR-THIN II 28G LANCET M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)ALCOHOL 70% PADS Tier 3ALCOHOL 70% PREP PADS Tier 3ALCOHOL 70% SWABS Tier 3ALCOHOL PREP PADS Tier 3ALCOHOL PREP PADS 70% Tier 3ALCOHOL PREP SWABS Tier 3ALCOHOL SWAB Tier 3ALCOHOL SWABS Tier 3ALCOHOL WIPES Tier 3ALTERNATE SITE 26G LANCETS M BALTERNATE SITE LANCETS M BANTI-STICK INSULIN 0.5 ML SYR Tier 3ANTI-STICK INSULIN 1 ML SYR Tier 3ASCENSIA AUTODISC CTRL SOLN M BASSURE 3 CONTROL SOLUTION M BASSURE 4 CONTROL SOLUTION M BASSURE DOSE CONTROLM BSOLUTIONASSURE HAEMOLANCE PLUS 18G M BASSURE HAEMOLANCE PLUS 21G M BASSURE HAEMOLANCE PLUS 25G M BASSURE HAEMOLANCE PLUS M BLANCETSASSURE ID SYR 0.5 ML 29GX1/2 Tier 3ASSURE ID SYR 1 ML 29GX1/2 Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 53

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ASSURE II CONTROL SOLUTION M BASSURE LANCE 25G LANCETS M BASSURE LANCE MICRO FLOW M BLANCETASSURE PRO CONTROL SOLUTION M BASSURE ULTRA THIN LANCETS M BAT-LAST LANCETS M BAURORA HEALTHCARE LANCETS M BAURORA PEN NEEDLE 6MM 31G Tier 3AURORA PEN NEEDLES 12MM 29G Tier 3AURORA PEN NEEDLES 8MM 31G Tier 3AURORA SUPER THIN LANCET M BAURORA THIN LANCETS M BAUTODISC NORMAL CONTROL M BSOLNAUTOJECT 2 INJECTION DEVICE Tier 3AUTOPEN 1 TO 16 UNITS Tier 3AUTOPEN 1 TO 21 UNITS Tier 3AUTOPEN 2 TO 32 UNITS Tier 3AUTOPEN 2 TO 42 UNITS Tier 3BD 10 ML SYRINGE WITH NEEDLE Tier 3BD AUTO INJECTOR Tier 3BD ECLIPSE 30GX1/2 SYRINGE Tier 3BD INSUL SYR 0.3 ML 31GX15/64 Tier 3BD INSUL SYR 0.5 ML 31GX15/64 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)BD INSULIN SYR 0.3 ML 28GX1/2 Tier 3BD INSULIN SYR 0.3 ML 29GX1/2 Tier 3BD INSULIN SYR 0.3 ML 30GX1/2 Tier 3BD INSULIN SYR 0.3ML 31GX5/16 Tier 3BD INSULIN SYR 0.5 ML 28GX1/2 Tier 3BD INSULIN SYR 0.5 ML 29GX1/2 Tier 3BD INSULIN SYR 0.5 ML 30GX1/2 Tier 3BD INSULIN SYR 0.5ML 31GX5/16 Tier 3BD INSULIN SYR 1 ML 25GX1 Tier 3BD INSULIN SYR 1 ML 25GX5/8 Tier 3BD INSULIN SYR 1 ML 26GX1/2 Tier 3BD INSULIN SYR 1 ML 27GX5/8 Tier 3BD INSULIN SYR 1 ML 28GX1/2 Tier 3BD INSULIN SYR 1 ML 29GX1/2 Tier 3BD INSULIN SYR 1 ML 30GX1/2 Tier 3BD INSULIN SYR 1 ML 31GX15/64 Tier 3BD INSULIN SYR 1 ML 31GX5/16 Tier 3BD INSULIN SYRINGE 1 ML Tier 3B-D INSULIN U100 2 ML SYRNGE Tier 3BD INSULIN U100-1 ML SYRNGE Tier 3B-D INSULIN U100-2 ML SYRNGE Tier 3BD INSULIN U100-3/10 ML SYR Tier 3B-D INSULIN U100-3/10 ML SYR Tier 3BD INTEGRA SYR 1 ML 29GX1/2 Tier 3BD INTEGRA SYRINGE 1 ML 25GX1 Tier 354Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)BD LANCETS 30G M BBD LANCETS 33G M BBD LANCETS MICROTAINER M BBD LANCETS MICROTAINER 21G M BBD LANCETS MICROTAINER 30G M BBD LUER-LOK SYRINGE 1 ML Tier 3BD LUER-LOK SYRINGE 1ML 20GX1 Tier 3BD NEEDLES 26GX0.5 Tier 3BD NEEDLES 27GX0.5 Tier 3BD PEN INSULIN DEVICE Tier 3BD PEN MINI INSULIN DEVICE Tier 3BD PEN NEEDLE 29GX1/2 Tier 3BD PEN NEEDLE 29GX3/16 Tier 3BD PEN NEEDLE 29GX5/16 Tier 3BD PEN NEEDLE 30GX3/16 Tier 3BD PEN NEEDLE MINI 31GX3/16 Tier 3BD PEN NEEDLE NANO 32GX5/32 Tier 3BD PEN NEEDLE ORIG 29GX1/2 Tier 3BD PEN NEEDLE SHORT 31GX5/16 Tier 3BD SAFETYGLIDE SYRINGE 27GX5/8 Tier 3BD SAFTGLD INS 0.3 ML 31GX5/16 Tier 3BD SAFTGLD INS SYR 0.3 ML 29G Tier 3BD SAFTGLD INS SYR 0.5 ML 30G Tier 3BD SINGLE USE ALCOHOL SWAB Tier 3BD SINGLE USE SWAB Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)BD SYR 0.3 ML 31GX15/64 (1/2) Tier 3BD SYR 0.3 ML 31GX5/16 (1/2) Tier 3BD ULTRA FINE LANCETS M BBL ALCOHOL PREP SWABS Tier 3BL INSULIN 0.3 ML SYRINGE Tier 3BL INSULIN 0.5 ML SYRINGE Tier 3BL INSULIN 1 ML SYRINGE Tier 3BL LANCETS M BBLOOD GLUCOSE CONTROL M BSOLUTIONBREEZE 2 SOLUTION M BBULLSEYE MINI SAFETY 21G M BBULLSEYE MINI SAFETY 28G LANCT M BBULLSEYE MINI SAFETY LANCETS M BCAREONE INS SYR 1 ML 30GX5/16 Tier 3CAREONE THIN LANCET M BCAREONE ULTRA THIN LANCET M BCAREONE UNIFINE PENTIP 5MM Tier 331GCAREONE UNIFINE PENTIP 6MM Tier 331GCAREONE UNIFINE PENTIP 8MM Tier 331GCAREONE UNIFINE PNTP 12MM 29G Tier 3CARESENS CONTROL SOLUTION M BQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 55

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)CLEVER CHEK 30G LANCETS M BCLEVER CHEK CONTROL SOLUTION M BCLEVER CHEK ULTRA THINM BLANCETSCLICKFINE 31G X 1/4 NEEDLES Tier 3CLICKFINE 31G X 5/16 NEEDLES Tier 3CLICKFINE UNIVERSAL 31G X 1/4 Tier 3CLICKFINE UNIVERSAL 31GX5/16 Tier 3CLOSERCARE LANCETS M BCOAGUCHEK LANCETS M BCOMFORT EZ INS 0.3ML 30GX1/2 Tier 3COMFORT EZ INS 0.3ML 30GX5/16 Tier 3COMFORT EZ INSULIN SYR 0.3 ML Tier 3COMFORT EZ INSULIN SYR 0.5 ML Tier 3COMFORT EZ PEN NEEDLES 5MM Tier 331GCOMFORT EZ PEN NEEDLES 6MM Tier 331GCOMFORT EZ PEN NEEDLES 8MM Tier 331GCOMFORT EZ SYR 0.3 ML 29GX1/2 Tier 3COMFORT EZ SYR 0.5 ML 28GX1/2 Tier 3COMFORT EZ SYR 0.5 ML 29GX1/2 Tier 3COMFORT EZ SYR 0.5 ML 30GX1/2 Tier 3COMFORT EZ SYR 1 ML 28GX1/2 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)COMFORT EZ SYR 1 ML 29GX1/2 Tier 3COMFORT EZ SYR 1 ML 30GX1/2 Tier 3COMFORT EZ SYR 1 ML 30GX5/16 Tier 3COMFORT EZ SYR 1 ML 31GX5/16 Tier 3COMFORT LANCETS M BCONTOUR NEXT LEV 1 CONTROL M BSOLCONTOUR NEXT LEV 2 CONTROL M BSOLCONTOUR SOLUTION M BCONTROL SOLUTION NORMAL M BCORNWALL METAL PIPET HOLDER Tier 3CURITY ALCOHOL PREPS Tier 3CURITY ALCOHOL SWABS Tier 3CVS ALCOHOL 70% PREP SWABS Tier 3CVS ALCOHOL SWABS Tier 3CVS INSULIN SYR 1 ML 29GX1/2 Tier 3CVS ISOPROPYL ALCOHOL 70% Tier 3WIPECVS LANCETS M BCVS LANCETS-ORIGINAL M BCVS LANCETS-THIN M BCVS LANCING DEVICE M BCVS MICRO THIN 33G LANCETS M BCVS SYRINGE 1/2 ML Tier 356Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)CVS SYRINGE 3/10 ML Tier 3CVS THIN LANCETS M BCVS ULTRA THIN LANCETS M BDR LANCET M BDR SUPER THIN 30G LANCETS M BDR ULTRA THIN LANCET M BDR UNIFINE PENTIPS 12MM NDL Tier 3DR UNIFINE PENTIPS 6MM NDL Tier 3DR UNIFINE PENTIPS 8MM NDL Tier 3DROPLET 30G LANCETS M BDRUG MART THIN LANCETS M BDRUG MART ULTRA COMFORT SYR Tier 3DRUG MART ULTRA THIN LANCETS M BDUO-CARE CONTROL SOLUTION M BEASY CHECK CONTROL SOLN HIGH M BEASY CHECK CONTROL SOLN LOW M BEASY COMFORT 0.3 ML SYRINGE Tier 3EASY COMFORT 0.5 ML SYRINGE Tier 3EASY COMFORT 30G LANCETS M BEASY COMFORT INSULIN 1 ML SYR Tier 3EASY TALK CONTROL SOLN LOW M BEASY TALK HIGH CONTROL SOLN M BEASY TEST II LANCETS M BEASY TEST LANCETS M BEASY TOUCH 0.3 ML SYR 30GX1/2 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)EASY TOUCH 0.5 ML SYR 27GX1/2 Tier 3EASY TOUCH 0.5 ML SYR 30GX1/2 Tier 3EASY TOUCH 1 ML SYR 27GX1/2 Tier 3EASY TOUCH 1 ML SYR 30GX1/2 Tier 3EASY TOUCH ALCOHOL 70% PADS Tier 3EASY TOUCH CONTROL SOLUTION M BEASY TOUCH INSULIN SYR 0.3 ML Tier 3EASY TOUCH INSULIN SYR 0.5 ML Tier 3EASY TOUCH INSULIN SYR 1 ML Tier 3EASY TOUCH LANCETS M BEASY TOUCH PEN NDL 32GX1/4 Tier 3EASY TOUCH PEN NDL 32GX3/16 Tier 3EASY TOUCH PEN NEEDLE 29G Tier 3EASY TOUCH PEN NEEDLE 31G Tier 3EASY TOUCH PEN NEEDLETier 331GX3/16EASY TRAK CONTROL SOLN HIGH M BEASY TRAK CONTROL SOLNM BNORMALEASYMAX HIGH CONTROL SOLN M BEASYMAX LOW CONTROL SOLN M BEASYMAX NORMAL CONTROL SOLN M BEASY-TOUCH INS 1 ML 31GX5/16 Tier 3ECLIPSE CONTROL SOLN NORMAL M BQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 57

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ECLIPSE CONTROL SOLUTION M BHIGHECLIPSE CONTROL SOLUTION LOW M BELEMENT CONTROL SOLN NORMAL M BELEMENT CONTROL SOLUTION M BHIGHELEMENT CONTROL SOLUTION M BLOWELEMENT PLUS CONTROLM BSOLUTIONELITE-THIN INS SYR 0.5CC Tier 3ELITE-THIN INSUL SYR 0.3CC Tier 3ELITE-THIN INSUL SYR 0.5CC Tier 3ELITE-THIN INSUL SYR 1/2CC Tier 3ELITE-THIN INSUL SYR 1CC Tier 3ELITE-THIN INSULIN SYR 1CC Tier 3EMBRACE GLUC CONTROL SOLN M BLOWENVISION CONTROL SOLN HIGH M BENVISION CONTROL SOLN LOW M BENVISION CONTROL SOLN NORMAL M BEQL COLOR LANCETS M BEQL INS SYR 0.3 ML 29GX1/2 Tier 3EQL INS SYR 0.3 ML 30GX5/16 Tier 3EQL INS SYR 0.5 ML 29GX1/2 Tier 3EQL INS SYR 0.5 ML 30GX5/16 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)EQL INS SYR 1 ML 29GX1/2 Tier 3EQL INSUL SYR 0.3 ML 31GX5/16 Tier 3EQL INSUL SYR 0.5 ML 31GX5/16 Tier 3EQL INSULIN 0.3 ML SYRINGE Tier 3EQL INSULIN 0.5 ML SYRINGE Tier 3EQL INSULIN 1 ML SYRINGE Tier 3EQL INSULIN SYR 1 ML 29GX1/2 Tier 3EQL INSULIN SYR 1 ML 30GX5/16 Tier 3EQL INSULIN SYR 1 ML 31GX5/16 Tier 3EQL LANCETS THIN M BEQL PEN 8MM 31G X 5/16 NEEDLE Tier 3EQL PEN NEEDLE 6MM 31G Tier 3EQL SUPER THIN LANCETS M BEVENCARE CONTROL SOLUTION M BEVENCARE G2 CONTROLM BSOLUTIONEVENCARE G3 CONTROLM BSOLUTIONEVOLUTION CONTROL SOLN M BNORMALEXEL HYPO NEEDLE 26GX0.5 Tier 3EXEL HYPO NEEDLE 26GX1.5 Tier 3EXEL HYPO NEEDLE 27GX0.5 Tier 3EXEL INS SYR U100 1 ML 28GX1/2 Tier 3EXEL INSUL PEN NEEDLES 8MM Tier 358Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)EXEL INSUL SYR 0.5 ML 28GX1/2 Tier 3EXEL INSULIN PEN NEEDLE Tier 3EXEL INSULIN SYRINGE 27G-1 ML Tier 3EXEL INSULIN SYRN 27G-1/2 ML Tier 3EXEL U100 0.3 ML 29GX1/2 Tier 3EXEL U100 0.3 ML 30GX5/16 Tier 3EXEL U100 0.5 ML 28GX1/2 Tier 3EXEL U100 0.5 ML 29GX1/2 Tier 3EXEL U100 0.5 ML 30GX5/16 Tier 3EXEL U100 1 ML 30GX5/16 Tier 3EXEL U100 INS SYR 1 ML 29GX1/2 Tier 3E-Z JECT COLORED LANCETS M BE-Z JECT LANCETS M BE-Z JECT SUPER THIN LANCETS M BEZ SMART BLOOD GLUCOSE M BLANCETSEZ SMART HIGH CONTROLM BSOLUTIONEZ SMART LOW CONTROLM BSOLUTIONEZ SMART NORMAL CONTROL M BSOLNE-ZJECT COLOR 32G LANCETS M BE-ZJECT COLOR 33G LANCETS M BE-ZJECT THIN LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)EZ-LETS LANCETS 23G M BFAST TAKE MONITORING SYSTEM M B Q C D (1/365)FAST TAKE TEST STRIPS M B Q C D (300/30)FIFTY50 ALCOHOL PREP PADS Tier 3FIFTY50 GLUCOSE CONTROL SOLN M BFIFTY50 INS SYR 1 ML 31GX5/16 Tier 3FIFTY50 INSULIN SYRINGE 0.3 ML Tier 3FIFTY50 INSULIN SYRINGE 0.5 ML Tier 3FIFTY50 PEN 31G X 3/16 NEEDLE Tier 3FIFTY50 PEN 31G X 5/16 NEEDLE Tier 3FIFTY50 SAFETY SEAL 30G LANCET M BFIFTY50 SAFETY SEAL 32G LANCET M BFINE 30 UNIVERSAL 30G LANCETS M BFINGERSTIX LANCETS M BFORA HIGH CONTROL SOLUTION M BFORA LANCETS M BFORA LOW CONTROL SOLUTION M BFORA NORMAL CONTROLM BSOLUTIONFREESTYLE CONTROL SOLUTION M BFREESTYLE LANCETS M BFREESTYLE PREC 0.5 ML 30GX5/16 Tier 3FREESTYLE PREC 0.5 ML 31GX5/16 Tier 3FREESTYLE PREC 1 ML 30GX5/16 Tier 3FREESTYLE PREC 1 ML 31GX5/16 Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 59

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)FREESTYLE UNISTIK 2 LANCETS M BGE100 CONTROL SOLUTION M BNORMALGENTLE-LET G.P. LANCETS M BGENTLE-LET GP 26G LANCETS M BGENTLE-LET GP 28G LANCETS M BGENTLE-LET SAFETY LANCETS M BGLUCOCARD 01 CONTROLM BSOLUTIONGLUCOCARD EXPRESSION CNTRL M BSLNGLUCOCARD X-METER CONTROL M BSOLNGLUCOCOM 30G LANCETS M BGLUCOCOM 33G LANCETS M BGLUCOCOM CONTROL SOLUTION M BGLUCOCOM LANCETS 28G M BGLUCOLAB CONTROL SOLN M BNORMALGLUCOLAB CONTROL SOLUTION M BHIGHGLUCOLAB CONTROL SOLUTION M BLOWGLUCOPRO INSUL SYR U100 0.3 ML Tier 3GLUCOPRO INSUL SYR U100 0.5 ML Tier 3GLUCOPRO INSULIN SYR 0.5 ML Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)GLUCOPRO INSULIN SYR 1 ML Tier 3GLUCOPRO INSULIN SYR U100 1 Tier 3MLGLUCOPRO SYRINGE U100 1 ML Tier 3GLUCOPRO U100 INSUL SYR 0.3 ML Tier 3GLUCOSE CONTROL SOLNM BNORMALGLUCOSE CONTROL SOLUTION M BGLUCOSOURCE LANCETS M BGNP ALCOHOL PREP SWABS Tier 3GNP ALCOHOL SWAB Tier 3GNP CLICKFINE 31G X 1/4 NDL Tier 3GNP CLICKFINE 31G X 5/16 NDL Tier 3GNP CLICKFINE PEN NDL 31GX1/4 Tier 3GNP CLICKFINE PEN NDL 31GX5/16 Tier 3GNP INSUL SYR 0.3 ML 31GX5/16 Tier 3GNP INSUL SYR 0.5 ML 31GX5/16 Tier 3GNP INSULIN SYR 1 ML 31GX5/16 Tier 3GNP LANCETS M BGNP MICRO THIN 33G LANCETS M BGNP SUPER THIN LANCETS M BGNP THIN LANCETS M BGNP ULTRA COMFORT 0.5 ML SYR Tier 3GNP ULTRA COMFORT 1 ML Tier 3SYRINGE60Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)GNP ULTRA COMFORT 3/10 ML SYR Tier 3H&H THINLET LANCETS M BHAEMOLANCE LANCET M BHAEMOLANCE PLUS LANCET M BHAEMOLANCE PLUS LANCETS M BHAEMOLANCE, RETRACTABLE M BHEALTHY ACCENTS PENTIP 5MM Tier 331GHEALTHY ACCENTS PENTIP 6MM Tier 331GHEALTHY ACCENTS PENTIP 8MM Tier 331GHEALTHY ACCENTS PENTP 12MM Tier 329GHEALTHY ACCENTS UNILET 30G M BHM MICRO THIN 33G LANCETS M BHM ULTRA THIN 30G LANCETS M BHUMAPEN LUXURA HD Tier 3HUMAPEN MEMOIR Tier 3HYPODERMIC NEEDLE,ALUM HUB Tier 3HY-VEE LANCETS M BHY-VEE THIN LANCET M BIN CONTROL PEN NEEDLE 12MM Tier 329GIN CONTROL PEN NEEDLE 6MM 31G Tier 3IN CONTROL PEN NEEDLE 8MM 31G Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)INCONTROL PEN NDL 31GX3/16 Tier 3INCONTROL PEN NEEDLES 4MM Tier 332GINCONTROL SUPER THIN LANCETS M BINCONTROL ULTRA THIN LANCETS M BINFINITY CONTROL SOLN HIGH M BINFINITY CONTROL SOLN LOW M BINFINITY CONTROL SOLN NORMAL M BINJECT EASE 28G LANCETS M BINJECT EASE 30G LANCETS M BINJECT-EASE SYR NDL INTRODUCER Tier 3INJEX 30 AMPULE Tier 3INSULIN 1 ML SYRINGE Tier 3INSULIN 1/2 ML SYRINGE Tier 3INSULIN 3/10 ML SYRINGE Tier 3INSULIN SYR 1/2 ML BULK PACK Tier 3INSULIN SYRIN 0.3 ML 29GX1/2 Tier 3INSULIN SYRIN 0.3 ML 30GX1/2 Tier 3INSULIN SYRIN 0.3 ML 30GX5/16 Tier 3INSULIN SYRIN 0.3 ML 31GX5/16 Tier 3INSULIN SYRIN 0.5 ML 28GX1/2 Tier 3INSULIN SYRIN 0.5 ML 29GX1/2 Tier 3INSULIN SYRIN 0.5 ML 30GX1/2 Tier 3INSULIN SYRIN 0.5 ML 30GX5/16 Tier 3INSULIN SYRIN 0.5 ML 31GX5/16 Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 61

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)INSULIN SYRIN 1 ML 29GX1/2 Tier 3INSULIN SYRINGE 0.3 ML Tier 3INSULIN SYRINGE 0.5 ML Tier 3INSULIN SYRINGE 1 ML Tier 3INSULIN SYRINGE 1 ML 28GX1/2 Tier 3INSULIN SYRINGE 1 ML 29GX1/2 Tier 3INSULIN SYRINGE 1 ML 30GX1/2 Tier 3INSULIN SYRINGE 1 ML 30GX5/16 Tier 3INSULIN SYRINGE 1 ML 31GX5/16 Tier 3INSULIN SYRINGE 1 ML-HARD PK Tier 3INSULIN SYRINGE 30GX1 ML SYR Tier 3INSULIN SYRINGE U100 0.5 ML Tier 3INSULIN SYRINGE U100 1 ML Tier 3INSULIN SYRINGE U100 1ML Tier 3INSULIN U100-1 ML SYRINGE Tier 3INSUMED SYR 0.3 ML 31GX5/16 Tier 3INSUPEN 29G ULTRAFIN NEEDLE Tier 3INSUPEN 30G ULTRAFIN NEEDLE Tier 3INSUPEN 31G ULTRAFIN NEEDLE Tier 3INSUPEN 32G 4MM PEN NEEDLE Tier 3INSUPEN 32G 6MM PEN NEEDLE Tier 3INSUPEN 32G 8MM PEN NEEDLE Tier 3INVACARE 30G LANCETS M BKEEP FIT SAFETY 21G LANCETS M BKEEP FIT SAFETY 23G LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)KEEP FIT SAFETY 26G LANCETS M BKEEP FIT SAFETY LANCETS 28G M BKEEP FIT TWIST 30G LANCETS M BKEEP FIT TWIST 32G LANCETS M BKEEP FIT TWIST 33G LANCETS M BKEEP FIT TWIST LANCETS 28G M BKINNEY BRAND 23G LANCETS M BKINRAY INS SYR 1 ML 31GX5/16 Tier 3KINRAY SYRING 0.3 ML 31GX5/16 Tier 3KINRAY SYRING 0.5 ML 31GX5/16 Tier 3KMART VALU PLUS SYR 1/2 ML Tier 3KMART VALU PLUS SYR 3/10 ML Tier 3KMART VALU PLUS SYRINGE 1 ML Tier 3KN THIN LANCETS M BKROGER INS SYR 0.3 ML 30GX5/16 Tier 3KROGER INS SYR 0.5 ML 29GX1/2 Tier 3KROGER INS SYR 1 ML 29GX1/2 Tier 3KROGER INS SYR 1 ML 31GX5/16 Tier 3KROGER INS SYRINGE 3/10 ML Tier 3KROGER INSULIN SYRINGE 1 ML Tier 3KROGER LANCETS M BKROGER PEN NEEDLES 29G Tier 3KROGER PEN NEEDLES 31G X 5/16 Tier 3KROGER SUPER THIN LANCETS M BKROGER SYR 0.5 ML 30GX5/16 Tier 362Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)KROGER SYRING 0.3 ML 31GX5/16 Tier 3KROGER SYRING 0.5 ML 31GX5/16 Tier 3KROGER THIN LANCETS M BLADY LITE LANCETS M BLANCETS M BLANCETS 26G X 1.8MM M BLANCETS 28G M BLANCETS 30G M BLANCETS THIN M BLANCETS ULTRA THIN M BLEADER COLORED LANCETS M BLEADER INS SYR 0.3 ML 29GX1/2 Tier 3LEADER INS SYR 0.5 ML 28GX1/2 Tier 3LEADER INS SYR 0.5 ML 29GX1/2 Tier 3LEADER INS SYR 0.5 ML 30GX1/2 Tier 3LEADER INS SYR 1 ML 28GX1/2 Tier 3LEADER INS SYR 1 ML 29GX1/2 Tier 3LEADER INS SYR 1 ML 30GX1/2 Tier 3LEADER INS SYR 1 ML 30GX5/16 Tier 3LEADER INS SYR 1 ML 31GX5/16 Tier 3LEADER INSULIN SYRINGE 0.3 ML Tier 3LEADER PEN NEEDLE 6MM 31G Tier 3LEADER PEN NEEDLES 12MM 29G Tier 3LEADER PEN NEEDLES 31G Tier 3LEADER SUPER THIN LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)LEADER SYRING 0.3 ML 31GX5/16 Tier 3LEADER SYRING 0.5 ML 31GX5/16 Tier 3LEADER THIN LANCETS M BLIBERTY CONTROL SOLN NORMAL M BLIBERTY CONTROL SOLUTION HIGH M BLIBERTY LEV 1 GLUCOSE CTRL SOL M BLIBERTY LEV 2 GLUCOSE CTRL SOL M BLIFESCAN FINE POINT LANCETS M BLIFESCAN UNISTIK 2 LANCETS M BLITE TOUCH 30G LANCETS M BLITE TOUCH INSULIN 0.3 ML SYR Tier 3LITE TOUCH INSULIN 0.5 ML SYR Tier 3LITE TOUCH INSULIN 1 ML SYR Tier 3LITE TOUCH INSULIN SYR 0.3 ML Tier 3LITE TOUCH INSULIN SYR 0.5 ML Tier 3LITE TOUCH INSULIN SYR 1 ML Tier 3LITE TOUCH PEN NEEDLE 29G Tier 3LITE TOUCH PEN NEEDLE 31G Tier 3LIVE BETTER PEN NEEDLE 6MM 31G Tier 3LIVE BETTER PEN NEEDLES 12MM Tier 3LIVE BETTER PEN NEEDLES 8MM Tier 3LIVE BETTER SUPER THIN LANCET M BLIVE BETTER ULTRA THIN LANCET M BLONGS LANCETS 21G M BLONGS THIN LANCETS 26G M BQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 63

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)LONGS THIN LANCETS 30G M BMAGELLAN INSUL SYRINGE 0.5 ML Tier 3MAGELLAN INSULIN SYRINGE 1 ML Tier 3MAJOR COMFORT LANCETS M BMAXI-COMFORT INS 0.5 ML 28G Tier 3MAXI-COMFORT INS 1 ML 28GX1/2 Tier 3MAXIMA CONTROL SOLUTION M BMEDI-LANCE LANCETS M BMEDISENSE CONTROL SOLUTION M BMEDISENSE GLUC-KET CONT SOL M BMEDISENSE H-L CONTROLM BSOLUTIONMEDISENSE H-M-L CONTROL SOLN M BMEDISENSE MID CONTROLM BSOLUTIONMEDISENSE THIN LANCETS M BMEDLANCE PLUS 21G LANCETS M BMEDLANCE PLUS 30G LANCETS M BMEDLANCE PLUS EXTRA LANCETS M BMEDLANCE PLUS LITE 25GM BLANCETSMEDLANCE PLUS LITE LANCETS M BMEDLANCE PLUS UNIVERSAL M BLANCETMEDPOINT CONTROL SOLUTION M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)MEIJER LANCETS M BMEIJER THIN GAUGE LANCETS M BMICRO THIN 33G LANCETS M BMICRODOT HIGH-LOW CONTROL M BSOLMICRODOT NORMAL CONTROL M BSOLUTMICROLET LANCETS M BMICROTAINER SAFETY LANCET M BMINI ULTRA-THIN II PEN NDL 31G Tier 3MONOJECT 0.3 ML INSULIN SYR Tier 3MONOJECT 0.5 ML INSULIN SYR Tier 3MONOJECT 0.5 ML SYRN 28GX1/2 Tier 3MONOJECT 0.5 ML SYRN 29GX1/2 Tier 3MONOJECT 1 ML INSULIN SYRINGE Tier 3MONOJECT 1 ML SYRN 25X5/8 Tier 3MONOJECT 1 ML SYRN 27X1/2 Tier 3MONOJECT 1 ML SYRN 28GX1/2 Tier 3MONOJECT BLOOD LANCET STERL M BMONOJECT INSUL SYR U100 Tier 3MONOJECT INSUL SYR U100 0.5 ML Tier 3MONOJECT INSUL SYR U100 1 ML Tier 3MONOJECT INSULIN SYR 0.3 ML Tier 3MONOJECT INSULIN SYR 0.5 ML Tier 3MONOJECT INSULIN SYR 1 ML Tier 364Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)MONOJECT INSULIN SYR U-100 Tier 3MONOJECT INSULIN SYRN 3/10 ML Tier 3MONOJECT SAFETY SYRINGE Tier 3MONOJECT SYRINGE 0.3 ML Tier 3MONOJECT SYRINGE 0.5 ML Tier 3MONOJECT SYRINGE 1 ML Tier 3MONOLET LANCETS M BMS INS SYR 0.5 ML 29GX1/2 Tier 3MS INS SYR 1 ML 29GX1/2 Tier 3MS INS SYRINGE 1 ML 30GX1/2 Tier 3MS INSUL SYR 0.3 ML 31GX5/16 Tier 3MS INSUL SYR 0.5 ML 30GX1/2 Tier 3MS INSUL SYR 0.5 ML 31GX5/16 Tier 3MS INSULIN SYR 0.3 ML 29GX1/2 Tier 3MS INSULIN SYR 1 ML 31GX5/16 Tier 3MS INSULIN SYRINGE 0.3 ML Tier 3MS LANCETS M BMS PEN NEEDLE 6MM 31G Tier 3MS SUPER THIN LANCETS M BMS THIN LANCETS M BMYGLUCOHEALTH 30G LANCETS M BNEXGEN NORMAL CONTROL M BSOLUTIONNORDIPEN 15 DELIVERY SYSTEM Tier 3NORDIPEN 5 DELIVERY SYSTEM Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)NORM-JECT 1 ML SYRINGE Tier 3NOVA MAX GLUCOSE CONTROL M BSOLNNOVA SAFETY 23G LANCETS M BNOVA SAFETY LANCETS 28G M BNOVA SUREFLEX LANCETS M BNOVA SUREFLEX THIN LANCETS M BNOVAMAX PLUS GLU-KET CTRL M BSOLNNOVOFINE 30 NEEDLES Tier 3NOVOFINE 30G X 1/3 NEEDLES Tier 3NOVOFINE 32G NEEDLES Tier 3NOVOFINE AUTOCOVER 30G Tier 3NEEDLENOVOPEN 3 INSULIN DEVICE Tier 3NOVOPEN 3 PENMATE DEVICE Tier 3NOVOPEN JR INSULIN DEVICE Tier 3NOVOTWIST NEEDLE 30G 8MM Tier 3NOVOTWIST NEEDLE 32G 5MM Tier 3ON CALL 30G LANCET M BON CALL PLUS 30G LANCET M BON CALL PLUS CONTROLM BSOLUTIONON CALL VIVID CONTROL SOLUTION M BONE TOUCH BASIC SYSTEM KIT M B Q C D (1/365)Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 65

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ONE TOUCH CLUB LANCETS M BONE TOUCH COMBO PACK M BONE TOUCH DELICA 30G LANCETS M BONE TOUCH DELICA 33G LANCETS M BONE TOUCH PROFILE SYSTEM KT M B Q C D (1/365)ONE TOUCH SURESOFT LANCING M BDEVONE TOUCH TEST STRIPS M B Q C D (300/30)ONE TOUCH ULTRA 2 GLUCOSE M B Q C D (1/365)SYSTONE TOUCH ULTRA CONTROL M BSOLNONE TOUCH ULTRA SMART METER M B Q C D (1/365)ONE TOUCH ULTRA SYSTEM KIT M B Q C D (1/365)ONE TOUCH ULTRA TEST STRIPS M B Q C D (300/30)ONE TOUCH ULTRALINK SYSTEM M B Q C D (1/365)ONE TOUCH ULTRAMINI METER M B Q C D (1/365)ONE TOUCH ULTRASOFT LANCETS M BONE TOUCH VERIO HIGH CNTRL M BSOLONE TOUCH VERIO IQ METER M B Q C D (1/365)ONE TOUCH VERIO MID CNTRL M BSOLNONE TOUCH VERIO TEST STRIP M B Q C D (300/30)ORSINI INSUL SYR U100 0.5 ML Tier 3ORSINI INSUL SYR U100 1 ML Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)PC SUPER THIN 30G LANCETS M BPC UNIFINE PENTIPS 12MM NEEDLE Tier 3PC UNIFINE PENTIPS 31GX3/16 Tier 3PC UNIFINE PENTIPS 6MM NEEDLE Tier 3PC UNIFINE PENTIPS 8MM NEEDLE Tier 3PEN NEEDLE 30G X 5/16 Tier 3PEN NEEDLE 31G X 3/16 Tier 3PEN NEEDLE 31G X 5/16 Tier 3PEN NEEDLE 6MM 31G Tier 3PEN NEEDLES 12MM 29G Tier 3PEN NEEDLES 29G Tier 3PEN NEEDLES 31G Tier 3PEN NEEDLES 5MM 31G Tier 3PEN NEEDLES 6MM 31G Tier 3PEN NEEDLES 8MM 31G Tier 3PHARM CHOICE ALCOHOL PREP Tier 3PADSPHARMACIST CHOICE 28GM BLANCETSPHARMACIST CHOICE 30GM BLANCETSPLASTIC INSULIN CARTRIDGE Tier 3POCKETCHEM EZ CONTROL M BSOLUTIONPRECISION CONTROL SOLUTION M B66Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)PRECISION SURE DOSE SYRINGE Tier 3PRECISION THINS 28G LANCETS M BPRECISION THINS GP LANCETS M BPRECISION ULTRA 28G LANCETS M BPREF PLUS SYR 0.5 ML 30GX5/16 Tier 3PREF PLUS SYRING 1 ML 29GX1/2 Tier 3PREFERRED PLUS 0.3 ML 30GX5/16 Tier 3PREFERRED PLUS 0.5 ML 29GX1/2 Tier 3PREFERRED PLUS COLORED M BLANCETSPREFERRED PLUS LANCETS M BPREFERRED PLUS SYRINGE 0.3 ML Tier 3PREFERRED PLUS SYRINGE 0.5 ML Tier 3PREFERRED PLUS SYRINGE 1 ML Tier 3PREFERRED PLUS THIN LANCETS M BPREFPLS INS SYR 1 ML 30GX5/16 Tier 3PREP EASE ALCOHOL PADS Tier 3PRESSURE ACTIVATED 21GM BLANCETSPRESSURE ACTIVATED 28GM BLANCETSPRESTIGE GLUCOSE CONTROL M BPRODIGY CONTROL SOLUTION M BPRODIGY CONTROL SOLUTION M BLOWMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)PRODIGY INS SYR 1ML 28GX1/2 Tier 3PRODIGY MINI PEN NDL 31GX3/16 Tier 3PRODIGY PEN NEEDLE 29GX1/2 Tier 3PRODIGY PEN NEEDLE 31GX5/16 Tier 3PRODIGY PRESSURE ACTIVATED M B28GPRODIGY PRESSURE ACTIVE M BLANCETPRODIGY SAFETY LANCETS M BPRODIGY SYRNG 0.5 ML 31GX5/16 Tier 3PRODIGY SYRNG 1 ML 29GX1/2 Tier 3PRODIGY SYRNGE 0.3ML 31GX5/16 Tier 3PRODIGY TWIST TOP 28G LANCET M BPSS SELECT GP LANCETS M BPSS SELECT SAFETY LANCETS M BPUB INS SYRIN 0.3 ML 30GX1/2 Tier 3PUB INS SYRINGE 1 ML 30GX1/2 Tier 3PUB INSUL SYR 0.3 ML 31GX5/16 Tier 3PUB INSUL SYR 0.5 ML 30GX1/2 Tier 3PUB INSUL SYR 0.5 ML 31GX5/16 Tier 3PUB INSULIN SYR 1 ML 31GX5/16 Tier 3PUB LANCETS M BPUB PEN 12MM 29G NEEDLES Tier 3PUB PEN 8MM 31G NEEDLES Tier 3PUB PEN NEEDLE 6MM 31G Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 67

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)PUBLIX 28G LANCET M BPV INS SYRIN 1 ML 29GX1/2 Tier 3PV INSUL SYR 0.3 ML 31GX5/16 Tier 3PV INSUL SYR 0.5 ML 31GX5/16 Tier 3PV INSULIN SYR 1 ML 31GX5/16 Tier 3PV INSULIN SYRINGE 0.5 ML Tier 3PV INSULIN SYRINGE 1 ML Tier 3PV ISOPROPYL ALCOHOL 70% Tier 3WIPESPV PEN NEEDLE 6MM 31G Tier 3PV PEN NEEDLES 12MM 29G Tier 3PV PEN NEEDLES 8MM 31G Tier 3PV ULTRA THIN 30G LANCETS M BPV UNIFINE PENTIPS 31GX3/16 Tier 3PX PEN 8MM 31G NEEDLES Tier 3QC ALCOHOL 70% SWABS Tier 3QC INSUL SYR 0.5 ML 31GX5/16 Tier 3QC INSULIN SYR 1 ML 31GX5/16 Tier 3QC INSULIN SYRINGE 0.3 ML Tier 3QC INSULIN SYRINGE 0.5 ML Tier 3QC INSULIN SYRINGE 1 ML Tier 3QC PEN NEEDLES 12MM 29G Tier 3QC PEN NEEDLES 6MM 31G Tier 3QC PEN NEEDLES 8MM 31G Tier 3QC SUPER THIN LANCET M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)QC ULTRA THIN LANCET M BQC UNIFINE PENTIP 12MM 29G Tier 3QC UNIFINE PENTIP 6MM 31G Tier 3QC UNIFINE PENTIP 8MM 31G Tier 3QC UNILET SUPER THIN 30G LANCT M BQUICKTEK CONTROL SOLUTION M BRA ALCOHOL SWABS Tier 3RA E-ZJECT 28G LANCETS M BRA E-ZJECT COLOR 33G LANCETS M BRA E-ZJECT LANCETS M BRA INS SYR 0.5 ML 29GX1/2 Tier 3RA INS SYR 0.5 ML 30GX5/16 Tier 3RA INS SYR 1 ML 29GX1/2 Tier 3RA INS SYRINGE 1 ML 30GX5/16 Tier 3RA ISOPROPYL ALCOHOL 70% Tier 3WIPESRA PEN NEEDLE 31GX3/16 Tier 3RA PEN NEEDLE 31GX5/16 Tier 3REALITY 1 ML SYRINGE Tier 3REALITY 1/2 ML SYRINGE Tier 3REALITY ALCOHOL SWABS Tier 3REALITY LANCETS M BREALITY TRIGGER LANCETS M BREFUAH PLUS CONTROL SOLUTION M BRELI ON 31G X 1/4 NEEDLES Tier 368Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)RELIAMED SAFETY SEAL LANCETS M BRELION INS SYR 0.3 ML 29GX1/2 Tier 3RELION INS SYR 0.3 ML 30GX5/16 Tier 3RELION INS SYR 0.5 ML 29GX1/2 Tier 3RELION INS SYR 1 ML 29GX1/2 Tier 3RELION INS SYR 1 ML 30GX5/16 Tier 3RELION INS SYR 1 ML 31GX5/16 Tier 3RELI-ON INSULIN 0.3 ML SYR Tier 3RELI-ON INSULIN 0.5 ML SYR Tier 3RELI-ON INSULIN 1 ML SYR Tier 3RELION INSULIN SYR 0.3 ML Tier 3RELION INSULIN SYR 0.5 ML Tier 3RELION INSULIN SYRINGE 1 ML Tier 3RELION LANCETS M BRELION MINI PEN 31G X 1/4 NDL Tier 3RELION PEN 29G NEEDLE Tier 3RELION PEN 29G X 1/2 NEEDLE Tier 3RELION PEN 31G NEEDLE Tier 3RELION PEN 31G X 5/16 NEEDLE Tier 3RELION SYR 0.5 ML 30GX5/16 Tier 3RELION SYRING 0.3 ML 31GX5/16 Tier 3RELION SYRING 0.5 ML 31GX5/16 Tier 3RELION THIN LANCETS M BRELION ULTRA THIN 30G LANCETS M BRELION ULTRA THIN PLUS 33G M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)RELION ULTRA THIN PLUS LANCETS M BRENEW ADVANCED MICRO-M BLANCETSRIGHTEST CONTROL SOLNM BNORMALRIGHTEST CONTROL SOLUTION M BHIGHRIGHTEST GL300 LANCETS M BSAFESNAP INSUL SYRINGE 0.3 ML Tier 3SAFESNAP INSUL SYRINGE 0.5 ML Tier 3SAFESNAP INSULIN SYRINGE 1 ML Tier 3SAFE-T-LANCE 21G LANCETS M BSAFE-T-LANCE 25G LANCETS M BSAFE-T-LANCE PLUS LANCETS M BSAFETY 21G LANCETS M BSAFETY 28G LANCETS M BSAFETY LANCET 2MM M BSAFETY LANCETS M BSAFETY SEAL 30G LANCETS M BSAFETY SYRINGE W-SHIELD 3 ML Tier 3SAFETY-LET LANCETS M BSB INS SYR 0.5 ML 29GX1/2 Tier 3SB INS SYR 0.5 ML 30GX5/16 Tier 3SB INS SYR 1 ML 29GX1/2 Tier 3SB INS SYRINGE 1 ML 30GX5/16 Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 69

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)SB INSULIN SYR 1 ML 31GX5/16 Tier 3SB INSULN SYR 0.5 ML 30GX5/16 Tier 3SB LANCETS THIN M BSB LANCETS ULTRA THIN M BSCHNUCKS SYR 0.5 ML 29GX1/2 Tier 3SCHNUCKS SYR 0.5 ML 30GX5/16 Tier 3SINGLE-LET LANCETS M BSM ALCOHOL 70% PREP PADS Tier 3SM ALCOHOL PREP PADS Tier 3SM COLORED LANCETS M BSM INS SYR 0.5 ML 29GX1/2 Tier 3SM INS SYR 0.5 ML 30GX5/16 Tier 3SM INS SYR 1 ML 29GX1/2 Tier 3SM INS SYRING 0.3 ML 30GX5/16 Tier 3SM INS SYRINGE 1 ML 28GX1/2 Tier 3SM INS SYRINGE 1 ML 30GX5/16 Tier 3SM INSUL SYR 0.3 ML 31GX5/16 Tier 3SM INSUL SYR 0.5 ML 31GX5/16 Tier 3SM INSULIN SYR 0.3 ML 29GX1/2 Tier 3SM INSULIN SYR 0.5 ML 28GX1/2 Tier 3SM INSULIN SYR 1 ML 31GX5/16 Tier 3SM LANCETS M BSM MICRO THIN 33G LANCETS M BSM SUPER THIN LANCETS M BSM THIN LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)SMART SENSE COLOR 33GM BLANCETSSMART SENSE STANDARD 21G M BSMART SENSE SUPER THIN 30G M BSMART SENSE THIN 26G LANCETS M BSMARTDIABETES VANTAGE 30G M BSMARTEST CONTROL SOLUTION M BSMARTEST LANCET M BSMS GLUCOSE CONTROL SOL M BNORMALSOFT TOUCH LANCETS M BSOFT TOUCH SAFE-T-PRO M BSOFTCLIX LANCETS M BSOLO V2 30G LANCETS M BSOLO V2 CONTROL SOLUTION M BHIGHSOLO V2 CONTROL SOLUTION LOW M BSTERILANCE TL TWIST 30G LANCET M BSTERILANCE TL TWIST 32G LANCET M BSUPER THIN 28G LANCETS M BSUPER THIN 30G LANCETS M BSUPER THIN 33G LANCETS M BSUPER THIN LANCETS M BSUPREME II CONTROL SOLUTION M BSURE COMFORT 0.3 ML SYRINGE Tier 370Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)SURE COMFORT 0.5 ML SYRINGE Tier 3SURE COMFORT 1 ML SYRINGE Tier 3SURE COMFORT 28G LANCETS M BSURE COMFORT 3/10 ML SYRINGE Tier 3SURE COMFORT 30G LANCETS M BSURE COMFORT 31G PEN NEEDLE Tier 3SURE COMFORT ALCOHOL PREP Tier 3PADSSURE COMFORT PEN NDL 29GX1/2 Tier 3SURE COMFORT PEN NDLTier 331GX3/16SURE EDGE GLUCOSE CONTROL M BSOLNSURECHEK GLUCOSE CONTROL M BSOLNSURE-FINE PEN NEEDLES 12.7MM Tier 3SURE-FINE PEN NEEDLES 5MM Tier 3SURE-FINE PEN NEEDLES 8MM Tier 3SURE-JECT INSU SYR U100 0.3 ML Tier 3SURE-JECT INSU SYR U100 0.5 ML Tier 3SURE-JECT INSU SYR U100 1 ML Tier 3SURE-JECT INSUL SYR U100 1 ML Tier 3SURE-JECT INSULIN SYR 0.3 ML Tier 3SURE-JECT INSULIN SYR 0.5 ML Tier 3SURE-JECT INSULIN SYRINGE 1 ML Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)SURE-LANCE 26G LANCETS M BSURE-LANCE FLAT LANCETS M BSURE-LANCE THIN LANCET M BSURE-LANCE ULTRA THIN 30G M BSURELITE LANCET REG BODY M BSURE-PREP ALCOHOL PREP PADS Tier 3SURESTEP GLUC CONTROL SOLN M BSURESTEP PRO CONTROL SOLN M BSURESTEP PRO LINEARITY KIT M B Q C D (1/365)SURESTEP PRO TEST STRIPS M B Q C D (300/30)SURESTEP TEST STRIPS M B Q C D (300/30)SURE-TEST EASYPLUS MINI SOLN M BSURE-TOUCH LANCET M BTECHLITE AST LANCETS M BTECHLITE BLOOD LANCET M BTELCARE CONTROL SOLUTION M BTERUMO INS SYR 0.3 ML 29GX1/2 Tier 3TERUMO INS SYRINGE U100-1 ML Tier 3TERUMO INS SYRINGE U100-1/2 ML Tier 3TERUMO INS SYRINGE U100-1/3 ML Tier 3TERUMO INS SYRNG U100-1/2 ML Tier 3TERUMO SURGUARD SYR 28G-1 ML Tier 3TERUMO SURGUARD SYR 28G-1/2 Tier 3MLQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 71

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)TERUMO SURGUARD SYR 29G-0.3 Tier 3MLTERUMO SURGUARD SYR 29G-1/2 Tier 3MLTERUMO SURGUARD SYRN 29G-1 Tier 3MLTHIN LANCET M BTHINLETS 28G(T) LANCETS M BTHINLETS GP LANCETS M BTHINPRO INS SYRIN U100-0.3 ML Tier 3THINPRO INS SYRIN U100-0.5 ML Tier 3THINPRO INS SYRIN U100-1 ML Tier 3TODAY’S HEALTH SUPER THIN 30G M BTODAY’S HLT PN NEEDLE 12MM 29G Tier 3TODAY’S HLTH PN NEEDLE 6MM 31G Tier 3TODAY’S HLTH PN NEEDLE 8MM 31G Tier 3TODAY’S HLTH ULTRA THIN LANCET M BTOPCARE CLICKFINE 31G X 1/4 Tier 3TOPCARE CLICKFINE 31G X 5/16 Tier 3TOPCARE ULTRA COMFORT Tier 3SYRINGETOPCARE UNIVERSAL1 THIN M BLANCETTRUECONTROL GLUCOSEM BSOLUTIONTRUEPLUS 33G LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)TRUEPLUS LANCETS 28G M BTRUEPLUS SUPER THIN 28G M BLANCETTRUEPLUS SYR 0.3ML 29GX1/2 Tier 3TRUEPLUS SYR 0.3ML 30GX5/16 Tier 3TRUEPLUS SYR 0.3ML 31GX5/16 Tier 3TRUEPLUS SYR 0.5ML 28GX1/2 Tier 3TRUEPLUS SYR 0.5ML 29GX1/2 Tier 3TRUEPLUS SYR 0.5ML 30GX5/16 Tier 3TRUEPLUS SYR 0.5ML 31GX5/16 Tier 3TRUEPLUS SYR 1ML 28GX1/2 Tier 3TRUEPLUS SYR 1ML 29GX1/2 Tier 3TRUEPLUS SYR 1ML 30GX5/16 Tier 3TRUEPLUS SYR 1ML 31GX5/16 Tier 3TRUEPLUS ULTRA THIN 30G LANCET M BTRUETEST CONTROL SOLN HIGH M BTRUETEST CONTROL SOLNM BNORMALTRUETEST CONTROL SOLUTION M BLOWTRUETRACK GLUCOSE CONTROL M BTWIST LANCETS M BULT CFT 0.3 ML 29GX1/2 (1/2) Tier 3ULT CFT 0.3 ML 30GX5/16 (1/2) Tier 3ULT CFT 0.3 ML 31GX5/16 (1/2) Tier 372Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTCARE INS SYR 1 ML 30GX5/16 Tier 3ULTCARE INS SYR 1 ML 31GX5/16 Tier 3ULTICARE 30GX0.3 ML SYRINGE Tier 3ULTICARE 30GX0.5 ML SYRINGE Tier 3ULTICARE 30GX1 ML SYRINGE Tier 3ULTICARE 31GX0.3 ML SYRINGE Tier 3ULTICARE 31GX0.5 ML SYRINGE Tier 3ULTICARE 31GX1 ML SYRINGE Tier 3ULTICARE INS 0.5 ML 29GX1/2 Tier 3ULTICARE INS SYR 1 ML 28GX1/2 Tier 3ULTICARE INS SYR 1 ML 29GX1/2 Tier 3ULTICARE INSUL SYR U100 0.3 ML Tier 3ULTICARE INSUL SYR U100 0.5 ML Tier 3ULTICARE INSULIN SYR U100 1 ML Tier 3ULTICARE PEN NEEDLES 12MM 29G Tier 3ULTICARE PEN NEEDLES 4MM 32G Tier 3ULTICARE PEN NEEDLES 6 MM 31 G Tier 3ULTICARE PEN NEEDLES 6MM 31G Tier 3ULTICARE PEN NEEDLES 8 MM 31 G Tier 3ULTICARE PEN NEEDLES 8MM 31G Tier 3ULTICARE SYR 0.3 ML 31GX5/16 Tier 3ULTICARE SYR 0.5 ML 30GX5/16 Tier 3ULTICARE SYR 0.5 ML 31GX5/16 Tier 3ULTICARE SYRIN 0.3 ML 29GX1/2 Tier 3ULTICARE SYRIN 0.5 ML 28GX1/2 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTICARE THIN 28G LANCETS M BULTICARE THIN 30G LANCETS M BULTICARE U100 0.3 ML 30GX5/16 Tier 3ULTICARE U100 0.5 ML 29GX1/2 Tier 3ULTI-LANCE AUTO-AD DEVICE M BULTILET 28G LANCETS M BULTILET 30G LANCETS M BULTILET ALCOHOL STERL SWAB Tier 3ULTILET ALCOHOL SWAB Tier 3ULTILET BASIC 30G LANCETS M BULTILET CLASSIC 26G LANCETS M BULTILET CLASSIC 28G LANCETS M BULTILET CLASSIC 30G LANCETS M BULTILET INSULIN SYRINGE 0.3 ML Tier 3ULTILET INSULIN SYRINGE 0.5 ML Tier 3ULTILET INSULIN SYRINGE 1 ML Tier 3ULTILET LANCETS M BULTILET SAFETY LANCETS M BULTRA COMFORT 0.3 ML 29GX1/2 Tier 3ULTRA COMFORT 0.3 ML SYRINGE Tier 3ULTRA COMFORT 0.5 ML 28GX1/2 Tier 3ULTRA COMFORT 0.5 ML 29GX1/2 Tier 3ULTRA COMFORT 0.5 ML 30GX5/16 Tier 3ULTRA COMFORT 0.5 ML 31GX5/16 Tier 3ULTRA COMFORT 0.5 ML SYRINGE Tier 3Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 73

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTRA COMFORT 1 ML 28GX1/2 Tier 3ULTRA COMFORT 1 ML 29GX1/2 Tier 3ULTRA COMFORT 1 ML 30GX5/16 Tier 3ULTRA COMFORT 1 ML 31GX5/16 Tier 3ULTRA COMFORT 1 ML SYRINGE Tier 3ULTRA COMFORT 3/10 ML SYR Tier 3ULTRA THIN 28 G LANCET M BULTRA THIN 28G LANCETS M BULTRA THIN 31G LANCETS M BULTRA THIN 33G LANCETS M BULTRA THIN LANCETS M BULTRACOMFORT 30GX0.5 ML SYR Tier 3ULTRACOMFORT 30GX1 ML Tier 3SYRINGEULTRACOMFORT 31GX0.5 ML SYR Tier 3ULTRACOMFORT 31GX1 ML Tier 3SYRINGEULTRACOMFORT INSUL SYR 0.5 ML Tier 3ULTRACOMFORT INSULIN SYR 1 ML Tier 3ULTRACOMFORT PEN NEEDLES Tier 36MMULTRACOMFORT PEN NEEDLES Tier 38MMULTRALANCE 26G LANCETS M BULTRALANCE 28G LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTRA-THIN II 26G LANCET M BULTRA-THIN II 28G LANCETS M BULTRA-THIN II 30G LANCETS M BULTRA-THIN II 31G SHORT NEEDLE Tier 3ULTRA-THIN II INS 0.3 ML 29G Tier 3ULTRA-THIN II INS 0.3 ML 30G Tier 3ULTRA-THIN II INS 0.3 ML 31G Tier 3ULTRA-THIN II INS 0.5 ML 29G Tier 3ULTRA-THIN II INS 0.5 ML 30G Tier 3ULTRA-THIN II INS 0.5 ML 31G Tier 3ULTRA-THIN II INS SYR 1 ML 29G Tier 3ULTRA-THIN II INS SYR 1 ML 30G Tier 3ULTRA-THIN II PEN NDL 29GX1/2 Tier 3ULTRA-THIN II PEN NDL 31GX5/16 Tier 3ULTRATRAK CONTROL SOL NORMAL M BULTRATRAK CONTROL SOLUTION M BULTRATRAK PRO CNTRL SOLUTION M BULTRATRAK ULTIMATE CNTRL SOLN M BUNIFINE PENTIP 0.5CC NEEDLE Tier 3UNIFINE PENTIP NEEDLES Tier 3UNIFINE PENTIPS 12MM 29G Tier 3UNIFINE PENTIPS 12MM NEEDLE Tier 3UNIFINE PENTIPS 31GX3/16 Tier 3UNIFINE PENTIPS 32GX5/32 Tier 3UNIFINE PENTIPS 6MM 31G Tier 374Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)UNIFINE PENTIPS 6MM NEEDLE Tier 3UNIFINE PENTIPS 6MM NEEDLES Tier 3UNIFINE PENTIPS 8MM 31G Tier 3UNIFINE PENTIPS 8MM NEEDLE Tier 3UNIFINE PENTIPS 8MM NEEDLES Tier 3UNIFINE PENTIPS NEEDLES 29G Tier 3UNIFINE PENTIPS NEEDLES 31G Tier 3UNILET COMFORTOUCH 26G M BLANCETSUNILET COMFORTOUCH LANCET M BUNILET EXCELITE II LANCET M BUNILET EXCELITE LANCET M BUNILET GP LANCET M BUNILET GP LANCET SUPERLITE M BUNILET LANCET M BUNILET LANCET 28G M BUNILET LANCET SUPERLITE M BUNILET SUPER THIN 30G LANCETS M BUNILET ULTRA THIN 28G LANCETS M BUNISTIK 3 COMFORT LANCET M BUNISTIK 3 EXTRA 21G LANCETS M BUNISTIK 3 NORMAL 23G LANCETS M BUNISTIK 3 SAFETY 21G LANCETS M BUNISTIK CZT COMFORT LANCET M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)UNISTIK CZT NORMAL 23GM BLANCETSUNIVERSAL 1 33G LANCETS M BVALUE PLUS STANDARD LANCETS M BVALUE PLUS SUPER THIN LANCETS M BVALUE PLUS THIN LANCETS M BVALUEPLUS SYR 0.3 ML 29GX1/2 Tier 3VANISHPOINT 0.5 ML 30GX1/2 SY Tier 3VANISHPOINT U-100 29X1/2 SYR Tier 3VH INS SYR 0.5 ML 29GX1/2 Tier 3VH INS SYR 1 ML 29GX1/2 Tier 3VICTORY HIGH-LOW CONTROL M BSOLNVITALET 23 GAUGE LANCET M BVITALET PRO LANCETS M BVITALET PRO PLUS LANCETS M BVITALET THIN 26GAUGE LANCET M BW & F 26G LANCETS M BW & F COLORED 21G LANCETS M BW&F COLORED LANCETS M BW&F THIN LANCETS M BWALGREENS LANCETS M BWALGREENS THIN LANCETS M BWALGREENS ULTRA THIN LANCETS M BQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 75

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)WAVESENSE CONTROL SOLN M BNORMALWD MEDIC SYR 0.3 ML 30GX5/16 Tier 3WD MEDIC SYR 0.5 ML 29GX1/2 Tier 3WD MEDIC SYR 0.5 ML 30GX5/16 Tier 3WD MEDIC SYR 1 ML 29GX1/2 Tier 3WDMEDIC INS SYR 1 ML 30GX5/16 Tier 3WDMEDIC SYRING 0.3 ML 29GX1/2 Tier 3WEBCOL ALCOHOL PREPS Tier 3XPRES CONTROL SOLUTION M BNORMALMusculoskeletal Medications: CNS Muscle Relaxantscarisoprodol compound Tier 2carisoprodol compound-codeine Tier 2carisoprodol tablet Tier 2carisoprodol-aspirin Tier 2carisoprodol-aspirin-codeine Tier 2chlorzoxazoneTier 2 P Acyclobenzaprine hcl capsule sustained Tier 2action, -tabletmetaxalone Tier 2methocarbamol tabletTier 2 P Aorphenadrine citrate injection Tier 2orphenadrine citrate tablet sustained Tier 2 P Aactionorphenadrine compoundTier 2 P Aorphenadrine compound forteTier 2 P ARILUTEK Tier 5Musculoskeletal Medications:Direct Muscle Relaxantsbaclofen tablet Tier 2dantrolene sodium capsule Tier 2DYSPORTTier 4 P Arevonto Tier 2tizanidine hcl capsule, -tablet Tier 2XEOMINTier 4 P A76Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Musculoskeletal Medications: Drugsto Prevent and Treat Goutallopurinol sodiumTier 2 H I Tallopurinol tablet Tier 1COLCRYS Tier 3KRYSTEXXA Tier 4probenecid Tier 2probenecid-colchicine Tier 2ULORICTier 4 S TMusculoskeletal Medications: Non-Steroidal Antiinflammatory AgentsCELEBREX Tier 4 Q C D (68/30),P Adiclofenac- misoprost Tier 2diclofenac potassium Tier 2diclofenac sodium e.c. tab, -tablet Tier 2sustained actionetodolac capsule, -tablet, -tablet Tier 2sustained actionfenoprofen calcium tablet Tier 2FLECTOR Tier 4flurbiprofen tablet Tier 2ibuprofen oral susp Tier 2ibuprofen tablet Tier 1indomethacin capsule, -capsule Tier 2sustained action, -injectionketoprofen capsule, -capsule sustained Tier 2actionketorolac tablet Tier 2ketorolac injectionTier 2 H I Tmeclofenamate sodium capsule Tier 2mefenamic acid capsule Tier 2meloxicam oral susp Tier 2meloxicam tablet Tier 1 Q C D (34/30)nabumetone Tier 2naproxen e.c. tab, -tablet Tier 1Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 77

Musculoskeletal Medications: Non-SteroidalAntiinflammatory Agents (continued)naproxen oral susp Tier 2naproxen sodium tablet Tier 2oxaprozin Tier 2piroxicam capsule Tier 2sulindac tablet Tier 2tolmetin sodium Tier 2Nutrition, Blood Modifiers,Electrolytes: Antiplatelet DrugsAGGRENOX Tier 4cilostazol Tier 2clopidogrel Tier 2dipyridamole tablet Tier 2EFFIENT Tier 3ticlopidine hcl Tier 2Musculoskeletal Medications:Other Drugs for Arthritischoline mag trisalicylate Tier 2CUPRIMINE Tier 3diflunisal tablet Tier 2HYALGAN M BRIDAURA Tier 3salsalate tablet Tier 1SUPARTZ M BSYNVISC M BSYNVISC-ONE M BSYPRINE Tier 5Nutrition, Blood Modifiers,Electrolytes: Blood Detoxicantsconstulose Tier 2enulose Tier 2generlac Tier 2lactulose Tier 2RENVELA Tier 378Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Nutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc.amino acids Tier 2AMINOSYN 3.5% IV SOLUTION, -7% Tier 4 H I TIV SOLUTION, -10% IV SOLUTIONAMINOSYN 8.5% IV SOLUTION Tier 4 H I TAMINOSYN IITier 4 H I TAMINOSYN II 5% IN 25% DEXTROSE Tier 4 H I TAMINOSYN MTier 4 H I TAMINOSYN WITH ELECTROLYTES Tier 4 H I TAMINOSYN-HBCTier 4 H I TAMINOSYN-HFTier 4 H I TAMINOSYN-PFTier 4 H I TAMINOSYN-RFTier 4 H I Tbacteriostatic saline vial, -0.9% syringe, M B-0.9% vial, -0.9% zr syrbacteriostatic water vial M Bcalcium chloride injection Tier 2CLINIMIX 2.75%-5% SOLUTION, Tier 4 H I T-4.25%-20% SOLUTION, -4.25%-25% SOLUTION, -4.25%-5%SOLUTION, -5%-15% SOLUTION,-5%-20% SOLUTION, -5%-25%SOLUTIONCLINIMIX 4.25%-10% SOLUTION Tier 4 H I TNutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc. (continued)CLINIMIX E 2.75%-10% SOLUTION,-2.75%-5% SOLUTION, -4.25%-25%SOLUTION, -4.25%-5% SOLUTION,-5%-15% SOLUTION, -5%-20%SOLUTION, -5%-25% SOLUTIONCYSTAGONd5%-1/4ns-kcl 10 meq/l iv sol, -d5%-1/4ns-kcl 30 meq/l iv sol, -d5%-1/4ns-kcl 40 meq/l iv solTier 4 H I TTier 3 L P A, N M OTier 2 H I Td5w-kcl 30 meq/l iv solution, -d5w/kcl Tier 2 H I T30 meq/l iv solutiondelflex with 1.5% dextrose Tier 2delflex with 2.5% dextrose Tier 2delflex with 4.25% dextrose Tier 2dextrose 10%-1/4nsTier 2 H I Tdextrose 10%-ns iv solution Tier 2dextrose 2.5%-water iv soln,-25%-water syringe, -30%-water ivsoln, -40%-water iv soln, -50%-waterabboject, -50%-water iv soln,-50%-water syringe, -50%-water vial,-70%-water iv solndextrose 5%-1/2ns-kcldextrose 5%-1/3ns-kclTier 2Tier 2 H I TTier 2 H I TQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 79

Nutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc. (continued)dextrose 5%-1/4ns iv solution, -5%-sod Tier 2 H I Tchloride 0.2%, -5%-1/3ns iv solution,-d10%-1/2ns soln/excel cont, -5%-1/2ns iv solution, -2.5%-1/2ns iv soln,-5%-ns iv solutiondextrose 5%-electrolyte #48 Tier 2dextrose 5%-ns-kclTier 2 H I Tdextrose 5%-water iv soln, -10%-water Tier 2 H I Tiv solutiondextrose in lactated ringersTier 2 H I Tdextrose in ringers injection Tier 2kcl 10 meq in d5w-1/4 ns, -kcl 10 meq Tier 2 H I Tin d5w-1/4 ns, -kcl 20 meq in d5w-1/4 ns, -kcl 5 meq in d5w-1/4 nslactated ringers injectionTier 2 H I Tlactated ringers solution Tier 2liposyn iii Tier 2LYSINE HCL Tier 2magnesium sulfate injection Tier 2mannitol injection Tier 2MONOJECT PREFILL 0.9% FLUSH M BMONOJECT PREFILL 0.9% NA SYR M Bnormal saline flush M BNORMOSOL-M AND DEXTROSE Tier 4NORMOSOL-R Tier 4NORMOSOL-R AND DEXTROSE Tier 4Nutrition, Blood Modifiers, Electrolytes:Electrolytes, Irrigating Solutions, etc. (continued)NORMOSOL-R PH 7.4 Tier 4nutrilyte Tier 2nutrilyte ii Tier 2potassium chl-normal saline M Bpotassium chloride-nacl M Bringers injection M Bringers irrigation Tier 2saline 0.45% soln-excel con, -0.45% Tier 2 H I Tsoln, -saline 0.9% soln-excel cont,-0.9% solution, -cl 2.5 meq/ml vial,-3% iv soln, -5% iv solnsaline flush M Bsodium acetate Tier 2sodium bicarbonate Tier 2sodium chloride 0.9% soln, -0.9% soln.,-4 meq/ml vl, -solutionsodium lactateTier 2Tier 2 H I Tsodium phosphate Tier 2sterile water for injection, -for injection Tier 2ampul, -for injection vialsyrex M Btri-vitamin with fluoride Tier 280Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Nutrition, Blood Modifiers,Electrolytes: Fluoride Productsdenta 5000 plus Tier 2dentagel Tier 2epiflur Tier 2fluor-a-day chew tab Tier 2FLUOR-A-DAY ORAL DROPS Tier 3fluoride Tier 2fluoridex daily defense Tier 2fluoritab chew tab Tier 2lozi-flur Tier 2ludent fluoride Tier 2neutragard advanced Tier 2perio med Tier 2sf Tier 2sf 5000 plus Tier 2sodium fluoride Tier 2stannous fluoride dental/mucousmembrn productsTier 2Nutrition, Blood Modifiers, Electrolytes:Injectable Anticoagulantsenoxaparin 100 mg/ml syr Tier 2 Q C D (60/30)enoxaparin 120 mg/0.8 ml syr Tier 5 Q C D (48/30)enoxaparin 150 mg/ml syr Tier 5 Q C D (60/30)enoxaparin 30 mg/0.3 ml syr Tier 2 Q C D (18/30)enoxaparin 300 mg/3 ml vial Tier 2 Q C D (180/30)enoxaparin 40 mg/0.4 ml syr Tier 2 Q C D (24/30)enoxaparin 60 mg/0.6 ml syr Tier 2 Q C D (36/30)enoxaparin 80 mg/0.8 ml syr Tier 2 Q C D (48/30)fondaparinux 10 mg/0.8 ml syr Tier 5 Q C D (24/30)fondaparinux 2.5 mg/0.5 ml syr Tier 2 Q C D (15/30)fondaparinux 5 mg/0.4 ml syr Tier 5 Q C D (12/30)fondaparinux 7.5 mg/0.6 ml syr Tier 5 Q C D (18/30)heparin iv flush 1 unit/ml syr, -iv flush10 unit/ml sy, -lock flush 10 units/ml,-iv flush 100 units/ml, -lock flush 100unit/mlheparin lock 10 units/ml vial, -flush 10units/ml, -100 units/ml vial, -flush 100unit/mlheparin sod 1,000 unit/ml vial, -sod5,000 unit/ml vial, -sod 10,000 unit/mlvl, -sod 20,000 unit/ml vlheparin sod 2,000 unit/ml vial, -sod2,500 unit/ml vial, -sod 5,000 unit/ml syr, -sod 5,000 unit/ 0.5 ml, -sod5,000 unit/0.5 mlM BM BH I TH I TTier 2 H I TTier 2 H I TQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 81

Nutrition, Blood Modifiers, Electrolytes:Injectable Anticoagulants (continued)heparin sodium in 0.45% naclTier 2 H I Theparin-d5w 20,000 unit/500 ml Tier 2 H I Theparin-d5w 25,000 unit/500 ml, --d5w Tier 2 H I T25,000 unit/250 mlheparin-ns 1,000 unit/500 mlTier 2 H I Theparin-ns 2,000 unit/1,000 ml Tier 2 H I Tmonoject heparin 10 units/ml M B H I Tmonoject heparin 10 units/ml, -heparin100 units/mlM BNutrition, Blood Modifiers, Electrolytes:Oral Anticoagulants, Vitamin Kjantoven Tier 1PRADAXA Tier 4warfarin sodium tablet Tier 1XARELTO Tier 3H I TNutrition, Blood Modifiers, Electrolytes:Potassium Supplementscytra-2 Tier 2effer-k 25 meq tablet eff Tier 2k effervescent Tier 2kcl 20 meq in d5w solution, -d5w/kcl Tier 2 H I T40 meq/l iv solution, -kcl 40 meq ind5w solutionkcl 20 meq in d5w-lact ringerTier 2 H I Tkcl 40 meq in d5w-lact ringerTier 2 H I Tklor-con 10 Tier 1klor-con 20 meq packet Tier 1klor-con 8 Tier 1klor-con m10 Tier 1klor-con m15 Tier 2klor-con m20 Tier 1klor-con-ef Tier 2phospha 250 neutral Tier 2potassium acetate injection Tier 2potassium bicarbonate Tier 2potassium chloride sa capsule, -sa Tier 1tabletpotassium cl injectionTier 2 H I Tpotassium cl solution Tier 2sodium citrate & citric acid Tier 282Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Nutrition, Blood Modifiers, Electrolytes:Therapeutic Vitamins and Mineralscalcitriol capsule, -solution Tier 2calcitriol injectionTier 2 H I Tcalcium acetate Tier 2eliphos Tier 2levocarnitine injectionTier 2 H I Tlevocarnitine solution, -tablet Tier 2ZEMPLAR CAPSULE Tier 3ZEMPLAR INJECTIONTier 3 H I TObstetrical and GynecologicalMedications: Androgen DrugsANADROL-50 Tier 5androxy Tier 2AXIRON Tier 4danazol capsule Tier 2FORTESTA Tier 4METHITEST Tier 3oxandrolone tablet Tier 2TESTIM Tier 3testosterone cypionate injection Tier 2testosterone enanthate injection Tier 2Obstetrical and GynecologicalMedications: Contraceptivesaltavera Tier 2alyacen Tier 2amethia Tier 2amethia lo Tier 2amethyst Tier 2apri Tier 2aranelle Tier 2aviane Tier 2azurette Tier 2balziva Tier 2briellyn Tier 2camrese Tier 2camrese lo Tier 2caziant Tier 2cesia Tier 2cryselle Tier 2cyclafem Tier 2drospirenone-eth estradiol Tier 2ELLA Tier 4emoquette Tier 2enpresse Tier 2gianvi Tier 2gildagia Tier 2gildess fe Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 83

Obstetrical and Gynecological Medications:Contraceptives (continued)introvale Tier 2jolessa Tier 2junel Tier 2junel fe Tier 2kariva Tier 2kelnor 1-35 Tier 2leena Tier 2lessina Tier 2levonest Tier 2levonorgestrel Tier 2levonorg-eth estrad eth estrad Tier 2levonorgestrel-eth estradiol Tier 2levora-28 Tier 2loryna Tier 2low-ogestrel Tier 2lutera Tier 2marlissa Tier 2microgestin Tier 2microgestin fe Tier 2mononessa Tier 2myzilra Tier 2necon Tier 2next choice Tier 2next choice one dose Tier 2Obstetrical and Gynecological Medications:Contraceptives (continued)norethindrone-ethin estradiol Tier 2norgestimate-ethinyl estradiol Tier 2norgestrel-ethiny estra Tier 2nortrel Tier 2ocella Tier 2ogestrel Tier 2orsythia Tier 2ORTHO EVRA Tier 4philith Tier 2portia Tier 2previfem Tier 2quasense Tier 2reclipsen Tier 2solia Tier 2sprintec Tier 2sronyx Tier 2syeda Tier 2tilia fe Tier 2tri-legest fe Tier 2trinessa Tier 2tri-previfem Tier 2tri-sprintec Tier 2trivora-28 Tier 2velivet Tier 284Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Obstetrical and Gynecological Medications:Contraceptives (continued)vestura Tier 2viorele Tier 2zarah Tier 2zenchent Tier 2zenchent fe Tier 2zeosa Tier 2zovia 1-35e Tier 2zovia 1-50e Tier 2Obstetrical and GynecologicalMedications: Estrogen DrugsESTRACE VAGINAL PRODUCTS Tier 3estradiol adh. patch Tier 2 Q C D (5/30)estradiol tablet Tier 2estradiol valerate injection Tier 2estropipate Tier 2MENEST Tier 3PREMARIN INJECTIONTier 4 H I TPREMARIN TABLET, -VAGINAL Tier 4PRODUCTSVAGIFEM Tier 3Obstetrical and Gynecological Medications:Estrogen/Progestin CombinationsCLIMARA PRO Tier 3 Q C D (5/30)estradiol-norethindrone acetat Tier 2FEMHRT 0.5 MG-2.5 MCG TABLET Tier 3jevantique Tier 2jinteli Tier 2mimvey Tier 2Obstetrical and Gynecological Medications:Ob/Gyn Topical AntiinfectivesCLEOCIN 100 MG VAGINAL OVULE Tier 3clindamycin phosphate vaginal products Tier 2fem ph Tier 2metronidazole vaginal products Tier 2vandazole Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 85

Obstetrical and GynecologicalMedications: Prenatal Vitaminsbal-care dha Tier 2cavan one omega Tier 2cavan-alpha kit Tier 2cavan-ec sod dha Tier 2cavan-heme ob Tier 2complete natal dha Tier 2completenate Tier 2co-natal fa Tier 2elite ob dha Tier 2elite-ob Tier 2elite-ob 400 Tier 2fe c Tier 2folbecal Tier 2folcal dha Tier 2folcaps omega-3 Tier 2folinatal plus b Tier 2folivane-ec calcium dha nf Tier 2folivane-ob Tier 2folivane-prx dha nf Tier 2gentex ade Tier 2hemenatal ob Tier 2hemenatal ob + dha Tier 2inatal advance Tier 2inatal gt Tier 2Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)inatal ultra Tier 2levomefolate dha Tier 2levomefolatepnv Tier 2macnatal cn dha Tier 2multinatal plus Tier 2mynatal Tier 2mynatal advance Tier 2mynatal plus Tier 2mynatal-z Tier 2mynate 90 plus Tier 2nutri-tab ob Tier 2nutri-tab ob + dha Tier 2ob-natal one Tier 2pnv ob+dha Tier 2pnv-dha Tier 2pnv-dha + docusate Tier 2pnv-omega Tier 2pnv-select Tier 2pnv-total Tier 2pr natal 400 Tier 2pr natal 400 ec Tier 2pr natal 430 Tier 2pr natal 430 ec Tier 2prenafirst Tier 286Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)prenaissance Tier 2prenaissance balance Tier 2prenaissance next Tier 2prenaissance plus Tier 2prenaplus Tier 2prenatabs fa Tier 2prenatabs rx Tier 2prenatal 19 Tier 2prenatal ad Tier 2prenatal low iron Tier 2prenatal plus Tier 2prenatal-u Tier 2prenate plus Tier 2relnate dha Tier 2se-care Tier 2se-care conceive Tier 2se-care gesture Tier 2se-natal 19 Tier 2se-natal 90 Tier 2se-natal one Tier 2se-plete dha Tier 2se-tan dha Tier 2setonet Tier 2setonet-ec Tier 2Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)taron a prenatal Tier 2taron ec calcium Tier 2taron-bc Tier 2taron-c dha Tier 2taron-duo ec Tier 2taron-ec cal Tier 2taron-prex prenatal Tier 2tl-assure one Tier 2tl-select Tier 2tri rx Tier 2triadvance Tier 2trimesis rx Tier 2trinatal gt Tier 2trinatal rx 1 Tier 2trinatal ultra Tier 2trinate Tier 2triveen-duo dha Tier 2triveen-one Tier 2triveen-prx rnf Tier 2triveen-ten Tier 2triveen-u Tier 2ultimate ob dha Tier 2ultimatecare advantage Tier 2ultimatecare one Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 87

Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)ultimatecare one nf Tier 2vemavite-prx 2 Tier 2vena-bal dha Tier 2venatal complete dha Tier 2venatal-fa Tier 2vinacal Tier 2vinate az Tier 2vinate az extra Tier 2vinate c Tier 2vinate calcium Tier 2vinate care Tier 2vinate gt Tier 2vinate ic Tier 2vinate ii Tier 2vinate one Tier 2vinate pn care Tier 2vinate ultra Tier 2vinate-m Tier 2virt-bal dha Tier 2virt-pn Tier 2virt-pn dha Tier 2vitafol-ob Tier 2vitafol-pn Tier 2vitaspire Tier 2Obstetrical and Gynecological Medications:Prenatal Vitamins (continued)vol-nate Tier 2vol-plus Tier 2vol-tab rx Tier 2vp-ch-pnv Tier 2vp-era ob plus Tier 2vp-ggr-b6 Tier 2zatean-ch Tier 2zatean-pn Tier 2zatean-pn dha Tier 2zatean-pn plus Tier 288Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Obstetrical and GynecologicalMedications: Progestin Drugscamila Tier 2errin Tier 2heather Tier 2jolivette Tier 2MAKENATier 4 P Amedroxyprogesterone acetate injection, Tier 2-tabletnora-be Tier 2norethindrone Tier 2norethindrone acetate tablet Tier 2progesterone capsule, -oil 50 mg/ml vl Tier 2progesterone oil 50 mg/ml vl Tier 2Obstetrical and Gynecological Medications:Specialized Ob/Gyn Drugschorionic gonadotropin injection Tier 2leuprolide acetate injection Tier 2LUPRON DEPOT 11.25 MG 3MO KIT Tier 5LUPRON DEPOT 3.75 MG KIT, -7.5 MG Tier 5KIT, -22.5 MG 3MO KIT, --4 MONTHKITLUPRON DEPOT-PED Tier 5methylergonovine maleate Tier 2novarel injection Tier 2oxytocin injection Tier 2SYNAREL Tier 5Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 89

Ophthalmic Medications: Antiglaucoma Drugsacetazolamide capsule sustained action, Tier 2-tabletacetazolamide sodiumTier 2 H I Tapraclonidine hcl Tier 2betaxolol hcl ophth drops Tier 2brimonidine tartrate Tier 1carteolol hcl Tier 1dorzolamide hcl Tier 2dorzolamide-timolol Tier 2latanoprost Tier 2levobunolol hcl Tier 1methazolamide tablet Tier 2metipranolol Tier 2PHOSPHOLINE IODIDE Tier 3pilocarpine hcl ophth drops Tier 1timolol maleate ophth drops Tier 1TRAVATAN Z Tier 3travoprost ophth drops Tier 2Ophthalmic Medications: OphthalmicAntiinfective/Corticosteroidsneomycin-bacitracin-poly-hc Tier 2neomycin-polymyxin-dexameth Tier 1neomycin-polymyxin-hc ophth drops Tier 2poly-dex Tier 1sulfacetamide-prednisolone Tier 2tobramycin-dexamethasone Tier 2Ophthalmic Medications: OphthalmicCorticosteroid Drugsdexamethasone sodium phosphate Tier 2ophth dropsfluorometholone ophth drops Tier 2PRED MILD Tier 3prednisolone acetate ophth drops Tier 2prednisolone sodium phosphate ophthdropsTier 290Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Ophthalmic Medications: OphthalmicTopical Antibacterial Drugsak-poly-bac Tier 2bacitracin oint Tier 2bacitracin-polymyxin Tier 2ciprofloxacin hcl ophth drops Tier 2erythromycin oint Tier 1garamycin ophth drops Tier 1gentak Tier 1gentamicin 3 mg/gm eye oint, -ophth Tier 1dropslevofloxacin ophth drops Tier 2neomycin-bacitracin-polymyxin Tier 2neomycin-polymyxin-gramicidin Tier 2neo-polycin Tier 2ofloxacin ophth drops Tier 2polycin-b Tier 2polymyxin b sul-trimethoprim Tier 1romycin Tier 1sulfacetamide sodium oint Tier 2sulfacetamide sodium ophth drops Tier 1sulfamide Tier 1tobramycin sulfate ophth drops Tier 1Ophthalmic Medications: Other Ophthalmic Drugsak-con Tier 2akorn balanced salt Tier 2altafrin Tier 2atropine care Tier 2atropine sulfate oint, -ophth drops Tier 2azelastine hcl ophth drops Tier 2BOTOXTier 4 P Abromfenac sodium Tier 2cromolyn sodium ophth drops Tier 2cyclopentolate hcl ophth drops Tier 2diclofenac sodium ophth drops Tier 2epinastine hcl Tier 2flurbiprofen sodium Tier 2homatropaire Tier 2homatropine Tier 2ketorolac 0.4% ophth solution Tier 2ketorolac 0.5% ophth solution Tier 2 Q C D (10/30)LACRISERT Tier 3mydral Tier 2NATACYN Tier 3neofrin Tier 2parcaine Tier 2phenylephrine hcl ophth drops Tier 2proparacaine hcl ophth drops Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 91

Ophthalmic Medications: OtherOphthalmic Drugs (continued)RESTASIS Tier 3 Q C D (64vials/30)trifluridine ophth drops Tier 2ZIRGAN Tier 4Respiratory Medications: Antihistamineand Decongestant Drugsarbinoxa Tier 2carbinoxamine maleate Tier 2cetirizine hcl Tier 2clemastine fumarate syrup, -tablet Tier 2cyproheptadine hcl syrup, -tablet Tier 2desloratadine Tier 2desloratadine odt Tier 2 Q C D (34/30)dexchlorpheniramine maleate Tier 2diphenhydramine 50 mg/ml vial Tier 2 H I Tdiphenhydramine hcl capsuleTier 2 P Adiphenhydramine hcl elix, -50 mg/ml Tier 2syrngfexofenadine hcl Tier 2levocetirizine dihydrochloride solution Tier 2levocetirizine dihydrochloride tablet Tier 2 Q C D (34/30)palgic Tier 2promethazine hcl injection Tier 2promethazine hcl syrup, -tablet Tier 2 P Apromethazine vcTier 2 P ASEMPREX-D Tier 4zoden pd Tier 292Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Respiratory Medications: Beta-2 Adrenergic Drugsalbuterol sulfate nebsTier 2 P Aalbuterol sulfate syrup, -tablet, -tablet Tier 2sustained actionARCAPTA NEOHALER Tier 4 Q C D (30/30)BROVANATier 3 P AFORADIL Tier 3 Q C D (120/30)levalbuterol concentrateTier 2 P Ametaproterenol sulfate syrup, -tablet Tier 2PERFOROMISTTier 3 P APROAIR HFA Tier 3 Q C D (25.5gm/30)PROVENTIL HFA Tier 3 Q C D (20.1gm/30)SEREVENT DISKUS Tier 3 Q C D (60doses/30)terbutaline sulfate injection, -tablet Tier 2XOPENEXTier 3 P ARespiratory Medications: Methyl Xanthine Drugsaminophylline 250 mg/10 ml vl Tier 2 H I Taminophylline tablet Tier 2caffeine citrate solution Tier 2dylix Tier 2theochron Tier 2theophylline Tier 2theophylline anhydrous tablet sustainedactionTier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 93

Respiratory Medications: Other Drugs for Asthmaacetylcysteine nebsTier 2 P AADVAIR DISKUS Tier 4 Q C D (60doses/30), P AADVAIR HFA Tier 4 Q C D (24gm/30), P AATROVENT HFA Tier 3 Q C D (38.7gm/30)budesonide nebs Tier 2 Q C D (140/30),P ACOMBIVENT Tier 3 Q C D (29.4gm/30)COMBIVENT RESPIMATTier 3 Q C D (8 gm/30)cromolyn sodium nebsTier 2 P Acromolyn sodium solution Tier 2DULERA Tier 3 Q C D (26gm/30), P Aepinephrine 0.1 mg/ml syringe, -1 mg/ Tier 2ml ampul, -1 mg/ml vialEPINEPHRINE 0.15 MG AUTO-INJCT, Tier 4-0.3 MG AUTO-INJECTEPIPEN Tier 3EPIPEN JR Tier 3FLOVENT DISKUS Tier 3 Q C D (120doses/30)FLOVENT HFA 110 MCG INHALER Tier 3 Q C D (12gm/30)FLOVENT HFA 220 MCG INHALER Tier 3 Q C D (36gm/30)Respiratory Medications: OtherDrugs for Asthma (continued)FLOVENT HFA 44 MCG INHALER Tier 3 Q C D (21.2gm/30)HYPER-SAL M Bipratropium bromide nebsTier 2 P Aipratropium-albuterolTier 2 P Amontelukast Tier 2QVAR Tier 3 Q C D (26.1/30)sodium chloride nebs M BSPIRIVA Tier 3 Q C D (60capsules/30)SYMBICORT 160-4.5 MCG INHALER Tier 3 Q C D (20.4/30),P ASYMBICORT 80-4.5 MCG INHALER Tier 3 Q C D (13.8/30),P ATUDORZA Tier 3XOLAIRTier 5 P A, L P A, N M OzafirlukastTier 2 P A94Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information.

Respiratory Medications: Other Respiratory DrugsARALAST NP 500 MG VIAL Tier 5 P A, L P A, H I T,N M OGLASSIA Tier 5 P A, L P A, H I T,N M OKALYDECO TABLETTier 5 P APROLASTIN CTier 5 P A, H I T, N M OPULMOZYMETier 5 P AUrological Medications: AnticholinergicAntispasmodicsDETROLTier 4 S TDETROL LATier 4 S TENABLEXTier 3 S Tflavoxate hcl Tier 2oxybutynin chloride er Tier 2oxybutynin chloride syrup, -tablet Tier 2tolterodine tartrate Tier 2trospium chloride Tier 2Urological Medications: Other Genitourinary Productsacetic acid 0.25% irrig soln Tier 2alfuzosin hcl Tier 2bethanechol chloride tablet Tier 2CYSTADANETier 3 N M Ocytra-3 Tier 2cytra-k Tier 2finasteride 5mg tablet Tier 2glycine Tier 2K-PHOS M.F. Tier 3K-PHOS NO.2 Tier 3K-PHOS ORIGINAL Tier 3neomycin-polymyxin b Tier 2potassium citrate TABLET SUSTAINED Tier 2ACTIONpotassium citrate-citric acid Tier 2SORBITOL Tier 3tamsulosin hcl Tier 2taron-crystals Tier 2tricitrates Tier 2Q C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 95

IndexSymbols1ST CHOICE SUPER THINLANCETS. ............. 511ST CHOICE THINLANCETS. ............. 511ST CHOICE ULTRA THINLANCETS. ............. 511ST TIER COMFORTOUCH28G LANCT. ........... 511ST TIER COMFORTOUCH30G LANCT. ........... 511ST TIER UNIFINE PENTP5MM 31G. ............. 511ST TIER UNIFINE PNTIP 4MM32G. .................. 511ST TIER UNIFINE PNTIP 6MM31G. .................. 511ST TIER UNIFINE PNTIP 8MM31G. .................. 511ST TIER UNIFINE PNTP12MM 29G ............ 512TEK CONTROLSOLUTION ............ 518-MOP. ................. 38Aabacavir .................. 8ABILIFY 20 MG TABLET, -30MG TABLET, -300 MG ERINJECTION ............ 21ABILIFY DISCMELT. ...... 21ABILIFY INJECTION,-SOLUTION, -2 MG TABLET,-5 MG TABLET, -10 MGTABLET, -15 MG TABLET. 21acarbose ................ 43ACCU-CHEK ACTIVEGLUCOSE SOL ........ 51ACCU-CHEK ACTIVE TESTSTRIP ................. 51ACCU-CHEK ADVANTAGEKIT. ................... 51ACCU-CHEK AVIVA PLUSMETER ................ 51ACCU-CHEK AVIVA PLUSTEST STRP ............ 51ACCU-CHEK AVIVASOLUTION ............ 51ACCU-CHEK AVIVA TESTSTRIPS. ............... 51ACCU-CHEK CMFRT CURVESOLN . . . . . . . . . . . . . . . . . 51ACCU-CHEK CMFRT CURVESTRIP ................. 51ACCU-CHEK COMFORTCURVE STRIP. ......... 51ACCU-CHEK COMPACT BLUECONTROL. ............ 51ACCU-CHEK COMPACTCARE KIT .............. 52ACCU-CHEK COMPACTDRUM STRIPS ......... 52ACCU-CHEK COMPACT PLUSKIT. ................... 52ACCU-CHEK COMPACTSTRIPS. ............... 52ACCU-CHEK COMPACT TESTDRUM. ................ 52ACCU-CHEK CONTROLSOLUTION ............ 52ACCU-CHEK FASTCLIXLANCETS. ............. 52ACCU-CHEK III DIABETESKIT. ................... 52ACCU-CHEK MULTICLIXLANCET ............... 52ACCU-CHEK MULTICLIXLANCET KIT. ........... 52ACCU-CHEK MULTICLIXLANCETS. ............. 52ACCU-CHEK NANOSMARTVIEW METER. ... 52ACCU-CHEK SAFE-T-PRO 23GLANCT ................ 52ACCU-CHEK SAFE-T-PROLANCETS. ............. 52ACCU-CHEK SAFE-T-PROPLUS 23G ............. 52ACCU-CHEK SMARTVIEWCONTRL SOL. ......... 52ACCU-CHEK SMARTVIEWSTRIP ................. 52ACCU-CHEK SMARTVIEWTEST STRIP. ........... 52ACCU-CHEK SOFTCLIXLANCETS. ............. 52ACCU-CHEK VOICEMATESYSTEM ............... 52ACCUTREND GLUCOSECONTROL. ............ 52acebutolol hcl capsule ..... 32acetaminophen-caffdihydrocodeine......... 25acetaminophen-codeine. ... 25acetasol hc .............. 41acetazolamide capsule sustainedaction, -tablet ........... 90acetazolamide sodium ..... 90acetic acid 0.25% irrig soln. 95acetic acid-aluminum ...... 41acetic acid otic drops. ..... 41acetylcysteine nebs ....... 94ACTEMRA. .............. 50ACTHIB ................. 48acticin. .................. 38ACTI-LANCE 23GLANCETS. ............. 52ACTI-LANCE 28GLANCETS. ............. 52ACTI-LANCE LITE 28GLANCETS. ............. 52ACTI-LANCE SPECIAL 17GLANCETS. ............. 52ACTI-LANCE UNIVERS 23GLANCETS. ............. 52ACTIMMUNE ............ 50ACTOS 15 MG TABLET ... 43ACTOS 30 MG TABLET, -45MG TABLET. ........... 43ACURA CONTROL SOLUTIONHIGH ................. 52ACURA CONTROL SOLUTIONLOW .................. 52ACURA CONTROL SOLUTIONNORMAL . . . . . . . . . . . . . . 52acyclovir. ................ 11acyclovir injection . . . . . . . . . 1196

acyclovir ointment ......... 11ADACEL ................ 48ADAGEN. ............... 40adapalene ............... 37ADCIRCA ............... 36adenosine injection. ....... 34adriamycin injection ....... 15adrucil .................. 15ADVAIR DISKUS ......... 94ADVAIR HFA. ............ 94ADVANCED TRAVEL LANCETS28G. .................. 52ADVANCE MICRO-DRAWCNTRL SOLN .......... 52ADVANCE MICRO-DRAWCONTRL SOLN ........ 52ADVANCE NORMALCONTROL SOLN. ...... 52ADVOCATE 26G LANCETS 52ADVOCATE 30G LANCETS 52ADVOCATE CONTROLSOLUTION HIGH. ...... 52ADVOCATE CONTROLSOLUTION LOW ....... 52ADVOCATE INS 0.3 ML30GX5/16 ............. 52ADVOCATE INS 0.3 ML31GX5/16 ............. 52ADVOCATE INS 0.5 ML30GX5/16 ............. 52ADVOCATE INS 0.5 ML31GX5/16 ............. 52ADVOCATE INS 1 ML31GX5/16 ............. 52ADVOCATE INS SYR 0.3ML29GX1/2 .............. 53ADVOCATE INS SYR 0.5ML29GX1/2 .............. 53ADVOCATE INS SYR 1 ML29GX1/2 .............. 53ADVOCATE INS SYR 1 ML30GX5/16 ............. 53ADVOCATE PEN NEEDLES5MM 31G. ............. 53ADVOCATE PEN NEEDLES8MM 31G. ............. 53ADVOCATE REDI-CODE+CTRL SOLN. ........... 53afeditab cr ............... 32AFINITOR ............... 15AFLURIA 2011-2012. ..... 48AFLURIA 2011-2012 (PF) . 48AGAMATRIX HIGH CONTROLSOLN . . . . . . . . . . . . . . . . . 53AGAMATRIX NORM-HICONTROL SOLN. ...... 53AGGRENOX ............ 78AIMSCO INS PEN NDL29GX1/2 .............. 53AIMSCO INS PEN NDL31GX3/16 ............. 53AIMSCO INS PEN NDL31GX5/16 ............. 53AIMSCO INS SYR 0.3 ML29GX1/2 .............. 53AIMSCO INS SYR 0.3 ML30GX5/16 ............. 53AIMSCO INS SYR 0.5 ML28GX1/2 .............. 53AIMSCO INS SYR 0.5 ML29GX1/2 .............. 53AIMSCO INS SYR 1 ML28GX1/2 .............. 53AIMSCO INS SYR 1 ML29GX1/2 .............. 53AIMSCO INS SYR 1 ML30GX5/16 ............. 53AIMSCO SYRING 0.3 ML31GX5/16 ............. 53AIMSCO SYRING 0.5 ML30GX5/16 ............. 53AIMSCO SYRING 0.5 ML31GX5/16 ............. 53AIMSCO ULTR-THIN II 28GLANCET ............... 53ak-con .................. 91akorn balanced salt. ....... 91ak-poly-bac .............. 91ALBENZA ................ 7albuterol sulfate nebs ...... 93albuterol sulfate syrup, -tablet,-tablet sustained action. .. 93alclometasone dipropionate. 38ALCOHOL 70% PADS .... 53ALCOHOL 70% PREPPADS ................. 53ALCOHOL 70% SWABS .. 53ALCOHOL PREP PADS ... 53ALCOHOL PREP PADS70%. .................. 53ALCOHOL PREP SWABS. 53ALCOHOL SWAB ........ 53ALCOHOL SWABS. ...... 53ALCOHOL WIPES ....... 53ALDURAZYME. .......... 44alendronate sodium 5 mg tablet,-10 mg tab, -40 mg tab. .. 44alendronate sodium 35 mg tab,-70 mg tab ............. 44alfentanil hydrochloride .... 24alfuzosin hcl. ............. 95ALIMTA ................. 15ALINIA .................. 10ALKERAN TABLET. ....... 15allopurinol sodium. ........ 77allopurinol tablet . . . . . . . . . . 77alprazolam er ............. 23alprazolam intensol ........ 23alprazolam odt. ........... 23alprazolam tablet. ......... 23alprazolam xr . . . . . . . . . . . . . 23alprostadil injection. ....... 35altafrin .................. 91altavera ................. 83ALTERNATE SITE 26GLANCETS. ............. 53ALTERNATE SITELANCETS. ............. 53alyacen. ................. 83amantadine .............. 11amcinonide .............. 38a-methapred ............. 42amethia ................. 83amethia lo ............... 83amethyst ................ 83amifostine ............... 15amikacin. ................. 7amiloride hcl tablet ........ 36amiloride-hydrochlorothiazide 36amino acids .............. 79aminocaproic acid injection,-syrup, -500 mg tab. ..... 4097

aminophylline 250 mg/10 mlvl ..................... 93aminophylline tablet ....... 93AMINOSYN 3.5% IVSOLUTION, -7% IVSOLUTION, -10% IVSOLUTION ............ 79AMINOSYN 8.5% IVSOLUTION ............ 79AMINOSYN-HBC ........ 79AMINOSYN-HF .......... 79AMINOSYN II ............ 79AMINOSYN II 5% IN 25%DEXTROSE ............ 79AMINOSYN M ........... 79AMINOSYN-PF. .......... 79AMINOSYN-RF .......... 79AMINOSYN WITHELECTROLYTES. ....... 79amiodarone injection ...... 34amiodarone tablet. ........ 34AMITIZA. ................ 46amitriptyline hcl tablet. ..... 30amlodipine-atorvastatin .... 33amlodipine besylate 2.5 mg tab,-5 mg tab .............. 32amlodipine besylate 10 mgtab .................... 32amlodipine besylatebenazepril.............. 35ammonium lactate cream,-lotion ................. 39amnesteem .............. 38amoxapine ............... 29amoxicillin. ............... 13amoxicillin-clavulanate er ... 13amox tr-potassiumclavulanate ............. 13amphetamine salt combo. .. 25amphotericin b injection .... 12ampicillin injection. ........ 13ampicillin-sulbactam injection 13ampicillin trihydrate ........ 13AMPYRA ................ 40ANADROL-50. ........... 83anagrelide hcl ............ 15anastrozole tablet . . . . . . . . . 15androxy. ................. 83antipyrine-benzocaine. ..... 41ANTI-STICK INSULIN 0.5 MLSYR................... 53ANTI-STICK INSULIN 1 MLSYR................... 53APOKYN ................ 28apraclonidine hcl. ......... 90apri ..................... 83APRISO. ................ 46APTIVUS ................. 8ARALAST NP 500 MG VIAL 95aranelle ................. 83ARANESP 25 MCG/0.42 MLSYRING ............... 48ARANESP 25 MCG/ML VIAL,-40 MCG/ML VIAL, -60 MCG/ML VIAL ............... 48ARANESP 40 MCG/0.4 MLSYRINGE. ............. 48ARANESP 60 MCG/0.3 MLSYRINGE. ............. 48ARANESP 100 MCG/0.5 MLSYRINGE. ............. 48ARANESP 100 MCG/ML VIAL,-200 MCG/ML VIAL, -300MCG/ML VIAL, -500 MCG/1ML SYRINGE .......... 48ARANESP 150 MCG/0.3 MLSYRINGE. ............. 48ARANESP 150 MCG/0.75 MLVIAL. .................. 48ARANESP 200 MCG/0.4 MLSYRINGE. ............. 48ARANESP 300 MCG/0.6 MLSYRINGE. ............. 48arbinoxa ................. 92ARCALYST .............. 50ARCAPTA NEOHALER .... 93ARICEPT 23 MG TABLET . 20ARRANON .............. 15ARZERRA. .............. 15ASACOL ................ 46ASACOL HD ............ 46ASCENSIA AUTODISC CTRLSOLN . . . . . . . . . . . . . . . . . 53ascomp with codeine ...... 26ASSURE 3 CONTROLSOLUTION ............ 53ASSURE 4 CONTROLSOLUTION ............ 53ASSURE DOSE CONTROLSOLUTION ............ 53ASSURE HAEMOLANCE PLUS18G. .................. 53ASSURE HAEMOLANCE PLUS21G. .................. 53ASSURE HAEMOLANCE PLUS25G. .................. 53ASSURE HAEMOLANCE PLUSLANCETS. ............. 53ASSURE ID SYR 0.5 ML29GX1/2 .............. 53ASSURE ID SYR 1 ML29GX1/2 .............. 53ASSURE II CONTROLSOLUTION ............ 54ASSURE LANCE 25GLANCETS. ............. 54ASSURE LANCE MICROFLOW LANCET. ........ 54ASSURE PRO CONTROLSOLUTION ............ 54ASSURE ULTRA THINLANCETS. ............. 54atenolol-chlorthalidone ..... 35atenolol tablet . . . . . . . . . . . . 32AT-LAST LANCETS ....... 54atorvastatin calcium ....... 33atovaquone-proguanil hcl. .. 13ATRIPLA ................. 8atropine care ............. 91atropine sulfate injection ... 29atropine sulfate oint, -ophthdrops. ................. 91ATROVENT HFA. ......... 94AUBAGIO TABLET ....... 40aurodex ................. 41auroguard ............... 41AURORA HEALTHCARELANCETS. ............. 54AURORA PEN NEEDLE 6MM31G. .................. 54AURORA PEN NEEDLES 8MM31G. .................. 5498

AURORA PEN NEEDLES12MM 29G ............ 54AURORA SUPER THINLANCET ............... 54AURORA THIN LANCETS . 54AUTODISC NORMALCONTROL SOLN. ...... 54AUTOJECT 2 INJECTIONDEVICE ............... 54AUTOPEN 1 TO 16 UNITS. 54AUTOPEN 1 TO 21 UNITS. 54AUTOPEN 2 TO 32 UNITS. 54AUTOPEN 2 TO 42 UNITS. 54AVANDAMET ............ 43AVANDIA 2 MG TABLET, -4 MGTABLET. ............... 43AVANDIA 8 MG TABLET. .. 43AVASTIN ................ 15aviane. .................. 83AVONEX ................ 50AVONEX ADMINISTRATIONPACK ................. 50AVONEX PEN ........... 50AXIRON ................ 83AZACTAM-ISO-OSMOT 1GM/50 ML. ............ 10AZACTAM-ISO-OSMOT 2GM/50 ML. ............ 10azathioprine sodium ....... 15azathioprine tablet. ........ 15azelastine hcl nasal drops/sprays ................. 41azelastine hcl ophth drops .. 91AZILECT . . . . . . . . . . . . . . . . 28azithromycin injection ...... 12azithromycin packet,-suspension, -tablet ...... 12aztreonam vial . . . . . . . . . . . . 10azurette ................. 83Bbaciim. .................. 10bacitracin injection ........ 10bacitracin oint ............ 91bacitracin-polymyxin ....... 91baclofen tablet ........... 76bacteriostatic saline vial, -0.9%syringe, -0.9% vial, -0.9% zrsyr .................... 79bacteriostatic water vial .... 79bal-care dha. ............. 86balsalazide disodium ...... 46balziva .................. 83BANZEL 400 MG TABLET . 27BANZEL ORAL SUSP, -200MG TABLET. ........... 27BARACLUDE SOLUTION . 11BARACLUDE TABLET. .... 11baycadron ............... 42BD 10 ML SYRINGE WITHNEEDLE. .............. 54BD AUTO INJECTOR ..... 54BD ECLIPSE 30GX1/2SYRINGE. ............. 54BD INSULIN SYR 0.3 ML28GX1/2 .............. 54BD INSULIN SYR 0.3 ML29GX1/2 .............. 54BD INSULIN SYR 0.3 ML30GX1/2 .............. 54BD INSULIN SYR 0.3ML31GX5/16 ............. 54BD INSULIN SYR 0.5 ML28GX1/2 .............. 54BD INSULIN SYR 0.5 ML29GX1/2 .............. 54BD INSULIN SYR 0.5 ML30GX1/2 .............. 54BD INSULIN SYR 0.5ML31GX5/16 ............. 54BD INSULIN SYR 1 ML25GX1 ................ 54BD INSULIN SYR 1 ML25GX5/8 .............. 54BD INSULIN SYR 1 ML26GX1/2 .............. 54BD INSULIN SYR 1 ML27GX5/8 .............. 54BD INSULIN SYR 1 ML28GX1/2 .............. 54BD INSULIN SYR 1 ML29GX1/2 .............. 54BD INSULIN SYR 1 ML30GX1/2 .............. 54BD INSULIN SYR 1 ML31GX5/16 ............. 54BD INSULIN SYR 1 ML31GX15/64 ............ 54BD INSULIN SYRINGE 1ML. ................... 54BD INSULIN U100-1 MLSYRNGE .............. 54B-D INSULIN U100 2 MLSYRNGE .............. 54B-D INSULIN U100-2 MLSYRNGE .............. 54B-D INSULIN U100-3/10 MLSYR................... 54BD INSULIN U100-3/10 MLSYR................... 54BD INSUL SYR 0.3 ML31GX15/64 ............ 54BD INSUL SYR 0.5 ML31GX15/64 ............ 54BD INTEGRA SYR 1 ML29GX1/2 .............. 54BD INTEGRA SYRINGE 1 ML25GX1 ................ 54BD LANCETS 30G ....... 55BD LANCETS 33G ....... 55BD LANCETSMICROTAINER . . . . . . . . . 55BD LANCETS MICROTAINER21G. .................. 55BD LANCETS MICROTAINER30G. .................. 55BD LUER-LOK SYRINGE 1ML. ................... 55BD LUER-LOK SYRINGE 1ML20GX1 ................ 55BD NEEDLES 26GX0.5 ... 55BD NEEDLES 27GX0.5 ... 55BD PEN INSULIN DEVICE. 55BD PEN MINI INSULINDEVICE ............... 55BD PEN NEEDLE 29GX1/2 55BD PEN NEEDLE29GX3/16 ............. 55BD PEN NEEDLE29GX5/16 ............. 55BD PEN NEEDLE30GX3/16 ............. 55BD PEN NEEDLE MINI31GX3/16 ............. 5599

BD PEN NEEDLE NANO32GX5/32 ............. 55BD PEN NEEDLE ORIG29GX1/2 .............. 55BD PEN NEEDLE SHORT31GX5/16 ............. 55BD SAFETYGLIDE SYRINGE27GX5/8 .............. 55BD SAFTGLD INS 0.3 ML31GX5/16 ............. 55BD SAFTGLD INS SYR 0.3 ML29G. .................. 55BD SAFTGLD INS SYR 0.5 ML30G. .................. 55BD SINGLE USE ALCOHOLSWAB. ................ 55BD SINGLE USE SWAB .. 55BD SYR 0.3 ML 31GX5/16(1/2) .................. 55BD SYR 0.3 ML 31GX15/64(1/2) .................. 55BD ULTRA FINE LANCETS 55benazepril hcl tablet ....... 31benazeprilhydrochlorothiazide...... 35BENLYSTA 120 MG VIAL .. 15BENLYSTA 400 MG VIAL .. 15benztropine injection ...... 20benztropine tablet. ........ 20betamethasone acetate-sodphos .................. 42betamethasone dipropionatecream, -gel, -lotion, -oint .. 38betamethasone valerate cream,-lotion, -oint, -foam ....... 38BETASERON ............ 50betaxolol hcl ophth drops. .. 90betaxolol hcl tablet ........ 32bethanechol chloride tablet . 95bicalutamide ............. 15BICNU. ................. 15bisoprolol fumarate ........ 32bisoprololhydrochlorothiazide...... 35BL ALCOHOL PREPSWABS ............... 55bleomycin sulfate injection. . 15BL INSULIN 0.3 MLSYRINGE. ............. 55BL INSULIN 0.5 MLSYRINGE. ............. 55BL INSULIN 1 MLSYRINGE. ............. 55BL LANCETS ............ 55BLOOD GLUCOSE CONTROLSOLUTION ............ 55BOOSTRIX. ............. 48BOSULIF TABLET ........ 15BOTOX ................. 91bp 10-1 ................. 37BREEZE 2 SOLUTION. ... 55briellyn .................. 83brimonidine tartrate. ....... 90bromfenac sodium ........ 91bromocriptine mesylate capsule,-tablet ................. 28BROVANA. .............. 93budeprion sr ............. 28budesonide ec ........... 46budesonide nebs ......... 94BULLSEYE MINI SAFETY21G. .................. 55BULLSEYE MINI SAFETY 28GLANCT ................ 55BULLSEYE MINI SAFETYLANCETS. ............. 55bumetanide injection ...... 34bumetanide tablet. ........ 34BUPHENYL TABLET ...... 40bupivacaine-dextrose ....... 7bupivacaine hcl-epinephrine . 7bupivacaine hcl injection .... 7buprenorphine. ........... 20buprenorphine hcl tab, sl ... 25buprenorphine-naloxon. .... 25buproban ................ 30bupropion hcl sr .......... 28bupropion hcl tablet ....... 28bupropion xl. ............. 28buspirone hcl tablet ....... 23BUSULFEX. ............. 15butalb-caff-acetaminophcodein................. 26butalbital compound-codeine 26butorphanol tartrate aerosol. 26butorphanol tartrate injection 20BYDUREON ............. 42BYETTA . . . . . . . . . . . . . . . . . 42Ccabergoline .............. 44caffeine citrate injection .... 25caffeine citrate solution .... 93calcipotriene ............. 37calcitonin-salmon ......... 44calcitriol capsule, -solution. . 83calcitriol injection ......... 83CALCITRIOL OINT ....... 37calcium acetate. .......... 83calcium chloride injection. .. 79calcium folinate injection ... 15camila. .................. 89CAMPATH ............... 15CAMPHOR. ............. 39CAMPRAL. .............. 29camrese ................. 83camrese lo. .............. 83CANCIDAS .............. 12candesartan- hctz ......... 35candin .................. 48CAPASTAT SULFATE. ...... 9CAPRELSA. ............. 15captopril-hydrochlorothiazide 35captopril tablet ........... 31CARBAGLU ............. 40carbamazepine capsulesustained action, -oral susp 23carbamazepine chew tab,-tablet ................. 23carbamazepine er ......... 23carbamazepine xr ......... 23carbidopa-levodopa ....... 28carbidopa-levodopaentacapone............. 28carbinoxamine maleate. .... 92carboplatin. .............. 15CAREONE INS SYR 1 ML30GX5/16 ............. 55CAREONE THIN LANCET . 55CAREONE ULTRA THINLANCET ............... 55CAREONE UNIFINE PENTIP5MM 31G. ............. 55CAREONE UNIFINE PENTIP6MM 31G. ............. 55100

CAREONE UNIFINE PENTIP8MM 31G. ............. 55CAREONE UNIFINE PNTP12MM 29G ............ 55CARESENS CONTROLSOLUTION ............ 55carisoprodol-aspirin ....... 76carisoprodol-aspirin-codeine 76carisoprodol compound .... 76carisoprodol compoundcodeine................ 76carisoprodol tablet ........ 76carteolol hcl. ............. 90cartia xt ................. 32carvedilol ................ 32cavan-alpha kit ........... 86cavan-ec sod dha ......... 86cavan-heme ob ........... 86cavan one omega . . . . . . . . . 86CAYSTON ............... 10caziant .................. 83CEENU . . . . . . . . . . . . . . . . . 15cefaclor .................. 9cefaclor er . . . . . . . . . . . . . . . . 9cefadroxil ................. 9cefazolin. ................. 9cefdinir ................... 9cefepime ................. 9cefotaxime ................ 9cefotetan . . . . . . . . . . . . . . . . . 9cefoxitin .................. 9cefpodoxime proxetil. ....... 9cefprozil .................. 9ceftazidime ............... 9ceftriaxone ................ 9cefuroxime ................ 9cefuroxime axetil ........... 9cefuroxime sodium ......... 9CELEBREX. ............. 77CELLCEPT INJECTION ... 16CELLCEPT ORAL SUSP .. 16CELONTIN .............. 30cephalexin ................ 9CEREZYME ............. 44cerubidine ............... 16CERVARIX .............. 48cesia. ................... 83cetirizine hcl. ............. 92cevimeline hcl ............ 41CHANTIX. ............... 30CHEMET. ............... 40chloramphenicol sodsuccinate .............. 10chlordiazepoxide-amitriptyline 28chlordiazepoxide hcl ....... 23chlorhexidine gluconate dental/mucous membrn products 41chloroprocaine hcl ......... 7chloroquine phosphate tablet 13chlorothiazide ............ 36chlorothiazide sodium. ..... 36chlorpromazine hcl injection. 21chlorpromazine hcl tablet ... 21chlorpropamide ........... 43chlorthalidone ............ 36chlorzoxazone ............ 76cholestyramine ........... 33cholestyramine light ....... 33choline mag trisalicylate .... 78chorionic gonadotropininjection ............... 89ciclodan ................. 12ciclopirox . . . . . . . . . . . . . . . . 12cidofovir vial. ............. 11cilostazol ................ 78cimetidine injection. ....... 46cimetidine solution, -tablet .. 46CINRYZE ............... 48CIPRODEX. ............. 41ciprofloxacin-d5w injection . 13ciprofloxacin er ........... 13ciprofloxacin hcl ophth drops 91ciprofloxacin injection ...... 13ciprofloxacin tablet ........ 13cisplatin ................. 16citalopram hbr solution. .... 30citalopram hbr tablet. ...... 30cladribine ................ 16claravis. ................. 38clarithromycin er .......... 12clarithromycin suspension,-tablet ................. 12clemastine fumarate syrup,-tablet ................. 92clenia emulsion ........... 37CLEOCIN 100 MG VAGINALOVULE . . . . . . . . . . . . . . . . 85CLEVER CHEK 30GLANCETS. ............. 56CLEVER CHEK CONTROLSOLUTION ............ 56CLEVER CHEK ULTRA THINLANCETS. ............. 56CLICKFINE 31G X 1/4NEEDLES ............. 56CLICKFINE 31G X 5/16NEEDLES ............. 56CLICKFINE UNIVERSAL 31G X1/4. ................... 56CLICKFINE UNIVERSAL31GX5/16 ............. 56CLIMARA PRO. .......... 85clinda-benzoyl perox 1-5%gel .................... 37clindacin p ............... 37clindamycin-benzoyl peroxgel .................... 37clindamycin-d5w .......... 10clindamycin hcl capsule .... 10clindamycin injection ...... 10clindamycin palmitate hcl ... 10clindamycin phos-benzoylperox .................. 37clindamycin phosphate foam(non-contraceptive), -gel,-lotion, -soln, top, -swabs,applicators ............. 37clindamycin phosphate vaginalproducts ............... 85CLINIMIX 2.75%-5%SOLUTION, -4.25%-20%SOLUTION, -4.25%-25%SOLUTION, -4.25%-5%SOLUTION, -5%-15%SOLUTION, -5%-20%SOLUTION, -5%-25%SOLUTION ............ 79CLINIMIX 4.25%-10%SOLUTION ............ 79101

CLINIMIX E 2.75%-10%SOLUTION, -2.75%-5%SOLUTION, -4.25%-25%SOLUTION, -4.25%-5%SOLUTION, -5%-15%SOLUTION, -5%-20%SOLUTION, -5%-25%SOLUTION ............ 79clobetasol emollient ....... 38clobetasol propionate cream,-foam (non-contraceptive), -gel,-lotion, -oil,shampoo,cleanser,-oint, -soln, top .......... 38CLOLAR ................ 16clomipramine hcl capsule. .. 30clonazepam tablet. ........ 27clonidine ................ 33clonidine hcl injection. ..... 33clonidine hcl tablet . . . . . . . . 33clopidogrel. .............. 78clorazepate dipotassium ... 23CLOSERCARE LANCETS . 56clotrimazole .............. 12clotrimazole-betamethasone 14clotrimazole lozenge ....... 10clozapine . . . . . . . . . . . . . . . . 21COAGUCHEK LANCETS . 56COARTEM .............. 13codeine phosphate injection 24codeine sulfate ........... 24co-gesic. ................ 25COLCRYS. .............. 77colestipol hcl ............. 33colistimethate 150 mg vial .. 10COMBIVENT ............ 94COMBIVENT RESPIMAT .. 94COMBIVIR ............... 8COMETRIQ ............. 16COMFORT EZ INS 0.3ML30GX1/2 .............. 56COMFORT EZ INS 0.3ML30GX5/16 ............. 56COMFORT EZ INSULIN SYR0.3 ML ................ 56COMFORT EZ INSULIN SYR0.5 ML ................ 56COMFORT EZ PEN NEEDLES5MM 31G. ............. 56COMFORT EZ PEN NEEDLES6MM 31G. ............. 56COMFORT EZ PEN NEEDLES8MM 31G. ............. 56COMFORT EZ SYR 0.3 ML29GX1/2 .............. 56COMFORT EZ SYR 0.5 ML28GX1/2 .............. 56COMFORT EZ SYR 0.5 ML29GX1/2 .............. 56COMFORT EZ SYR 0.5 ML30GX1/2 .............. 56COMFORT EZ SYR 1 ML28GX1/2 .............. 56COMFORT EZ SYR 1 ML29GX1/2 .............. 56COMFORT EZ SYR 1 ML30GX1/2 .............. 56COMFORT EZ SYR 1 ML30GX5/16 ............. 56COMFORT EZ SYR 1 ML31GX5/16 ............. 56COMFORT LANCETS. .... 56COMPLERA .............. 8complete natal dha ........ 86completenate. ............ 86compro. ................. 22COMTAN. ............... 28COMVAX. ............... 48co-natal fa ............... 86CONDYLOX GEL. ........ 39constulose ............... 78CONTOUR NEXT LEV 1CONTROL SOL ........ 56CONTOUR NEXT LEV 2CONTROL SOL ........ 56CONTOUR SOLUTION ... 56CONTROL SOLUTIONNORMAL . . . . . . . . . . . . . . 56COPAXONE ............. 40cormax .................. 38CORNWALL METAL PIPETHOLDER .............. 56cortisone acetate tablet .... 42CRESTOR. .............. 33CRIXIVAN ................ 8cromolyn sodium nebs ..... 94cromolyn sodium ophthdrops. ................. 91cromolyn sodium solution .. 94cryselle. ................. 83CUBICIN. ............... 10CUPRIMINE. ............ 78CURITY ALCOHOL PREPS 56CURITY ALCOHOLSWABS ............... 56CUVPOSA .............. 46CVS ALCOHOL 70% PREPSWABS ............... 56CVS ALCOHOL SWABS .. 56CVS INSULIN SYR 1 ML29GX1/2 .............. 56CVS ISOPROPYL ALCOHOL70% WIPE ............. 56CVS LANCETS. .......... 56CVS LANCETS-ORIGINAL 56CVS LANCETS-THIN. ..... 56CVS LANCING DEVICE ... 56CVS MICRO THIN 33GLANCETS. ............. 56CVS SYRINGE 1/2 ML .... 56CVS SYRINGE 3/10 ML. .. 57CVS THIN LANCETS ..... 57CVS ULTRA THINLANCETS. ............. 57cyclafem. ................ 83cyclobenzaprine hcl capsulesustained action, -tablet .. 76cyclopentolate hcl ophthdrops. ................. 91cyclophosphamide injection 16cyclophosphamide tablet ... 16cyclosporine 50 mg/ml amp 16cyclosporine capsule, -50 mg/mlvial, -solution. ........... 16cyclosporine modified ..... 16CYKLOKAPRON ......... 40CYMBALTA 20 MG CAPSULE,-60 MG CAPSULE ...... 28CYMBALTA 30 MGCAPSULE ............. 28cyproheptadine hcl syrup,-tablet ................. 92CYSTADANE. ............ 95CYSTAGON ............. 79cytarabine ............... 16102

cytra-2 .................. 82cytra-3 .................. 95cytra-k .................. 95Dd5%-1/4ns-kcl 10 meq/l iv sol,-d5%-1/4ns-kcl 30 meq/l ivsol, -d5%-1/4ns-kcl 40 meq/liv sol .................. 79d5w-kcl 30 meq/l iv solution,-d5w/kcl 30 meq/l ivsolution ................ 79dacarbazine .............. 16DACOGEN .............. 16danazol capsule .......... 83dantrolene sodium capsule . 76DAPSONE TABLET ........ 7DAPTACEL .............. 48DARAPRIM .............. 13daunorubicin . . . . . . . . . . . . . 16DECAVAC ............... 48delflex with 1.5% dextrose. . 79delflex with 2.5% dextrose. . 79delflex with 4.25% dextrose. 79DELZICOL .............. 46demeclocycline hcl tablet. .. 14DEMSER. ............... 33DENAVIR. ............... 11denta 5000 plus .......... 81dentagel. ................ 81depade. ................. 29DEPOCYT. .............. 16desipramine hcl tablet ..... 29desloratadine. ............ 92desloratadine odt ......... 92desmopressin ac injection .. 44desmopressin ac nasal drops/sprays, -solution, -tablet .. 44desonide cream, -lotion, -oint 38desoximetasone cream, -gel,-oint ................... 38DESVENLAFAXINE ER. ... 28DETROL ................ 95DETROL LA ............. 95dexamethasone elix. ....... 42dexamethasone intensol. ... 42dexamethasone sodiumphosphate injection ...... 42dexamethasone sodiumphosphate ophth drops. .. 90dexamethasone tablet ..... 42dexchlorpheniramine maleate 92dexmethylphenidate hcl .... 25dexrazoxane. ............. 16dextroamphetamineamphetamineer 10mg cap, -er15mg cap, -er 25mg cap, -er5mg cap ............... 25dextroamphetamineamphetamineer 20mg cap, -er30mg cap .............. 25dextroamphetamine sulfatecapsule sustained action,-tablet ................. 25dextrose 2.5%-wateriv soln, -25%-watersyringe, -30%-water ivsoln, -40%-water iv soln,-50%-water abboject,-50%-water iv soln,-50%-water syringe,-50%-water vial, -70%-water ivsoln . . . . . . . . . . . . . . . . . . . 79dextrose 5%-1/2ns-kcl. .... 79dextrose 5%-1/3ns-kcl. .... 79dextrose 5%-1/4ns iv solution,-5%-sod chloride 0.2%, -5%-1/3ns iv solution, -d10%-1/2nssoln/excel cont, -5%-1/2ns ivsolution, -2.5%-1/2ns iv soln,-5%-ns iv solution ....... 80dextrose 5%-electrolyte #48 80dextrose 5%-ns-kcl. ....... 80dextrose 5%-water iv soln,-10%-water iv solution. ... 80dextrose 10%-1/4ns. ...... 79dextrose 10%-ns iv solution. 79dextrose in lactated ringers . 80dextrose in ringers injection . 80diazepam injection, -solution,-tablet ................. 23diazepam rectal. .......... 27DIBENZYLINE ........... 33diclofenac- misoprost ...... 77diclofenac potassium ...... 77diclofenac sodium e.c. tab,-tablet sustained action. .. 77diclofenac sodium ophthdrops. ................. 91dicloxacillin sodium. ....... 13dicyclomine hcl capsule, -syrup,-tablet ................. 46didanosine ................ 8DIFICID ................. 10diflorasone diacetate ...... 38diflunisal tablet ........... 78digoxin injection .......... 35digoxin solution ........... 35digoxin tablet. ............ 35dihydroergotamine mesylateinjection ............... 26DILANTIN 30 MGCAPSULE ............. 26dilt-cd ................... 32diltiazem 24hr cd ......... 32diltiazem 24hr er .......... 32diltiazem 125 mg/25 ml vial, -50mg/10 ml vial ........... 32diltiazem er .............. 32diltiazem hcl tablet ........ 32diltiazem injection . . . . . . . . . 32dilt-xr. ................... 32diltzac er ................ 32dimenhydrinate injection. ... 22DIOVAN. ................ 31diphenhydramine 50 mg/mlvial .................... 92diphenhydramine hcl capsule 92diphenhydramine hcl elix, -50mg/ml syrng ............ 92diphenoxylate-atropine ..... 45DIPHTHERIA-TETANUSTOXOID ............... 48dipyridamole tablet ........ 78diskets .................. 24disopyramide phosphate ... 31103

disulfiram ................ 29divalproex sodium ......... 31divalproex sodium er. ...... 31dobutamine hcl ........... 35dobutamine hcl in dextrose . 35DOCEFREZ . . . . . . . . . . . . . 16docetaxel 20 mg/ml vial .... 16docetaxel 80 mg/8 ml vial, -80mg/4 ml vial ............ 16docetaxel 160 mg/16 ml vial, -20mg/2 ml vial, -20 mg/0.5 mlvial, -80 mg/2 ml vial ..... 16donepezil hcl ............. 20dopamine hcl in 5% dextrose 35dopamine hcl injection ..... 35DORIBAX VIAL. .......... 10dorzolamide hcl. .......... 90dorzolamide-timolol. ....... 90doxazosin mesylate 1 mg tab 36doxazosin mesylate 2 mg tab, -4mg tab, -8 mg tab ....... 36doxepin hcl capsule,-solution ............... 30DOXIL .................. 16doxorubicin .............. 16doxycycline hyclate 20 mgtab .................... 41doxycycline hyclate capsule, -e.c.cap, -e.c. tab, -100 mg tab 14doxycycline hyclate injection 14doxycycline monohydrate. .. 14DRITHOCREME HP ...... 37DR LANCET ............. 57dronabinol 2.5 mg capsule, -5mg capsule. ............ 22dronabinol 10 mg capsule .. 22droperidol injection. ........ 7DROPLET 30G LANCETS . 57drospirenone-eth estradiol .. 83DR SUPER THIN 30GLANCETS. ............. 57DRUG MART THINLANCETS. ............. 57DRUG MART ULTRACOMFORT SYR ........ 57DRUG MART ULTRA THINLANCETS. ............. 57DR ULTRA THIN LANCET . 57DR UNIFINE PENTIPS 6MMNDL. .................. 57DR UNIFINE PENTIPS 8MMNDL. .................. 57DR UNIFINE PENTIPS 12MMNDL. .................. 57DULERA ................ 94DUO-CARE CONTROLSOLUTION ............ 57duramorph 0.5mg/ml ampul,-1mg/ml ampul .......... 24duramorph 5mg/10ml ampul,-10mg/10ml ampul ...... 24dylix .................... 93DYSPORT ............... 76EEASY CHECK CONTROLSOLN HIGH ........... 57EASY CHECK CONTROLSOLN LOW ............ 57EASY COMFORT 0.3 MLSYRINGE. ............. 57EASY COMFORT 0.5 MLSYRINGE. ............. 57EASY COMFORT 30GLANCETS. ............. 57EASY COMFORT INSULIN 1ML SYR ............... 57EASYMAX HIGH CONTROLSOLN . . . . . . . . . . . . . . . . . 57EASYMAX LOW CONTROLSOLN . . . . . . . . . . . . . . . . . 57EASYMAX NORMALCONTROL SOLN. ...... 57EASY TALK CONTROL SOLNLOW .................. 57EASY TALK HIGH CONTROLSOLN . . . . . . . . . . . . . . . . . 57EASY TEST II LANCETS ... 57EASY TEST LANCETS .... 57EASY TOUCH 0.3 ML SYR30GX1/2 .............. 57EASY TOUCH 0.5 ML SYR27GX1/2 .............. 57EASY TOUCH 0.5 ML SYR30GX1/2 .............. 57EASY TOUCH 1 ML SYR27GX1/2 .............. 57EASY TOUCH 1 ML SYR30GX1/2 .............. 57EASY TOUCH ALCOHOL 70%PADS ................. 57EASY TOUCH CONTROLSOLUTION ............ 57EASY-TOUCH INS 1 ML31GX5/16 ............. 57EASY TOUCH INSULIN SYR0.3 ML ................ 57EASY TOUCH INSULIN SYR0.5 ML ................ 57EASY TOUCH INSULIN SYR 1ML. ................... 57EASY TOUCH LANCETS . . 57EASY TOUCH PEN NDL32GX1/4 .............. 57EASY TOUCH PEN NDL32GX3/16 ............. 57EASY TOUCH PEN NEEDLE29G. .................. 57EASY TOUCH PEN NEEDLE31G. .................. 57EASY TOUCH PEN NEEDLE31GX3/16 ............. 57EASY TRAK CONTROL SOLNHIGH ................. 57EASY TRAK CONTROL SOLNNORMAL . . . . . . . . . . . . . . 57ECLIPSE CONTROL SOLNNORMAL . . . . . . . . . . . . . . 57ECLIPSE CONTROLSOLUTION HIGH. ...... 58ECLIPSE CONTROLSOLUTION LOW ....... 58econazole nitrate. ......... 12EDURANT. ............... 8effer-k 25 meq tablet eff. ... 82EFFIENT ................ 78ELELYSO. ............... 44ELEMENT CONTROL SOLNNORMAL . . . . . . . . . . . . . . 58ELEMENT CONTROLSOLUTION HIGH. ...... 58ELEMENT CONTROLSOLUTION LOW ....... 58ELEMENT PLUS CONTROLSOLUTION ............ 58104

ELIDEL ................. 39ELIGARD ............... 16eliphos .................. 83ELITEK. ................. 16elite-ob. ................. 86elite-ob 400. ............. 86elite ob dha .............. 86ELITE-THIN INS SYR 0.5CC 58ELITE-THIN INSULIN SYR1CC .................. 58ELITE-THIN INSUL SYR0.3CC. ................ 58ELITE-THIN INSUL SYR0.5CC. ................ 58ELITE-THIN INSUL SYR1/2CC. ................ 58ELITE-THIN INSUL SYR1CC .................. 58ELLA ................... 83ELSPAR................. 16EMBRACE GLUC CONTROLSOLN LOW ............ 58EMCYT ................. 16EMEND 40 MG CAPSULE,-125 MG CAPSULE ..... 22EMEND 80 MG CAPSULE 22EMEND INJECTION ...... 22EMEND TRIFOLD PACK .. 22emoquette ............... 83EMSAM ................. 26EMTRIVA. ................ 8ENABLEX . . . . . . . . . . . . . . . 95enalaprilat ............... 31enalapril-hydrochlorothiazide 35enalapril maleate tablet .... 31ENBREL 25 MG/0.5 MLSYRINGE, -50 MG/MLSURECLICK SYR. ...... 16ENBREL 25 MG KIT ...... 16ENBREL 50 MG/MLSYRINGE. ............. 16endocet ................. 24endodan. ................ 24ENGERIX-B ............. 48enoxaparin 30 mg/0.3 ml syr 81enoxaparin 40 mg/0.4 ml syr 81enoxaparin 60 mg/0.6 ml syr 81enoxaparin 80 mg/0.8 ml syr 81enoxaparin 100 mg/ml syr .. 81enoxaparin 120 mg/0.8 mlsyr .................... 81enoxaparin 150 mg/ml syr .. 81enoxaparin 300 mg/3 ml vial 81enpresse ................ 83entacapone .............. 28enulose ................. 78ENVISION CONTROL SOLNHIGH ................. 58ENVISION CONTROL SOLNLOW .................. 58ENVISION CONTROL SOLNNORMAL . . . . . . . . . . . . . . 58epiflur ................... 81epinastine hcl ............ 91epinephrine 0.1 mg/ml syringe,-1 mg/ml ampul, -1 mg/mlvial .................... 94EPINEPHRINE 0.15 MGAUTO-INJCT, -0.3 MG AUTO-INJECT ................ 94EPIPEN ................. 94EPIPEN JR .............. 94epirubicin ................ 16epitol ................... 23EPIVIR HBV ............. 11EPIVIR SOLUTION ........ 8eplerenone. .............. 36EPOGEN 2,000 UNITS/MLVIAL, -3,000 UNITS/ML VIAL,-4,000 UNITS/ML VIAL,-20,000 UNITS/2 ML VIAL,-20,000 UNITS/ML VIAL . 48EPOGEN 10,000 UNITS/MLVIAL. .................. 48epoprostenol sodium ...... 36eprosartan mesylate ....... 31EPZICOM ................ 8EQL COLOR LANCETS ... 58EQL INS SYR 0.3 ML29GX1/2 .............. 58EQL INS SYR 0.3 ML30GX5/16 ............. 58EQL INS SYR 0.5 ML29GX1/2 .............. 58EQL INS SYR 0.5 ML30GX5/16 ............. 58EQL INS SYR 1 ML29GX1/2 .............. 58EQL INSULIN 0.3 MLSYRINGE. ............. 58EQL INSULIN 0.5 MLSYRINGE. ............. 58EQL INSULIN 1 MLSYRINGE. ............. 58EQL INSULIN SYR 1 ML29GX1/2 .............. 58EQL INSULIN SYR 1 ML30GX5/16 ............. 58EQL INSULIN SYR 1 ML31GX5/16 ............. 58EQL INSUL SYR 0.3 ML31GX5/16 ............. 58EQL INSUL SYR 0.5 ML31GX5/16 ............. 58EQL LANCETS THIN. ..... 58EQL PEN 8MM 31G X 5/16NEEDLE. .............. 58EQL PEN NEEDLE 6MM31G. .................. 58EQL SUPER THINLANCETS. ............. 58ERBITUX. ............... 16ergoloid mesylates tablet ... 40ERIVEDGE .............. 16errin .................... 89ery. ..................... 37ery-tab ................... 9erythrocin stearate ......... 9ERYTHROCIN VIAL FORINJECTION ............. 9erythromycin-benzoylperoxide ............... 37erythromycin e.c. cap, -tablet. 9erythromycin ethylsuccinatetablet. .................. 9erythromycin gel, -soln, top,-swabs, applicators ...... 37erythromycin oint. ......... 91erythromycin-sulfisoxazole .. 14escitalopram oxalate solution 30escitalopram oxalate tablet . 30estazolam. ............... 29105

ESTRACE VAGINALPRODUCTS. ........... 85estradiol adh. patch ....... 85estradiol-norethindroneacetat ................. 85estradiol tablet ........... 85estradiol valerate injection . . 85estropipate .............. 85ethambutol hcl. ............ 9ethosuximide capsule, -syrup 30etidronate disodium ....... 44etodolac capsule, -tablet, -tabletsustained action. ........ 77ETOPOPHOS ........... 16etoposide injection ........ 16EURAX ................. 38EVENCARE CONTROLSOLUTION ............ 58EVENCARE G2 CONTROLSOLUTION ............ 58EVENCARE G3 CONTROLSOLUTION ............ 58EVISTA. ................. 44EVOLUTION CONTROL SOLNNORMAL . . . . . . . . . . . . . . 58EXEL HYPO NEEDLE26GX0.5. .............. 58EXEL HYPO NEEDLE26GX1.5. .............. 58EXEL HYPO NEEDLE27GX0.5. .............. 58EXEL INS SYR U100 1 ML28GX1/2 .............. 58EXEL INSULIN PENNEEDLE. .............. 59EXEL INSULIN SYRINGE 27G-1 ML .................. 59EXEL INSULIN SYRN 27G-1/2ML. ................... 59EXEL INSUL PEN NEEDLES8MM .................. 58EXEL INSUL SYR 0.5 ML28GX1/2 .............. 59EXELON ADH. PATCH,-SOLUTION ............ 20EXEL U100 0.3 ML29GX1/2 .............. 59EXEL U100 0.3 ML30GX5/16 ............. 59EXEL U100 0.5 ML28GX1/2 .............. 59EXEL U100 0.5 ML29GX1/2 .............. 59EXEL U100 0.5 ML30GX5/16 ............. 59EXEL U100 1 ML30GX5/16 ............. 59EXEL U100 INS SYR 1 ML29GX1/2 .............. 59exemestane .............. 16EXFORGE .............. 35EXFORGE HCT .......... 35EXJADE 125 MG TABLET . 40EXJADE 250 MG TABLET, -500MG TABLET. ........... 40E-ZJECT COLOR 32GLANCETS. ............. 59E-ZJECT COLOR 33GLANCETS. ............. 59E-Z JECT COLOREDLANCETS. ............. 59E-Z JECT LANCETS ...... 59E-Z JECT SUPER THINLANCETS. ............. 59E-ZJECT THIN LANCETS .. 59EZ-LETS LANCETS 23G .. 59EZ SMART BLOOD GLUCOSELANCETS. ............. 59EZ SMART HIGH CONTROLSOLUTION ............ 59EZ SMART LOW CONTROLSOLUTION ............ 59EZ SMART NORMALCONTROL SOLN. ...... 59FFABRAZYME 35 MG VIAL . 44famciclovir 125 mg tablet, -500mg tablet. .............. 11famciclovir 250 mg tablet .. 11famotidine injection. ....... 46famotidine oral susp ....... 46famotidine tablet .......... 46FANAPT. ................ 21FARESTON .............. 16FASLODEX .............. 16FAST TAKE MONITORINGSYSTEM ............... 59FAST TAKE TEST STRIPS . 59FAZACLO ............... 21fe c ..................... 86felbamate. ............... 27felodipine er. ............. 32FEMHRT 0.5 MG-2.5 MCGTABLET. ............... 85fem ph .................. 85fenofibrate ............... 33fenoprofen calcium tablet. .. 77fentanyl ................. 24fentanyl 0.05 mg/ml ampul, -0.05mg/ml syringe, -0.05 mg/mlvial, -1 mg/20 ml vial, -100mcg/2 ml vial, -250 mcg/5 mlvial .................... 24fentanyl 2,500 mcg/50 mlvial .................... 24fentanyl citrate lozenge. .... 24FERRIPROX. ............ 40fexofenadine hcl .......... 92FIFTY50 ALCOHOL PREPPADS ................. 59FIFTY50 GLUCOSECONTROL SOLN. ...... 59FIFTY50 INS SYR 1 ML31GX5/16 ............. 59FIFTY50 INSULIN SYRINGE0.3 ML ................ 59FIFTY50 INSULIN SYRINGE0.5 ML ................ 59FIFTY50 PEN 31G X 3/16NEEDLE. .............. 59FIFTY50 PEN 31G X 5/16NEEDLE. .............. 59FIFTY50 SAFETY SEAL 30GLANCET ............... 59FIFTY50 SAFETY SEAL 32GLANCET ............... 59finasteride 5mg tablet. ..... 95FINE 30 UNIVERSAL 30GLANCETS. ............. 59FINGERSTIX LANCETS ... 59FIRAZYR ................ 48FIRMAGON ............. 16flavoxate hcl. ............. 95106

flecainide acetate ......... 31FLECTOR ............... 77FLOVENT DISKUS. ....... 94FLOVENT HFA 44 MCGINHALER .............. 94FLOVENT HFA 110 MCGINHALER .............. 94FLOVENT HFA 220 MCGINHALER .............. 94floxuridine. ............... 16FLUARIX 2011-2012. ..... 48fluconazole. .............. 12fluconazole 150 mg tablet .. 10fluconazole suspension, -50 mgtablet, -100 mg tablet, -200mg tablet. .............. 10flucytosine capsule ........ 10fludarabine 50 mg/2 ml vial . 16fludarabine 50mg vial ...... 16fludrocortisone acetatetablet. ................. 44FLULAVAL 2011-2012 .... 48flumazenil. ............... 29FLUMIST NASAL 2011-12VACCINE .............. 48flunisolide 0.025% spray ... 41flunisolide 29 mcg-0.025%spr .................... 41fluocinolone acetonide cream,-oil,shampoo,cleanser, -oint,-soln, top. .............. 38fluocinolone acetonide oil .. 41fluocinonide cream, -gel, -oint,-soln, top. .............. 38fluocinonide-e ............ 38fluocinonide emollient. ..... 38fluor-a-day chew tab ....... 81FLUOR-A-DAY ORALDROPS ............... 81fluoride. ................. 81fluoridex daily defense ..... 81fluoritab chew tab ......... 81fluorometholone ophth drops 90FLUOROPLEX ........... 39fluorouracil. .............. 16fluorouracil cream, -soln, top 39fluoxetine dr .............. 30fluoxetine hcl 10 mg capsule,-20 mg capsule ......... 30fluoxetine hcl 10 mg tablet. . 30fluoxetine hcl 20 mg tablet. . 30fluoxetine hcl 40 mg capsule 30fluoxetine hcl solution ...... 30fluphenazine decanoateinjection ............... 21fluphenazine hcl .......... 21flurazepam hcl ............ 29flurbiprofen sodium. ....... 91flurbiprofen tablet ......... 77flutamide ................ 16fluticasone propionate cream,-lotion, -oint. ............ 38fluticasone propionate nasalinhaled steroids ......... 41fluvastatin sodium 20 mgcap ................... 33fluvastatin sodium 40 mgcap ................... 33FLUVIRIN 2011-2012 ..... 48fluvoxamine maleate 25 mgtab .................... 30fluvoxamine maleate 50 mgtab .................... 30fluvoxamine maleate 100 mgtab .................... 30FLUZONE 2011-2012 .... 48FLUZONE 2011-2012 (PF) 48FLUZONE 2012-2013 .... 48FLUZONE HIGH-DOSE 2011-12 (PF) . . . . . . . . . . . . . . . . 48FLUZONE HIGH-DOSE 2012-13 .................... 48FLUZONE INTRADERMAL. 48FLUZONE INTRADERMAL2012-2013. ............ 48FLUZONE PEDI 2012-2013 48folbecal ................. 86folcal dha ................ 86folcaps omega-3 .......... 86folinatal plus b ............ 86folivane-ec calcium dha nf .. 86folivane-ob ............... 86folivane-prx dha nf. ........ 86FOLOTYN ............... 16fomepizole ............... 40fondaparinux 2.5 mg/0.5 mlsyr .................... 81fondaparinux 5 mg/0.4 ml syr 81fondaparinux 7.5 mg/0.6 mlsyr .................... 81fondaparinux 10 mg/0.8 mlsyr .................... 81FORADIL. ............... 93FORA HIGH CONTROLSOLUTION ............ 59FORA LANCETS ......... 59FORA LOW CONTROLSOLUTION ............ 59FORA NORMAL CONTROLSOLUTION ............ 59FORFIVO XL TABLET ..... 28FORTEO ................ 44FORTESTA .............. 83fortical .................. 44foscarnet sodium ......... 11fosinopril-hydrochlorothiazide 35fosinopril sodium. ......... 31fosphenytoin ............. 26FREESTYLE CONTROLSOLUTION ............ 59FREESTYLE LANCETS. ... 59FREESTYLE PREC 0.5 ML30GX5/16 ............. 59FREESTYLE PREC 0.5 ML31GX5/16 ............. 59FREESTYLE PREC 1 ML30GX5/16 ............. 59FREESTYLE PREC 1 ML31GX5/16 ............. 59FREESTYLE UNISTIK 2LANCETS. ............. 60furosemide injection ....... 34furosemide solution ....... 34furosemide tablet ......... 34FUSILEV ................ 17FUZEON ................. 8Ggabapentin capsule, -tablet . 27gabapentin solution ....... 27GABITRIL 12 MG TABLET -16MG TABLET. ........... 27galantamine hbr .......... 20107

GAMASTAN S-D. ......... 48GAMMAGARD LIQUID. ... 48GAMMAGARD S-D ....... 48GAMUNEX .............. 49GAMUNEX-C ............ 49ganciclovir injection ....... 11garamycin ophth drops. .... 91GARDASIL .............. 49gavilyte-c ................ 46gavilyte-g ................ 46gavilyte-n ................ 46GE100 CONTROL SOLUTIONNORMAL . . . . . . . . . . . . . . 60gemcitabine 1 gram/26.3 mlvl ..................... 17gemcitabine 200 mg/5.26 ml vl,-200 mg vial ............ 17gemcitabine hcl 1 gram vial,-2 gram/52.6 ml vl, -2 gramvial .................... 17gemfibrozil tablet. ......... 33generlac. ................ 78gengraf. ................. 17gentak .................. 91gentamicin. ............... 7gentamicin 3 mg/gm eye oint,-ophth drops. ........... 91gentamicin sulfate cream, -0.1%ointment ............... 14gentex ade. .............. 86GENTLE-LET GP 26GLANCETS. ............. 60GENTLE-LET GP 28GLANCETS. ............. 60GENTLE-LET G.P.LANCETS. ............. 60GENTLE-LET SAFETYLANCETS. ............. 60GEODON INJECTION .... 21gianvi ................... 83gildagia ................. 83gildess fe ................ 83GILENYA. ............... 40GLASSIA. ............... 95GLEEVEC ............... 17glimepiride ............... 43glipizide er ............... 43glipizide-metformin ........ 43glipizide tablet ............ 43glipizide xl ............... 43GLUCAGEN. ............ 42GLUCAGON EMERGENCYKIT. ................... 42GLUCOCARD 01 CONTROLSOLUTION ............ 60GLUCOCARD EXPRESSIONCNTRL SLN. ........... 60GLUCOCARD X-METERCONTROL SOLN. ...... 60GLUCOCOM 30GLANCETS. ............. 60GLUCOCOM 33GLANCETS. ............. 60GLUCOCOM CONTROLSOLUTION ............ 60GLUCOCOM LANCETS28G. .................. 60GLUCOLAB CONTROL SOLNNORMAL . . . . . . . . . . . . . . 60GLUCOLAB CONTROLSOLUTION HIGH. ...... 60GLUCOLAB CONTROLSOLUTION LOW ....... 60GLUCOPRO INSULIN SYR 0.5ML. ................... 60GLUCOPRO INSULIN SYR 1ML. ................... 60GLUCOPRO INSULIN SYRU100 1 ML. ............ 60GLUCOPRO INSUL SYR U1000.3 ML ................ 60GLUCOPRO INSUL SYR U1000.5 ML ................ 60GLUCOPRO SYRINGE U1001 ML .................. 60GLUCOPRO U100 INSUL SYR0.3 ML ................ 60GLUCOSE CONTROL SOLNNORMAL . . . . . . . . . . . . . . 60GLUCOSE CONTROLSOLUTION ............ 60GLUCOSOURCELANCETS. ............. 60glyburide-metformin hcl .... 43glyburide micronized. ...... 43glyburide tablet ........... 43glycine .................. 95glycopyrrolate injection,-tablet ................. 46GNP ALCOHOL PREPSWABS ............... 60GNP ALCOHOL SWAB ... 60GNP CLICKFINE 31G X 1/4NDL. .................. 60GNP CLICKFINE 31G X 5/16NDL. .................. 60GNP CLICKFINE PEN NDL31GX1/4 .............. 60GNP CLICKFINE PEN NDL31GX5/16 ............. 60GNP INSULIN SYR 1 ML31GX5/16 ............. 60GNP INSUL SYR 0.3 ML31GX5/16 ............. 60GNP INSUL SYR 0.5 ML31GX5/16 ............. 60GNP LANCETS .......... 60GNP MICRO THIN 33GLANCETS. ............. 60GNP SUPER THINLANCETS. ............. 60GNP THIN LANCETS ..... 60GNP ULTRA COMFORT 0.5ML SYR ............... 60GNP ULTRA COMFORT 1 MLSYRINGE. ............. 60GNP ULTRA COMFORT 3/10ML SYR ............... 61granisetron hcl 0.1 mg/ml vial, -4mg/4 ml vial ............ 22granisetron hcl 1 mg/ml vial. 22granisetron hcl tablet ...... 22granisol ................. 22griseofulvin micro tablet .... 10griseofulvin oral susp ...... 10griseofulvin ultra tablet ..... 10guanfacine hcl. ........... 33guanidine hcl ............. 29HHAEMOLANCE LANCET .. 61HAEMOLANCE PLUSLANCET ............... 61108

HAEMOLANCE PLUSLANCETS. ............. 61HAEMOLANCE,RETRACTABLE ......... 61HALAVEN ............... 17halobetasol propionate. .... 38halonate pac ............. 38haloperidol decanoate ..... 21haloperidol decanoate 100 . 21haloperidol injection . . . . . . . 21haloperidol lactate ........ 21haloperidol tablet ......... 21HAVRIX ................. 49HEALTHY ACCENTS PENTIP5MM 31G. ............. 61HEALTHY ACCENTS PENTIP6MM 31G. ............. 61HEALTHY ACCENTS PENTIP8MM 31G. ............. 61HEALTHY ACCENTS PENTP12MM 29G ............ 61HEALTHY ACCENTS UNILET30G. .................. 61heather. ................. 89hecoria 0.5 mg capsule, -1 mgcapsule ................ 17hecoria 5 mg capsule. ..... 17hemenatal ob. ............ 86hemenatal ob + dha ....... 86heparin-d5w 20,000 unit/500ml. .................... 82heparin-d5w 25,000 unit/500ml, --d5w 25,000 unit/250ml. .................... 82heparin iv flush 1 unit/ml syr, -ivflush 10 unit/ml sy, -lock flush10 units/ml, -iv flush 100 units/ml, -lock flush 100 unit/ml. 81heparin lock 10 units/ml vial,-flush 10 units/ml, -100 units/ml vial, -flush 100 unit/ml . 81heparin-ns 1,000 unit/500ml. .................... 82heparin-ns 2,000 unit/1,000ml. .................... 82heparin sod 1,000 unit/ml vial,-sod 5,000 unit/ml vial, -sod10,000 unit/ml vl, -sod 20,000unit/ml vl ............... 81heparin sod 2,000 unit/ml vial,-sod 2,500 unit/ml vial, -sod5,000 unit/ml syr, -sod 5,000unit/ 0.5 ml, -sod 5,000unit/0.5 ml. ............. 81heparin sodium in 0.45%nacl . . . . . . . . . . . . . . . . . . . 82HEPSERA. .............. 11HERCEPTIN. ............ 17HEXALEN ............... 17H&H THINLET LANCETS .. 61HIBERIX . . . . . . . . . . . . . . . . 49HM MICRO THIN 33GLANCETS. ............. 61HM ULTRA THIN 30GLANCETS. ............. 61homatropaire ............. 91homatropine ............. 91HORIZANT .............. 27hpr plus ................. 39HUMALOG .............. 43HUMALOG MIX 50-50 . . . . 43HUMALOG MIX 75-25 .... 43HUMAPEN LUXURA HD .. 61HUMAPEN MEMOIR ..... 61HUMATROPE. ........... 47HUMIRA 20 MG/0.4 MLSYRINGE. ............. 17HUMIRA 40 MG/0.8 ML PEN,-40 MG/0.8 ML SYRINGE,-CROHN’S STARTER PACK,-PSORIASIS STARTERPACK ................. 17HUMULIN 70-30 ......... 43HUMULIN N ............. 43HUMULIN R ............. 43HYALGAN ............... 78HYCAMTIN CAPSULE .... 17hydralazine hcl injection .... 36hydralazine hcl tablet ...... 36hydrochlorothiazide capsule,-tablet ................. 36hydrocodone-acetaminophen 25hydrocodone bit-ibuprofen. . 25hydrocortisone 1% cream .. 38hydrocortisone 1% cream, -plus1% cream, -2.5% cream,-lotion, -oint, -sol. ........ 39hydrocortisone-acetic acid. . 41hydrocortisone butyrate .... 39hydrocortisone rectal ...... 46hydrocortisone tablet ...... 42hydrocortisone valerate .... 39hydrogesic. .............. 25hydromorphone hcl injection,-rectal, -solution, -tablet. .. 24hydroxychloroquine sulfatetablet. ................. 13hydroxyurea capsule ....... 17hydroxyzine hcl injection. ... 23hydroxyzine hcl syrup, -tablet 23hydroxyzine pamoate capsule 23hypercare. ............... 39HYPER-SAL ............. 94HYPODERMIC NEEDLE,ALUMHUB .................. 61HY-VEE LANCETS ........ 61HY-VEE THIN LANCET .... 61Iibandronate sodium ....... 44ibuprofen oral susp. ....... 77ibuprofen tablet. .......... 77ibutilide fumarate. ......... 34ICLUSIG . . . . . . . . . . . . . . . . 17idarubicin hcl ............. 17ifosfamide 1 gm/ 20 ml vial, -3gm vial, -3 gm/ 60 ml vial . 17ifosfamide 1 gm vial ....... 17ifosfamide-mesna ......... 17ILARIS .................. 50imipenem-cilastatin sodium . 10imipramine hcl tablet. ...... 30imipramine pamoate ....... 30imiquimod cream. ......... 39IMOVAX RABIES VACCINE 49inatal advance ............ 86inatal gt ................. 86inatal ultra ............... 86INCIVEK ................. 8INCONTROL PEN NDL31GX3/16 ............. 61109

IN CONTROL PEN NEEDLE6MM 31G. ............. 61IN CONTROL PEN NEEDLE8MM 31G. ............. 61IN CONTROL PEN NEEDLE12MM 29G ............ 61INCONTROL PEN NEEDLES4MM 32G. ............. 61INCONTROL SUPER THINLANCETS. ............. 61INCONTROL ULTRA THINLANCETS. ............. 61INCRELEX .............. 44indapamide .............. 36indomethacin capsule, -capsulesustained action, -injection 77INFANRIX ............... 49INFERGEN 9 MCG/0.3 MLVIAL. .................. 50INFERGEN 15 MCG/0.5 MLVIAL. .................. 50INFINITY CONTROL SOLNHIGH ................. 61INFINITY CONTROL SOLNLOW .................. 61INFINITY CONTROL SOLNNORMAL . . . . . . . . . . . . . . 61INFLUENZA A (H1N1)2009 .................. 49INJECT EASE 28GLANCETS. ............. 61INJECT EASE 30GLANCETS. ............. 61INJECT-EASE SYR NDLINTRODUCER ......... 61INJEX 30 AMPULE ....... 61INLYTA. ................. 17INSULIN 1/2 ML SYRINGE 61INSULIN 1 ML SYRINGE. . 61INSULIN 3/10 MLSYRINGE. ............. 61INSULIN SYR 1/2 ML BULKPACK ................. 61INSULIN SYRIN 0.3 ML29GX1/2 .............. 61INSULIN SYRIN 0.3 ML30GX1/2 .............. 61INSULIN SYRIN 0.3 ML30GX5/16 ............. 61INSULIN SYRIN 0.3 ML31GX5/16 ............. 61INSULIN SYRIN 0.5 ML28GX1/2 .............. 61INSULIN SYRIN 0.5 ML29GX1/2 .............. 61INSULIN SYRIN 0.5 ML30GX1/2 .............. 61INSULIN SYRIN 0.5 ML30GX5/16 ............. 61INSULIN SYRIN 0.5 ML31GX5/16 ............. 61INSULIN SYRIN 1 ML29GX1/2 .............. 62INSULIN SYRINGE 0.3 ML 62INSULIN SYRINGE 0.5 ML 62INSULIN SYRINGE 1 ML. . 62INSULIN SYRINGE 1 ML28GX1/2 .............. 62INSULIN SYRINGE 1 ML29GX1/2 .............. 62INSULIN SYRINGE 1 ML30GX1/2 .............. 62INSULIN SYRINGE 1 ML30GX5/16 ............. 62INSULIN SYRINGE 1 ML31GX5/16 ............. 62INSULIN SYRINGE 1 ML-HARD PK .............. 62INSULIN SYRINGE 30GX1 MLSYR................... 62INSULIN SYRINGE U100 0.5ML. ................... 62INSULIN SYRINGE U100 1ML. ................... 62INSULIN SYRINGE U1001ML. .................. 62INSULIN U100-1 MLSYRINGE. ............. 62INSUMED SYR 0.3 ML31GX5/16 ............. 62INSUPEN 29G ULTRAFINNEEDLE. .............. 62INSUPEN 30G ULTRAFINNEEDLE. .............. 62INSUPEN 31G ULTRAFINNEEDLE. .............. 62INSUPEN 32G 4MM PENNEEDLE. .............. 62INSUPEN 32G 6MM PENNEEDLE. .............. 62INSUPEN 32G 8MM PENNEEDLE. .............. 62INTELENCE 25 MG TABLET 8INTELENCE 100 MG TABLET,-200 MG TABLET ........ 8INTRON A 3 MILLION UNIT/MLPEN, -6 MILLION UNIT/MLVL, -10 MILLION UNIT PEN,-10 MILLION UNIT/ML, -10MILLION UNITS VIAL. ... 50INTRON A 5 MILLION UNIT/ML PEN, -18 MILLION UNITSVIAL, -50 MILLION UNITSVIAL. .................. 50introvale ................. 84INTUNIV ................ 29INVACARE 30G LANCETS 62INVANZ VIAL ............ 10INVEGA. ................ 21INVEGA SUSTENNA 39 MGPREF SYR, -78 MG PREFSYR................... 21INVEGA SUSTENNA 117 MGPREF SY, -156 MG PREF SY,-234 MG PREF SY ...... 21INVIRASE CAPSULE. ...... 8INVIRASE TABLET. ........ 8IPOL. ................... 49ipratropium 0.03% spray ... 41ipratropium 0.06% spray ... 41ipratropium-albuterol. ...... 94ipratropium bromide nebs .. 94irbesartan. ............... 31irbesartanhydrochlorothiazide...... 35IRESSA ................. 17irinotecan hcl. ............ 17ISENTRESS .............. 8isoditrate ................ 34iso gentamicin. ............ 7isonarif ................... 9110

isoniazid injection, -syrup,-tablet .................. 9isosorbide dinitrate ........ 34isosorbide mononitrate. .... 34isosorbide mononitrate er .. 34isradipine ................ 32ISTODAX. ............... 17itraconazole capsule. ...... 10IXEMPRA ............... 17IXIARO. ................. 49JJAKAFI .................. 17jantoven ................. 82JANUMET . . . . . . . . . . . . . . . 43JANUMET XR ............ 43JANUVIA ................ 43jevantique ............... 85JE-VAX. ................. 49JEVTANA ................ 17jinteli. ................... 85jolessa .................. 84jolivette. ................. 89junel .................... 84junel fe .................. 84JUVISYNC. .............. 43KKADCYLA . . . . . . . . . . . . . . . 17KALETRA 100-25 MGTABLET. ................ 8KALETRA SOLUTION, -200-50MG TABLET. ............ 8kalexate ................. 35KALYDECO TABLET ...... 95kanamycin sulfate injection .. 7kariva ................... 84kcl 10 meq in d5w-1/4 ns, -kcl10 meq in d5w-1/4 ns, -kcl 20meq in d5w-1/4 ns, -kcl 5 meqin d5w-1/4 ns. .......... 80kcl 20 meq in d5w-lactringer. ................. 82kcl 20 meq in d5w solution,-d5w/kcl 40 meq/l ivsolution, -kcl 40 meq in d5wsolution ................ 82kcl 40 meq in d5w-lactringer. ................. 82KEEP FIT SAFETY 21GLANCETS. ............. 62KEEP FIT SAFETY 23GLANCETS. ............. 62KEEP FIT SAFETY 26GLANCETS. ............. 62KEEP FIT SAFETY LANCETS28G. .................. 62KEEP FIT TWIST 30GLANCETS. ............. 62KEEP FIT TWIST 32GLANCETS. ............. 62KEEP FIT TWIST 33GLANCETS. ............. 62KEEP FIT TWIST LANCETS28G. .................. 62k effervescent ............ 82kelnor 1-35 .............. 84KEPIVANCE ............. 49ketamine hcl .............. 7KETEK .................. 10ketoconazole ............. 12ketoconazole tablet. ....... 10ketodan foam. ............ 12ketoprofen capsule, -capsulesustained action. ........ 77ketorolac 0.4% ophthsolution ................ 91ketorolac 0.5% ophthsolution ................ 91ketorolac injection. ........ 77ketorolac tablet ........... 77KINERET. ............... 50KINNEY BRAND 23GLANCETS. ............. 62KINRAY INS SYR 1 ML31GX5/16 ............. 62KINRAY SYRING 0.3 ML31GX5/16 ............. 62KINRAY SYRING 0.5 ML31GX5/16 ............. 62KINRIX. ................. 49kionex oral susp .......... 35klor-con 8. ............... 82klor-con 10 .............. 82klor-con 20 meq packet .... 82klor-con-ef ............... 82klor-con m10 ............. 82klor-con m15 ............. 82klor-con m20 ............. 82KMART VALU PLUS SYR 1/2ML. ................... 62KMART VALU PLUS SYR 3/10ML. ................... 62KMART VALU PLUS SYRINGE1 ML .................. 62KN THIN LANCETS. ...... 62KOMBIGLYZE XR ........ 43KORLYM ................ 44K-PHOS M.F.. ............ 95K-PHOS NO.2 ........... 95K-PHOS ORIGINAL ...... 95KROGER INS SYR 0.3 ML30GX5/16 ............. 62KROGER INS SYR 0.5 ML29GX1/2 .............. 62KROGER INS SYR 1 ML29GX1/2 .............. 62KROGER INS SYR 1 ML31GX5/16 ............. 62KROGER INS SYRINGE 3/10ML. ................... 62KROGER INSULIN SYRINGE 1ML. ................... 62KROGER LANCETS ...... 62KROGER PEN NEEDLES29G. .................. 62KROGER PEN NEEDLES 31GX 5/16. ................ 62KROGER SUPER THINLANCETS. ............. 62KROGER SYR 0.5 ML30GX5/16 ............. 62KROGER SYRING 0.3 ML31GX5/16 ............. 63KROGER SYRING 0.5 ML31GX5/16 ............. 63KROGER THIN LANCETS . 63KRYSTEXXA ............. 77KUVAN. ................. 44Llabetalol hcl injection ...... 32labetalol hcl tablet. ........ 32LACRISERT ............. 91lactated ringers injection ... 80lactated ringers solution. ... 80111

lactulose ................ 78LADY LITE LANCETS ..... 63LAMISIL 125 MG GRANULESPACKET . . . . . . . . . . . . . . . 10LAMISIL 187.5 MG GRANULESPACK ................. 10LAMISIL SOLUTION ...... 12lamivudine ................ 8lamivudine-zidovudine. ...... 8lamotrigine. .............. 27lamotrigine er. ............ 27LANCETS ............... 63LANCETS 26G X 1.8MM .. 63LANCETS 28G. .......... 63LANCETS 30G. .......... 63LANCETS THIN .......... 63LANCETS ULTRA THIN. ... 63LANOXIN TABLET ........ 35lansoprazole capsule sustainedaction ................. 47LANTUS ................ 43LANTUS SOLOSTAR. ..... 43latanoprost. .............. 90LATUDA. ................ 21LEADER COLOREDLANCETS. ............. 63LEADER INS SYR 0.3 ML29GX1/2 .............. 63LEADER INS SYR 0.5 ML28GX1/2 .............. 63LEADER INS SYR 0.5 ML29GX1/2 .............. 63LEADER INS SYR 0.5 ML30GX1/2 .............. 63LEADER INS SYR 1 ML28GX1/2 .............. 63LEADER INS SYR 1 ML29GX1/2 .............. 63LEADER INS SYR 1 ML30GX1/2 .............. 63LEADER INS SYR 1 ML30GX5/16 ............. 63LEADER INS SYR 1 ML31GX5/16 ............. 63LEADER INSULIN SYRINGE0.3 ML ................ 63LEADER PEN NEEDLE 6MM31G. .................. 63LEADER PEN NEEDLES 12MM29G. .................. 63LEADER PEN NEEDLES31G. .................. 63LEADER SUPER THINLANCETS. ............. 63LEADER SYRING 0.3 ML31GX5/16 ............. 63LEADER SYRING 0.5 ML31GX5/16 ............. 63LEADER THIN LANCETS .. 63leena. ................... 84leflunomide .............. 17lessina .................. 84LETAIRIS ................ 36letrozole ................. 17leucovorin calcium injection. 17leucovorin calcium tablet ... 17LEUKERAN. ............. 17LEUKINE. ............... 51leuprolide acetate injection . 89levalbuterol concentrate. ... 93LEVEMIR. ............... 43levetiracetam injection ..... 27levetiracetam solution, -tablet,-tablet sustained action. .. 27levobunolol hcl ........... 90levocarnitine injection ...... 83levocarnitine solution, -tablet 83levocetirizine dihydrochloridesolution ................ 92levocetirizine dihydrochloridetablet. ................. 92levofloxacin-d5w injection .. 13levofloxacin injection. ...... 13levofloxacin ophth drops ... 91levofloxacin solution, -tablet. 13levomefolate dha. ......... 86levomefolatepnv .......... 86levonest ................. 84levonorgestrel ............ 84levonorgestrel-eth estradiol . 84levonorg-eth estrad ethestrad ................. 84levora-28 ................ 84levorphanol tartrate tablet .. 24levothroid. ............... 45LEVOTHYROXINE 100 MCGVIAL. .................. 45levothyroxine 500 mcg vial. . 45levothyroxine sodium tablet . 45levoxyl. .................. 45LEXIVA ORAL SUSP. ...... 8LEXIVA TABLET ........... 8LIBERTY CONTROL SOLNNORMAL . . . . . . . . . . . . . . 63LIBERTY CONTROLSOLUTION HIGH. ...... 63LIBERTY LEV 1 GLUCOSECTRL SOL ............. 63LIBERTY LEV 2 GLUCOSECTRL SOL ............. 63lidocaine hcl cream, -oint,-dental, -gel, -lotion ....... 7lidocaine hcl-dextrose. ...... 7lidocaine hcl-epinephrine .... 7lidocaine hcl injection ....... 7lidocaine hcl viscous. ....... 7lidocaine-hydrocortisone cream,-kit . . . . . . . . . . . . . . . . . . . . 39lidocaine-hydrocortisonerectal .................. 46lidocaine-prilocaine. ........ 7LIDODERM. .............. 7LIFESCAN FINE POINTLANCETS. ............. 63LIFESCAN UNISTIK 2LANCETS. ............. 63lindane .................. 38LINZESS CAPSULE ...... 46liothyronine sodium injection 45liothyronine sodium tablet .. 45LIPODOX ............... 17LIPODOX 50 ............ 17liposyn iii ................ 80lisinopril-hydrochlorothiazide 35lisinopril tablet ............ 31LITE TOUCH 30GLANCETS. ............. 63LITE TOUCH INSULIN 0.3 MLSYR................... 63LITE TOUCH INSULIN 0.5 MLSYR................... 63LITE TOUCH INSULIN 1 MLSYR................... 63112

LITE TOUCH INSULIN SYR 0.3ML. ................... 63LITE TOUCH INSULIN SYR 0.5ML. ................... 63LITE TOUCH INSULIN SYR 1ML. ................... 63LITE TOUCH PEN NEEDLE29G. .................. 63LITE TOUCH PEN NEEDLE31G. .................. 63lithium. .................. 29lithium carbonate capsule,-tablet, -tablet sustainedaction ................. 29LIVE BETTER PEN NEEDLE6MM 31G. ............. 63LIVE BETTER PEN NEEDLES8MM .................. 63LIVE BETTER PEN NEEDLES12MM ................. 63LIVE BETTER SUPER THINLANCET ............... 63LIVE BETTER ULTRA THINLANCET ............... 63LODOSYN .............. 28LONGS LANCETS 21G . . . 63LONGS THIN LANCETS26G. .................. 63LONGS THIN LANCETS30G. .................. 64loperamide capsule ....... 45lorazepam injection, -solution,-tablet ................. 23lorazepam intensol ........ 23loryna ................... 84losartan-hydrochlorothiazide 35losartan potassium ........ 31LOTRONEX ............. 46lovastatin 10 mg tablet. .... 33lovastatin 20 mg tablet, -40 mgtablet. ................. 33LOVAZA................. 33low-ogestrel. ............. 84loxapine ................. 21lozi-flur .................. 81ludent fluoride ............ 81lugol’s solution ........... 45LUPRON DEPOT 3.75 MG KIT,-7.5 MG KIT, -22.5 MG 3MOKIT, --4 MONTH KIT ..... 89LUPRON DEPOT 11.25 MG3MO KIT. .............. 89LUPRON DEPOT 45 MG 6MOKIT. ................... 17LUPRON DEPOT-PED .... 89lutera ................... 84LYRICA ................. 27LYSINE HCL ............. 80LYSODREN. ............. 17Mmacnatal cn dha . . . . . . . . . . 86mafenide acetate ......... 14MAGELLAN INSULINSYRINGE 1 ML. ........ 64MAGELLAN INSUL SYRINGE0.5 ML ................ 64magnesium sulfate injection. 80MAJOR COMFORTLANCETS. ............. 64MAKENA ................ 89malathion ................ 38mannitol injection ......... 80maprotiline hcl. ........... 28marlissa ................. 84MARPLAN. .............. 26MATULANE. ............. 17matzim la ................ 32MAXI-COMFORT INS 0.5 ML28G. .................. 64MAXI-COMFORT INS 1 ML28GX1/2 .............. 64MAXIMA CONTROLSOLUTION ............ 64meclizine hcl tablet ........ 22meclofenamate sodiumcapsule ................ 77MEDI-LANCE LANCETS. .. 64MEDISENSE CONTROLSOLUTION ............ 64MEDISENSE GLUC-KETCONT SOL ............ 64MEDISENSE H-L CONTROLSOLUTION ............ 64MEDISENSE H-M-L CONTROLSOLN . . . . . . . . . . . . . . . . . 64MEDISENSE MID CONTROLSOLUTION ............ 64MEDISENSE THINLANCETS. ............. 64MEDLANCE PLUS 21GLANCETS. ............. 64MEDLANCE PLUS 30GLANCETS. ............. 64MEDLANCE PLUS EXTRALANCETS. ............. 64MEDLANCE PLUS LITE 25GLANCETS. ............. 64MEDLANCE PLUS LITELANCETS. ............. 64MEDLANCE PLUS UNIVERSALLANCET ............... 64MEDPOINT CONTROLSOLUTION ............ 64medroxyprogesterone acetateinjection, -tablet ......... 89mefenamic acid capsule. ... 77mefloquine hcl. ........... 13megestrol acetate oral susp,-tablet ................. 17MEIJER LANCETS. ....... 64MEIJER THIN GAUGELANCETS. ............. 64meloxicam oral susp ....... 77meloxicam tablet .......... 77melphalan hcl ............ 17MENACTRA ............. 49MENEST ................ 85MENOMUNE-A-C-Y-W-135 49MENVEO A-C-Y-W-135-DIP 49meperidine hcl injection,-solution, -tablet ......... 24meperitab. ............... 24meprobamate ............ 23MEPRON ............... 10mercaptopurine tablet ..... 17meropenem vial. .......... 10mesalamine kit, -rectal ..... 46mesna .................. 17MESNEX TABLET ........ 17MESTINON SYRUP, -TABLETSUSTAINED ACTION. ... 29metadate er .............. 25113

metaproterenol sulfate syrup,-tablet ................. 93metaxalone .............. 76metformin hcl. ............ 44metformin hcl er 500 mg tab,-750 mg tablet .......... 44metformin hcl er 500 mg tablet,-1,000 mg tab .......... 44METHACHOLINECHLORIDE ............ 40methadone hcl injection .... 24methadone hcl solution,-tablet ................. 24methadone intensol ....... 24methadose. .............. 24methamphetamine hcl ..... 25methazolamide tablet . . . . . . 90methenamine hippurate .... 14methenamine mandelate e.c. tab,-tablet ................. 14methimazole tablet ........ 41METHITEST ............. 83methocarbamol tablet. ..... 76methotrexate injection ..... 17methotrexate tablet. ....... 17methscopolamine bromidetablet. ................. 46methyclothiazide .......... 36methyldopa .............. 33methyldopahydrochlorothiazide...... 35methyldopate hcl. ......... 33methylergonovine maleate .. 89METHYLIN TABLET ....... 25methylphenidate cd 10 mgcap ................... 25methylphenidate cd 50 mg cap,-60mg cap ............. 25methylphenidate er 10 mg tab,-20 mg tab ............. 25methylphenidate er 18mg tab,-27mg tab, 54mg tab .... 25methylphenidate er 20 mgcap ................... 25methylphenidate er 30 mg cap,-40 mg cap. ............ 25methylphenidate er 36mgtab .................... 25methylphenidate solution ... 25methylphenidate tablet ..... 25methylprednisolone injection 42methylprednisolone tab(inconvenience package),-tablet ................. 42methyl salicylate .......... 39metipranolol. ............. 90metoclopramide hcl tablet .. 46metoclopramide injection. .. 46metoclopramide syrup ..... 46metolazone .............. 36metoprololhydrochlorothiazide...... 35metoprolol succinate ...... 32metoprolol tartrate injection . 32metoprolol tartrate tablet ... 32metronidazole capsule, -tablet 7metronidazole cream, -gel,-lotion ................. 37metronidazole injection. ..... 7metronidazole vaginalproducts ............... 85METVIXIA ............... 39mexiletine hcl capsule. ..... 31MIACALCIN INJECTION. .. 44miconazole 3 ............. 15MICRODOT HIGH-LOWCONTROL SOL ........ 64MICRODOT NORMALCONTROL SOLUT. ..... 64microgestin .............. 84microgestin fe . . . . . . . . . . . . 84MICROLET LANCETS .... 64MICROTAINER SAFETYLANCET ............... 64MICRO THIN 33GLANCETS. ............. 64midodrine hcl. ............ 35migergot. ................ 26MILLIPRED DP. .......... 42millipred tablet. ........... 42milrinone in 5% dextrose ... 35milrinone lactate .......... 35mimvey .................. 85MINI ULTRA-THIN II PEN NDL31G. .................. 64minocycline hcl capsule, -tablet,-tablet sustained action. .. 14minoxidil tablet. ........... 36mirtazapine 7.5 mg tablet, -15mg odt, -30 mg odt, -30 mgtablet, -45 mg odt, -45 mgtablet. ................. 28mirtazapine 15 mg tablet ... 28misoprostol .............. 46mitomycin. ............... 17mitoxantrone ............. 18M-M-R II VACCINE. ....... 49modafinil tablet ........... 26moexipril hcl. ............. 31moexipril-hydrochlorothiazide 35mometasone furoate. ...... 39MONOJECT 0.3 ML INSULINSYR................... 64MONOJECT 0.5 ML INSULINSYR................... 64MONOJECT 0.5 ML SYRN28GX1/2 .............. 64MONOJECT 0.5 ML SYRN29GX1/2 .............. 64MONOJECT 1 ML INSULINSYRINGE. ............. 64MONOJECT 1 ML SYRN25X5/8 ................ 64MONOJECT 1 ML SYRN27X1/2 ................ 64MONOJECT 1 ML SYRN28GX1/2 .............. 64MONOJECT BLOOD LANCETSTERL ................ 64monoject heparin 10 units/ml 82monoject heparin 10 units/ml,-heparin 100 units/ml .... 82MONOJECT INSULIN SYR 0.3ML. ................... 64MONOJECT INSULIN SYR 0.5ML. ................... 64MONOJECT INSULIN SYR 1ML. ................... 64MONOJECT INSULIN SYRN3/10 ML ............... 65MONOJECT INSULIN SYRU-100 ................. 65MONOJECT INSUL SYRU100. ................. 64114

MONOJECT INSUL SYR U1000.5 ML ................ 64MONOJECT INSUL SYR U1001 ML .................. 64MONOJECT PREFILL 0.9%FLUSH ................ 80MONOJECT PREFILL 0.9% NASYR................... 80MONOJECT SAFETYSYRINGE. ............. 65MONOJECT SYRINGE 0.3ML. ................... 65MONOJECT SYRINGE 0.5ML. ................... 65MONOJECT SYRINGE 1ML. ................... 65MONOLET LANCETS ..... 65mononessa .............. 84montelukast .............. 94morphine sulfate er capsulesustained action. ........ 24morphine sulfate er tabletsustained action. ........ 24morphine sulfate in dextrose 24morphine sulfate injection,-rectal, -solution, -tablet. .. 24MOZOBIL. .............. 49MS INS SYR 0.5 ML29GX1/2 .............. 65MS INS SYR 1 ML29GX1/2 .............. 65MS INS SYRINGE 1 ML30GX1/2 .............. 65MS INSULIN SYR 0.3 ML29GX1/2 .............. 65MS INSULIN SYR 1 ML31GX5/16 ............. 65MS INSULIN SYRINGE 0.3ML. ................... 65MS INSUL SYR 0.3 ML31GX5/16 ............. 65MS INSUL SYR 0.5 ML30GX1/2 .............. 65MS INSUL SYR 0.5 ML31GX5/16 ............. 65MS LANCETS. ........... 65MS PEN NEEDLE 6MM31G. .................. 65MS SUPER THINLANCETS. ............. 65MS THIN LANCETS ...... 65MULTAQ ................ 34multinatal plus ............ 86mupirocin cream .......... 14mupirocin oint . . . . . . . . . . . . 14MUSTARGEN. ........... 18MYCAMINE. ............. 12MYCOBUTIN ............. 9mycophenolate mofetil ..... 18mydral .................. 91MYFORTIC .............. 18MYGLUCOHEALTH 30GLANCETS. ............. 65MYLERAN ............... 18mynatal. ................. 86mynatal advance .......... 86mynatal plus ............. 86mynatal-z ................ 86mynate 90 plus ........... 86myorisan ................ 38myzilra .................. 84Nnabumetone. ............. 77nadolol-bendroflumethiazide 35nadolol tablet. ............ 32nafcillin 1 gm/ 50 ml inj .... 13nafcillin 1 gm add-van vial .. 13nafcillin 1 gm vial. ......... 13nafcillin 2 gm/ 100 ml inj ... 13nafcillin 2 gm add-vant vial, -2gm vial. ................ 13nafcillin 10 gm bulk vial, -10 gmvial .................... 13NAGLAZYME ............ 44nalbuphine ............... 20naloxone hcl injection ...... 29naltrexone hcl tablet ....... 29NAMENDA .............. 20naproxen e.c. tab, -tablet ... 77naproxen oral susp . . . . . . . . 78naproxen sodium tablet .... 78naratriptan hcl ............ 26NATACYN ............... 91nateglinide ............... 44nature-throid ............. 45NEBUPENT ............. 10necon ................... 84nefazodone hcl ........... 28neofrin .................. 91neomycin-bacitracin-poly-hc 90neomycin-bacitracinpolymyxin.............. 91neomycin-polymyxin b. ..... 95neomycin-polymyxindexameth.............. 90neomycin-polymyxingramicidin.............. 91neomycin-polymyxin-hc ophthdrops. ................. 90neomycin-polymyxin-hcsuspensions, (not oral) ... 41neomycin-polymyxinhydrocort.............. 41neomycin sulfate tablet. ..... 7neo-polycin .............. 91neostigmine methylsulfateinjection ............... 29NEULASTA . . . . . . . . . . . . . . 51NEUMEGA .............. 50NEUPOGEN 300 MCG/0.5 MLSYR................... 51NEUPOGEN 300 MCG/MLVIAL. .................. 51NEUPOGEN 480 MCG/0.8 MLSYR................... 51NEUPOGEN 480 MCG/1.6 MLVIAL. .................. 51neutragard advanced . . . . . . 81nevirapine ................ 8NEXAVAR ............... 18NEXGEN NORMAL CONTROLSOLUTION ............ 65next choice .............. 84next choice one dose ...... 84NIASPAN. ............... 33nicardipine hcl capsule. .... 32nicardipine injection ....... 32NICOTROL. ............. 30NICOTROL NS .......... 30nifediac cc ............... 32nifedical xl ............... 32nifedipine capsule. ........ 32nifedipine er. ............. 32115

NILANDRON ............ 18nimodipine ............... 32nisoldipine ............... 33nitro-bid . . . . . . . . . . . . . . . . . 34nitrofurantoin macrocrystalcapsule ................ 14nitrofurantoin mono-macro. . 14nitrofurantoin oral susp. .... 14nitroglycerin in d5w ....... 34nitroglycerin injection ...... 34nitroglycerin patch ........ 34NITROSTAT. ............. 34nizatidine ................ 46nora-be. ................. 89NORDIPEN 5 DELIVERYSYSTEM ............... 65NORDIPEN 15 DELIVERYSYSTEM ............... 65norepinephrine bitartrate ... 35norethindrone ............ 89norethindrone acetate tablet 89norethindrone-ethin estradiol 84norgestimate-ethinylestradiol ............... 84norgestrel-ethiny estra ..... 84normal saline flush ........ 80NORM-JECT 1 MLSYRINGE. ............. 65NORMOSOL-M ANDDEXTROSE ............ 80NORMOSOL-R .......... 80NORMOSOL-R ANDDEXTROSE ............ 80NORMOSOL-R PH 7.4 .... 80nortrel. .................. 84nortriptyline hcl capsule,-solution ............... 29NORVIR. ................. 8NOVA MAX GLUCOSECONTROL SOLN. ...... 65NOVAMAX PLUS GLU-KETCTRL SOLN. ........... 65novarel injection .......... 89NOVA SAFETY 23GLANCETS. ............. 65NOVA SAFETY LANCETS28G. .................. 65NOVA SUREFLEXLANCETS. ............. 65NOVA SUREFLEX THINLANCETS. ............. 65NOVOFINE 30G X 1/3NEEDLES ............. 65NOVOFINE 30 NEEDLES . 65NOVOFINE 32G NEEDLES 65NOVOFINE AUTOCOVER 30GNEEDLE. .............. 65NOVOLIN 70-30 ......... 43NOVOLIN N ............. 43NOVOLIN R ............. 43NOVOLOG .............. 43NOVOLOG MIX 70-30 .... 43NOVOPEN 3 INSULINDEVICE ............... 65NOVOPEN 3 PENMATEDEVICE ............... 65NOVOPEN JR INSULINDEVICE ............... 65NOVOTWIST NEEDLE 30G8MM .................. 65NOVOTWIST NEEDLE 32G5MM .................. 65NOXAFIL ................ 10NPLATE ................. 49NUEDEXTA. ............. 29NULOJIX . . . . . . . . . . . . . . . . 18nutrilyte ................. 80nutrilyte ii . . . . . . . . . . . . . . . . 80nutri-tab ob .............. 86nutri-tab ob + dha. ........ 86NUTROPIN. ............. 47NUTROPIN AQ .......... 47NUTROPIN AQ NUSPIN .. 47nyamyc. ................. 12nystatin. .............. 10, 12nystatin-triamcinolone. ..... 14nystatin vaginal products ... 15nystop .................. 12Oob-natal one ............. 86ocella . . . . . . . . . . . . . . . . . . . 84OCTAGAM .............. 49octreotide acet 50 mcg/ml amp,-acet 50 mcg/ml syr, -acet 50mcg/ml vial, -acet 100 mcg/ml amp, -acet 100 mcg/ml syr,-acet 100 mcg/ml vl. ..... 18octreotide acet 200 mcg/ml vl,-acet 500 mcg/ml amp, -acet500 mcg/ml syr, -acet 500mcg/ml vl, -1,000 mcg/mlvial .................... 18ofloxacin ophth drops. ..... 91ofloxacin otic drops. ....... 41ofloxacin tablet ........... 13ogestrel ................. 84olanzapine 20 mg tablet. ... 21olanzapine-fluoxetine hcl ... 21olanzapine injection, -2.5 mgtablet, -5 mg tablet, -7.5 mgtablet, -10 mg tablet, -15 mgtablet. ................. 21olanzapine odt. ........... 21omeprazole dr 10 mg capsule,-dr 40 mg capsule ....... 47omeprazole dr 20 mgcapsule ................ 47omeprazole-sodiumbicarbonate ............ 47ON CALL 30G LANCET ... 65ON CALL PLUS 30GLANCET ............... 65ON CALL PLUS CONTROLSOLUTION ............ 65ON CALL VIVID CONTROLSOLUTION ............ 65ONCASPAR ............. 18ondansetron 40 mg/20 ml vial,-4 mg/2 ml syr, -4 mg/2 mlampule ................ 22ondansetron hcl 4 mg/2 mlvial .................... 22ondansetron hcl 4 mg tablet, -8mg tablet. .............. 22ondansetron hcl 24 mgtablet. ................. 22ondansetron hcl in dextrose. 22ondansetron hcl solution ... 22ondansetron in sodiumchloride ................ 22ondansetron odt .......... 22116

ONE TOUCH BASIC SYSTEMKIT. ................... 65ONE TOUCH CLUBLANCETS. ............. 66ONE TOUCH COMBOPACK ................. 66ONE TOUCH DELICA 30GLANCETS. ............. 66ONE TOUCH DELICA 33GLANCETS. ............. 66ONE TOUCH PROFILESYSTEM KT ............ 66ONE TOUCH SURESOFTLANCING DEV ......... 66ONE TOUCH TEST STRIPS 66ONE TOUCH ULTRA 2GLUCOSE SYST ....... 66ONE TOUCH ULTRACONTROL SOLN. ...... 66ONE TOUCH ULTRALINKSYSTEM ............... 66ONE TOUCH ULTRAMINIMETER ................ 66ONE TOUCH ULTRA SMARTMETER ................ 66ONE TOUCH ULTRASOFTLANCETS. ............. 66ONE TOUCH ULTRA SYSTEMKIT. ................... 66ONE TOUCH ULTRA TESTSTRIPS. ............... 66ONE TOUCH VERIO HIGHCNTRL SOL ........... 66ONE TOUCH VERIO IQMETER ................ 66ONE TOUCH VERIO MIDCNTRL SOLN .......... 66ONE TOUCH VERIO TESTSTRIP ................. 66ONFI ................... 27ONGLYZA. .............. 44ONTAK. ................. 18OPIUM TINCTURE ....... 24ORAP. .................. 21ORENCIA 125 MG/MLSYRINGE. ............. 18ORENCIA 250 MG VIAL .. 18ORFADIN ............... 40orphenadrine citrate injection 76orphenadrine citrate tabletsustained action. ........ 76orphenadrine compound ... 76orphenadrine compoundforte. .................. 76ORSINI INSUL SYR U100 0.5ML. ................... 66ORSINI INSUL SYR U100 1ML. ................... 66orsythia ................. 84ORTHO EVRA ........... 84OSMOPREP ............ 46oxacillin 1 gm/ 50 ml inj .... 13oxacillin 1 gm vial ......... 13oxacillin 2 gm/ 50 ml inj .... 13oxacillin 2 gm add-vantage vl, -2gm vial. ................ 13oxacillin 10 gm vial ........ 13oxaliplatin 50 mg/10 ml vial . 18oxaliplatin 100 mg/20 ml vial 18oxaliplatin 100 mg vial ..... 18oxandrolone tablet ........ 83oxaprozin . . . . . . . . . . . . . . . . 78oxazepam. ............... 23oxcarbazepine ............ 23oxybutynin chloride er. ..... 95oxybutynin chloride syrup,-tablet ................. 95oxycodone-acetaminophen . 24oxycodone concentrate .... 24oxycodone hcl ............ 24oxycodone hclacetaminophen.......... 24oxycodone hcl-aspirin. ..... 24oxycodone hcl-ibuprofen ... 24OXYCONTIN 10 MG TABLET,-15 MG TABLET, -20 MGTABLET, -30 MG TABLET, -40MG TABLET. ........... 24OXYCONTIN 60 MGTABLET. ............... 24OXYCONTIN 80 MGTABLET. ............... 24oxymorphone hcl er tablet .. 24oxymorphone hcl tablet .... 24oxytocin injection. ......... 89Ppacerone . . . . . . . . . . . . . . . . 34paclitaxel 100 mg/16.7 ml vial,-30 mg/5 ml vial ......... 18paclitaxel 300 mg/50 ml vial 18palgic ................... 92pamidronate ............. 45PANCREAZE ............ 46PANCRELIPASE 5,000. ... 46PANRETIN .............. 39pantoprazole sodium ...... 47pantoprazole sodium vial ... 47parcaine. ................ 91paregoric ................ 45paromomycin sulfate capsule 7paroxetine cr 12.5 mg tablet,-cr 37.5 mg tablet, -er 37.5 mgtablet. ................. 30paroxetine cr 25 mg tablet. . 30paroxetine hcl 10 mg tablet, -40mg tablet. .............. 30paroxetine hcl 20 mg tablet, -30mg tablet. .............. 30PASER................... 9PAXIL ORAL SUSP ....... 30PC SUPER THIN 30GLANCETS. ............. 66PC UNIFINE PENTIPS 6MMNEEDLE. .............. 66PC UNIFINE PENTIPS 8MMNEEDLE. .............. 66PC UNIFINE PENTIPS 12MMNEEDLE. .............. 66PC UNIFINE PENTIPS31GX3/16 ............. 66PEDIARIX ............... 49pedi-dri. ................. 12PEDVAXHIB ............. 49peg-3350 and electrolytes. . 46peg 3350-electrolyte ...... 46peg-3350 with flavor packs . 46PEGANONE. ............ 26PEGASYS 180 MCG/0.5 MLSYRINGE. ............. 50PEGASYS 180 MCG/MLVIAL. .................. 50PEGASYS PROCLICK 135MCG/0.5 .............. 50117

PEGASYS PROCLICK 180MCG/0.5 .............. 50PEGINTRON 50 MCG KIT. 50PEGINTRON 80 MCG KIT,-120 MCG KIT, -150 MCGKIT. ................... 50PEGINTRON REDIPEN . . . 50penicillin g k 5 million unit .. 13penicillin gk 20 million unit. . 13penicillin g procaine ....... 13penicillin g sodium ........ 13penicillin v potassium ...... 13PEN NEEDLE 6MM 31G .. 66PEN NEEDLE 30G X 5/16. 66PEN NEEDLE 31G X 3/16. 66PEN NEEDLE 31G X 5/16. 66PEN NEEDLES 5MM 31G . 66PEN NEEDLES 6MM 31G . 66PEN NEEDLES 8MM 31G . 66PEN NEEDLES 12MM 29G 66PEN NEEDLES 29G ...... 66PEN NEEDLES 31G ...... 66PENTACEL . . . . . . . . . . . . . . 49PENTASA ............... 46pentazocine-acetaminophen 20pentazocine-naloxone hcl. .. 20pentostatin. .............. 18pentoxifylline tablet sustainedaction ................. 35PERFOROMIST. ......... 93perindopril erbumine. ...... 31periogard ................ 41perio med. ............... 81PERJETA ................ 18permethrin cream ......... 38perphenazine. ............ 21perphenazine-amitriptyline .. 28PHARMACIST CHOICE 28GLANCETS. ............. 66PHARMACIST CHOICE 30GLANCETS. ............. 66PHARM CHOICE ALCOHOLPREP PADS. ........... 66phenadoz. ............... 22phenelzine sulfate tablet. ... 26phenobarbital elix, -tablet ... 27phenylephrine hcl ophthdrops. ................. 91phenytoin injection ........ 26phenytoin oral susp. ....... 26phenytoin sodium extended. 26phenytoin tablet chew ..... 26philith ................... 84phospha 250 neutral ...... 82PHOSPHOLINE IODIDE .. 90physostigmine salicylateinjection ............... 29PICATO ................. 39pilocarpine hcl ophth drops . 90pilocarpine hcl tablet ...... 41pindolol ................. 32pioglitazone-glimepiride .... 44pioglitazone hcl 15mg tablet 44pioglitazone hcl 30mg tablet,-45mg tab. ............. 44pioglitazone-metformin ..... 44piperacil-tazobact injection . 13piroxicam capsule ......... 78PLASTIC INSULINCARTRIDGE . . . . . . . . . . . 66PNEUMOVAX 23 VIAL .... 49pnv-dha ................. 86pnv-dha + docusate ....... 86pnv ob+dha .............. 86pnv-omega. .............. 86pnv-select ............... 86pnv-total. ................ 86POCKETCHEM EZ CONTROLSOLUTION ............ 66podofilox ................ 39polycin-b ................ 91poly-dex ................. 90polyethylene glycol 3350. .. 46polymyxin b sulfate injection 10polymyxin b sul-trimethoprim 91POMALYST .............. 18portia ................... 84potassium acetate injection . 82potassium bicarbonate. .... 82potassium chl-normal saline. 80potassium chloride-nacl .... 80potassium chloride sa capsule,-sa tablet. .............. 82potassium citrate-citric acid. 95potassium citrate TABLETSUSTAINED ACTION. ... 95potassium cl injection. ..... 82potassium cl solution ...... 82POTIGA. ................ 27PRADAXA ............... 82pramipexole dihydrochloride 28PRANDIN ............... 44prascion. ................ 37prascion fc. .............. 37pravastatin sodium ........ 33prazosin hcl .............. 36pre-attached lta kit ......... 7PRECISION CONTROLSOLUTION ............ 66PRECISION SURE DOSESYRINGE. ............. 67PRECISION THINS 28GLANCETS. ............. 67PRECISION THINS GPLANCETS. ............. 67PRECISION ULTRA 28GLANCETS. ............. 67PRED MILD ............. 90prednicarbate ............ 39prednisolone 5 mg/5 ml soln,-6.7 mg/5 ml soln, -15 mg/5 mlsoln, 25mg/5ml soln ..... 42prednisolone 15 mg/5 mlsoln . . . . . . . . . . . . . . . . . . . 42prednisolone acetate ophthdrops. ................. 90prednisolone sodium phosphateophth drops ............ 90prednisone intensol ....... 42prednisone solution ....... 42prednisone tab(in conveniencepackage), -tablet ........ 42PREFERRED PLUS 0.3 ML30GX5/16 ............. 67PREFERRED PLUS 0.5 ML29GX1/2 .............. 67PREFERRED PLUS COLOREDLANCETS. ............. 67PREFERRED PLUSLANCETS. ............. 67PREFERRED PLUS SYRINGE0.3 ML ................ 67118

PREFERRED PLUS SYRINGE0.5 ML ................ 67PREFERRED PLUS SYRINGE1 ML .................. 67PREFERRED PLUS THINLANCETS. ............. 67PREFPLS INS SYR 1 ML30GX5/16 ............. 67PREF PLUS SYR 0.5 ML30GX5/16 ............. 67PREF PLUS SYRING 1 ML29GX1/2 .............. 67PREMARIN INJECTION . . . 85PREMARIN TABLET, -VAGINALPRODUCTS. ........... 85prenafirst ................ 86prenaissance. ............ 87prenaissance balance. ..... 87prenaissance next. ........ 87prenaissance plus. ........ 87prenaplus. ............... 87prenatabs fa ............. 87prenatabs rx. ............. 87prenatal 19 .............. 87prenatal ad. .............. 87prenatal low iron .......... 87prenatal plus ............. 87prenatal-u. ............... 87prenate plus. ............. 87PREP EASE ALCOHOLPADS ................. 67PRESSURE ACTIVATED 21GLANCETS. ............. 67PRESSURE ACTIVATED 28GLANCETS. ............. 67PRESTIGE GLUCOSECONTROL. ............ 67prevalite ................. 33previfem ................. 84PREVNAR 13 ............ 49PREZISTA 75 MG TABLET,-800MG TABLET, -100MGSUSP .................. 8PREZISTA 150 MG TABLET,-400 MG TABLET, -600 MGTABLET. ................ 8PRIFTIN. ................. 9PRIMAQUINE. ........... 13primidone tablet .......... 27PRISTIQ ER ............. 28pr natal 400. ............. 86pr natal 400 ec ........... 86pr natal 430. ............. 86pr natal 430 ec ........... 86PROAIR HFA ............ 93probenecid .............. 77probenecid-colchicine ..... 77procainamide hcl injection .. 31prochlorperazine edisylateinjection ............... 22prochlorperazine maleaterectal .................. 22prochlorperazine maleatetablet. ................. 22PROCRIT 2,000 UNITS/ML VIAL, -3,000 UNITS/MLVIAL, -4,000 UNITS/ML VIAL,-10,000 UNITS/ML VIAL . 49PROCRIT 20,000 UNITS/MLVIAL, -40,000 UNITS/MLVIAL. .................. 49procto-pak ............... 46proctosol-hc ............. 46proctozone-hc ............ 47PRODIGY CONTROLSOLUTION ............ 67PRODIGY CONTROLSOLUTION LOW ....... 67PRODIGY INS SYR 1ML28GX1/2 .............. 67PRODIGY MINI PEN NDL31GX3/16 ............. 67PRODIGY PEN NEEDLE29GX1/2 .............. 67PRODIGY PEN NEEDLE31GX5/16 ............. 67PRODIGY PRESSUREACTIVATED 28G. ....... 67PRODIGY PRESSURE ACTIVELANCET ............... 67PRODIGY SAFETYLANCETS. ............. 67PRODIGY SYRNG 0.5 ML31GX5/16 ............. 67PRODIGY SYRNG 1 ML29GX1/2 .............. 67PRODIGY SYRNGE 0.3ML31GX5/16 ............. 67PRODIGY TWIST TOP 28GLANCET ............... 67progesterone capsule, -oil 50mg/ml vl ............... 89progesterone oil 50 mg/ml vl 89PROGLYCEM. ........... 42PROGRAF INJECTION. ... 18PROLASTIN C . . . . . . . . . . . 95PROLEUKIN. ............ 50PROLIA ................. 45PROMACTA ............. 49promethazine hcl injection .. 92promethazine hcl rectal .... 22promethazine hcl syrup,-tablet ................. 92promethazine vc .......... 92promethegan ............. 22propafenone hcl .......... 31propantheline bromide tablet 46proparacaine hcl ophthdrops. ................. 91propranolol hcl capsulesustained action, -tablet .. 32propranolol hcl injection. ... 32propranolol hcl solution .... 32propranololhydrochlorothiazid....... 35propylthiouracil tablet ...... 41PROQUAD .............. 49PROSTIGMIN ........... 29PROTOPIC .............. 39protriptyline hcl . . . . . . . . . . . 29PROVENTIL HFA ......... 93prudoxin ................. 39PSS SELECT GPLANCETS. ............. 67PSS SELECT SAFETYLANCETS. ............. 67PUB INS SYRIN 0.3 ML30GX1/2 .............. 67PUB INS SYRINGE 1 ML30GX1/2 .............. 67PUB INSULIN SYR 1 ML31GX5/16 ............. 67119

PUB INSUL SYR 0.3 ML31GX5/16 ............. 67PUB INSUL SYR 0.5 ML30GX1/2 .............. 67PUB INSUL SYR 0.5 ML31GX5/16 ............. 67PUB LANCETS .......... 67PUBLIX 28G LANCET .... 68PUB PEN 8MM 31GNEEDLES ............. 67PUB PEN 12MM 29GNEEDLES ............. 67PUB PEN NEEDLE 6MM31G. .................. 67PULMOZYME. ........... 95PV INS SYRIN 1 ML29GX1/2 .............. 68PV INSULIN SYR 1 ML31GX5/16 ............. 68PV INSULIN SYRINGE 0.5ML. ................... 68PV INSULIN SYRINGE 1ML. ................... 68PV INSUL SYR 0.3 ML31GX5/16 ............. 68PV INSUL SYR 0.5 ML31GX5/16 ............. 68PV ISOPROPYL ALCOHOL70% WIPES ........... 68PV PEN NEEDLE 6MM31G. .................. 68PV PEN NEEDLES 8MM31G. .................. 68PV PEN NEEDLES 12MM29G. .................. 68PV ULTRA THIN 30GLANCETS. ............. 68PV UNIFINE PENTIPS31GX3/16 ............. 68PX PEN 8MM 31GNEEDLES ............. 68PYLERA. ................ 47pyrazinamide .............. 9pyridostigmine bromidetablet. ................. 29QQC ALCOHOL 70%SWABS ............... 68QC INSULIN SYR 1 ML31GX5/16 ............. 68QC INSULIN SYRINGE 0.3ML. ................... 68QC INSULIN SYRINGE 0.5ML. ................... 68QC INSULIN SYRINGE 1ML. ................... 68QC INSUL SYR 0.5 ML31GX5/16 ............. 68QC PEN NEEDLES 6MM31G. .................. 68QC PEN NEEDLES 8MM31G. .................. 68QC PEN NEEDLES 12MM29G. .................. 68QC SUPER THIN LANCET 68QC ULTRA THIN LANCET . 68QC UNIFINE PENTIP 6MM31G. .................. 68QC UNIFINE PENTIP 8MM31G. .................. 68QC UNIFINE PENTIP 12MM29G. .................. 68QC UNILET SUPER THIN 30GLANCT ................ 68QUADRAMET. ........... 18QUALAQUIN ............ 13quasense ................ 84quetiapine fumarate ....... 21QUICKTEK CONTROLSOLUTION ............ 68quinapril hcl .............. 31quinapril-hydrochlorothiazide 35quinidine gluconate injection 31quinidine gluconate tabletsustained action. ........ 31quinidine sulfate tablet, -tabletsustained action. ........ 31quinine sulfate 324mgcapsule ................ 13QVAR. .................. 94RRA ALCOHOL SWABS ... 68RABAVERT .............. 49RA E-ZJECT 28G LANCETS 68RA E-ZJECT COLOR 33GLANCETS. ............. 68RA E-ZJECT LANCETS .... 68RA INS SYR 0.5 ML29GX1/2 .............. 68RA INS SYR 0.5 ML30GX5/16 ............. 68RA INS SYR 1 ML 29GX1/2 68RA INS SYRINGE 1 ML30GX5/16 ............. 68RA ISOPROPYL ALCOHOL70% WIPES ........... 68ramipril .................. 31RANEXA ................ 35ranitidine hcl capsule, -tablet 46ranitidine hcl injection. ..... 46ranitidine syrup ........... 46RAPAMUNE 2 MG TABLET 18RAPAMUNE SOLUTION,-0.5 MG TABLET, -1 MGTABLET. ............... 18RA PEN NEEDLE31GX3/16 ............. 68RA PEN NEEDLE31GX5/16 ............. 68RAYOS ................. 42REALITY 1/2 ML SYRINGE 68REALITY 1 ML SYRINGE .. 68REALITY ALCOHOLSWABS ............... 68REALITY LANCETS ....... 68REALITY TRIGGERLANCETS. ............. 68REBIF 22 MCG/0.5 MLSYRINGE, -44 MCG/0.5 MLSYRINGE. ............. 50REBIF TITRATION PACK .. 50RECLAST ............... 45reclipsen ................ 84RECOMBIVAX HB ....... 49RECTIV ................. 47REFUAH PLUS CONTROLSOLUTION ............ 68REGRANEX . . . . . . . . . . . . . 39RELENZA . . . . . . . . . . . . . . . 11RELIAMED SAFETY SEALLANCETS. ............. 69120

RELI ON 31G X 1/4NEEDLES ............. 68RELION INS SYR 0.3 ML29GX1/2 .............. 69RELION INS SYR 0.3 ML30GX5/16 ............. 69RELION INS SYR 0.5 ML29GX1/2 .............. 69RELION INS SYR 1 ML29GX1/2 .............. 69RELION INS SYR 1 ML30GX5/16 ............. 69RELION INS SYR 1 ML31GX5/16 ............. 69RELI-ON INSULIN 0.3 MLSYR................... 69RELI-ON INSULIN 0.5 MLSYR................... 69RELI-ON INSULIN 1 MLSYR................... 69RELION INSULIN SYR 0.3ML. ................... 69RELION INSULIN SYR 0.5ML. ................... 69RELION INSULIN SYRINGE 1ML. ................... 69RELION LANCETS ....... 69RELION MINI PEN 31G X 1/4NDL. .................. 69RELION PEN 29G NEEDLE 69RELION PEN 29G X 1/2NEEDLE. .............. 69RELION PEN 31G NEEDLE 69RELION PEN 31G X 5/16NEEDLE. .............. 69RELION SYR 0.5 ML30GX5/16 ............. 69RELION SYRING 0.3 ML31GX5/16 ............. 69RELION SYRING 0.5 ML31GX5/16 ............. 69RELION THIN LANCETS .. 69RELION ULTRA THIN 30GLANCETS. ............. 69RELION ULTRA THIN PLUS33G. .................. 69RELION ULTRA THIN PLUSLANCETS. ............. 69RELISTOR. .............. 47relnate dha. .............. 87remeven ................. 39REMICADE. ............. 18REMODULIN ............ 36RENEW ADVANCED MICRO-LANCETS. ............. 69RENVELA ............... 78reprexain ................ 25RESCRIPTOR ............ 8reserpine tablet ........... 35RESTASIS. .............. 92RETROVIR INJECTION. .... 8REVATIO INJECTION ..... 36REVLIMID ............... 18revonto. ................. 76REYATAZ 100 MG CAPSULE 8REYATAZ 150 MG CAPSULE,-200 MG CAPSULE, -300 MGCAPSULE .............. 8ribapak 200-400 mgdosepack .............. 11ribapak 400-400 mg dosepack,-400-600 mg, -600-400 mg,-600-600 mg ........... 11ribasphere 600 mg tablet .. 11ribasphere capsule, -200 mgtablet, -400 mg tablet .... 11ribavirin capsule, -tablet .... 11RIDAURA ............... 78rifampin capsule ........... 9rifampin injection. .......... 9RIGHTEST CONTROL SOLNNORMAL . . . . . . . . . . . . . . 69RIGHTEST CONTROLSOLUTION HIGH. ...... 69RIGHTEST GL300LANCETS. ............. 69RILUTEK . . . . . . . . . . . . . . . . 76rimantadine hcl ........... 11ringers injection. .......... 80ringers irrigation .......... 80RISPERDAL CONSTA 12.5 MGSYR, -25 MG SYR. ...... 21RISPERDAL CONSTA 37.5 MGSYR, -50 MG SYR. ...... 21risperidone. .............. 21risperidone m-tab ......... 21risperidone odt ........... 21RITUXAN. ............... 18rivastigmine .............. 20rizatriptan. ............... 26romycin ................. 91ropinirole hcl ............. 28rosadan cream, -gel ....... 37ROTARIX. ............... 49ROTATEQ ............... 49ROXICET SOLUTION ..... 24roxicet tablet ............. 24SSABRIL ................. 27SAFESNAP INSULIN SYRINGE1 ML .................. 69SAFESNAP INSUL SYRINGE0.3 ML ................ 69SAFESNAP INSUL SYRINGE0.5 ML ................ 69SAFE-T-LANCE 21GLANCETS. ............. 69SAFE-T-LANCE 25GLANCETS. ............. 69SAFE-T-LANCE PLUSLANCETS. ............. 69SAFETY 21G LANCETS ... 69SAFETY 28G LANCETS ... 69SAFETY LANCET 2MM. ... 69SAFETY LANCETS ....... 69SAFETY-LET LANCETS. ... 69SAFETY SEAL 30GLANCETS. ............. 69SAFETY SYRINGE W-SHIELD3 ML .................. 69SAIZEN ................. 47salicylic acid soln, top ..... 39saline 0.45% soln-excel con,-0.45% soln, -saline 0.9% solnexcelcont, -0.9% solution, -cl2.5 meq/ml vial, -3% iv soln,-5% iv soln ............. 80saline flush. .............. 80salsalate tablet ........... 78SAMSCA. ............... 45SANDOSTATIN LAR ...... 18SANTYL. ................ 39121

SAPHRIS ............... 21SAVELLA. ............... 28SB INS SYR 0.5 ML29GX1/2 .............. 69SB INS SYR 0.5 ML30GX5/16 ............. 69SB INS SYR 1 ML29GX1/2 .............. 69SB INS SYRINGE 1 ML30GX5/16 ............. 69SB INSULIN SYR 1 ML31GX5/16 ............. 70SB INSULN SYR 0.5 ML30GX5/16 ............. 70SB LANCETS THIN. ...... 70SB LANCETS ULTRA THIN 70SCHNUCKS SYR 0.5 ML29GX1/2 .............. 70SCHNUCKS SYR 0.5 ML30GX5/16 ............. 70se-care. ................. 87se-care conceive. ......... 87se-care gesture ........... 87selegiline hcl capsule, -tablet 28selenium sulfide 2.5% lotion 37selenium sulfide 2.25%shampoo. .............. 37SELZENTRY. ............. 8SEMPREX-D. ............ 92se-natal 19. .............. 87se-natal 90 .............. 87se-natal one. ............. 87SENSIPAR 30 MG TABLET 45SENSIPAR 60 MG TABLET, -90MG TABLET. ........... 45se-plete dha. ............. 87SEREVENT DISKUS ...... 93SEROMYCIN . . . . . . . . . . . . . 9SEROQUEL XR. ......... 21sertraline hcl 25 mg tablet, -50mg tablet. .............. 30sertraline hcl 100 mg tablet. 30sertraline hcl solution ...... 30se-tan dha ............... 87setonet. ................. 87setonet-ec . . . . . . . . . . . . . . . 87sf 81sf 5000 plus ............. 81sildenafil tablet ........... 36silver sulfadiazine cream. ... 14SIMULECT .............. 18simvastatin tablet ......... 33SINGLE-LET LANCETS ... 70SM ALCOHOL 70% PREPPADS ................. 70SM ALCOHOL PREP PADS 70SMARTDIABETES VANTAGE30G. .................. 70SMARTEST CONTROLSOLUTION ............ 70SMARTEST LANCET. ..... 70SMART SENSE COLOR 33GLANCETS. ............. 70SMART SENSE STANDARD21G. .................. 70SMART SENSE SUPER THIN30G. .................. 70SMART SENSE THIN 26GLANCETS. ............. 70SM COLORED LANCETS . 70SM INS SYR 0.5 ML29GX1/2 .............. 70SM INS SYR 0.5 ML30GX5/16 ............. 70SM INS SYR 1 ML29GX1/2 .............. 70SM INS SYRING 0.3 ML30GX5/16 ............. 70SM INS SYRINGE 1 ML28GX1/2 .............. 70SM INS SYRINGE 1 ML30GX5/16 ............. 70SM INSULIN SYR 0.3 ML29GX1/2 .............. 70SM INSULIN SYR 0.5 ML28GX1/2 .............. 70SM INSULIN SYR 1 ML31GX5/16 ............. 70SM INSUL SYR 0.3 ML31GX5/16 ............. 70SM INSUL SYR 0.5 ML31GX5/16 ............. 70SM LANCETS. ........... 70SM MICRO THIN 33GLANCETS. ............. 70SMS GLUCOSE CONTROLSOL NORMAL ......... 70SM SUPER THIN LANCETS 70SM THIN LANCETS ...... 70sodium acetate ........... 80sodium bicarbonate ....... 80sodium chloride 0.9% soln,-0.9% soln., -4 meq/ml vl,-solution ............... 80sodium chloride nebs ...... 94sodium citrate & citric acid. . 82sodium fluoride . . . . . . . . . . . 81sodium lactate. ........... 80sodium phenylbutyratepowder ................ 40sodium phosphate ........ 80sodium polystyrene sulfonate 35sodium sulfacetamide pad,medicated pad .......... 37sodium sulfacetamidesolution ................ 37sodium sulfacetamide-sulfurcream, -sulf-sulfur cleanser,-sulfacetamide-sulfur 8-4%susp .................. 37sodium sulfacetamide-sulfurfoam (non-contraceptive),-lotion, -sulfacet-sulfur wash,-sulf-sulfur cleanser, -pad,medicated pad, -sod.sulfacetsulfursusp ............. 37SOFTCLIX LANCETS ..... 70SOFT TOUCH LANCETS. . 70SOFT TOUCH SAFE-T-PRO 70SOLARAZE. ............. 39solia .................... 84SOLO V2 30G LANCETS. . 70SOLO V2 CONTROLSOLUTION HIGH. ...... 70SOLO V2 CONTROLSOLUTION LOW ....... 70SOLTAMOX. ............. 18SOMATULINE DEPOT .... 18SOMAVERT ............. 45SORBITOL .............. 95SORIATANE ............. 37SORIATANE CK .......... 37sorine ................... 34sotalol .................. 34122

sotalol af ................ 34sotret ................... 38SPIRIVA. ................ 94spironolactone-hctz ....... 36spironolactone tablet ...... 36sprintec ................. 84SPRYCEL ............... 18sps ..................... 35sronyx. .................. 84ssd ..................... 14stagesic ................. 25stannous fluoride dental/mucousmembrn products. ....... 81stavudine ................. 8STERILANCE TL TWIST 30GLANCET ............... 70STERILANCE TL TWIST 32GLANCET ............... 70sterile water for injection, -forinjection ampul, -for injectionvial .................... 80STIMATE ................ 45STIVARGA. .............. 18STRATTERA 10 MG CAPSULE,-18 MG CAPSULE, -25MG CAPSULE, -80 MGCAPSULE, -100 MGCAPSULE ............. 29STRATTERA 40 MG CAPSULE,-60 MG CAPSULE ...... 29STRIBILD ................ 8STROMECTOL. ........... 7sublimaze. ............... 24SUBOXONE. ............ 25SUCRAID ............... 47sucralfate oral susp, -tablet . 46sufenta .................. 20sufentanil citrate injection .. 20sulfacetamide-prednisolone. 90sulfacetamide sodium lotion 37sulfacetamide sodium oint .. 91sulfacetamide sodium ophthdrops. ................. 91sulfacetamide sodium-sulfur 37sulfacleanse 8-4 .......... 37sulfadiazine tablet ......... 14sulfamethoxazole-trimethopriminjection ............... 14sulfamethoxazole-trimethoprimoral susp, -tablet ........ 14sulfamide ................ 91SULFAMYLON . . . . . . . . . . . 14sulfasalazine dr . . . . . . . . . . . 47sulfasalazine tablet ........ 47sulfazine. ................ 47sulfazine ec .............. 47sulindac tablet. ........... 78sumatriptan 4 mg/0.5 ml cart,-4 mg/0.5 ml inject, -4 mg/0.5ml kit, -4 mg/0.5 ml refill, -4mg/0.5 ml vial, -6 mg/0.5 mlrefill, -6 mg/0.5 ml syrng .. 26sumatriptan 6 mg/0.5 ml inject,-6 mg/0.5 ml vial ........ 26sumatriptan succinate tablet 26SUPARTZ ............... 78SUPER THIN 28GLANCETS. ............. 70SUPER THIN 30GLANCETS. ............. 70SUPER THIN 33GLANCETS. ............. 70SUPER THIN LANCETS. .. 70SUPRAX . . . . . . . . . . . . . . . . . 9SUPREME II CONTROLSOLUTION ............ 70SURECHEK GLUCOSECONTROL SOLN. ...... 71SURE COMFORT 0.3 MLSYRINGE. ............. 70SURE COMFORT 0.5 MLSYRINGE. ............. 71SURE COMFORT 1 MLSYRINGE. ............. 71SURE COMFORT 3/10 MLSYRINGE. ............. 71SURE COMFORT 28GLANCETS. ............. 71SURE COMFORT 30GLANCETS. ............. 71SURE COMFORT 31G PENNEEDLE. .............. 71SURE COMFORT ALCOHOLPREP PADS. ........... 71SURE COMFORT PEN NDL29GX1/2 .............. 71SURE COMFORT PEN NDL31GX3/16 ............. 71SURE EDGE GLUCOSECONTROL SOLN. ...... 71SURE-FINE PEN NEEDLES5MM .................. 71SURE-FINE PEN NEEDLES8MM .................. 71SURE-FINE PEN NEEDLES12.7MM ............... 71SURE-JECT INSULIN SYR 0.3ML. ................... 71SURE-JECT INSULIN SYR 0.5ML. ................... 71SURE-JECT INSULINSYRINGE 1 ML. ........ 71SURE-JECT INSUL SYR U1001 ML .................. 71SURE-JECT INSU SYR U1000.3 ML ................ 71SURE-JECT INSU SYR U1000.5 ML ................ 71SURE-JECT INSU SYR U100 1ML. ................... 71SURE-LANCE 26GLANCETS. ............. 71SURE-LANCE FLATLANCETS. ............. 71SURE-LANCE THINLANCET ............... 71SURE-LANCE ULTRA THIN30G. .................. 71SURELITE LANCET REGBODY ................. 71SURE-PREP ALCOHOL PREPPADS ................. 71SURESTEP GLUC CONTROLSOLN . . . . . . . . . . . . . . . . . 71SURESTEP PRO CONTROLSOLN . . . . . . . . . . . . . . . . . 71SURESTEP PRO LINEARITYKIT. ................... 71SURESTEP PRO TESTSTRIPS. ............... 71SURESTEP TEST STRIPS . 71SURE-TEST EASYPLUS MINISOLN . . . . . . . . . . . . . . . . . 71SURE-TOUCH LANCET ... 71123

SUSTIVA ................. 8SUTENT ................ 18syeda ................... 84SYLATRON .............. 50SYLATRON 4-PACK ...... 50SYMBICORT 80-4.5 MCGINHALER .............. 94SYMBICORT 160-4.5 MCGINHALER .............. 94SYMLIN ................. 42SYMLINPEN 60. ......... 42SYMLINPEN 120. ........ 42SYNAREL ............... 89SYNRIBO ............... 18SYNTHROID. ............ 45SYNVISC. ............... 78SYNVISC-ONE. .......... 78SYPRINE. ............... 78syrex. ................... 80TTABLOID ................ 18tacrolimus 0.5 mg capsule, -1mg capsule. ............ 18tacrolimus 5 mg capsule ... 18TAMIFLU 30 MG GELCAP . 12TAMIFLU 45 MG GELCAP, -75MG GELCAP ........... 12TAMIFLU SUSPENSION .. 12tamoxifen citrate tablet ..... 18tamsulosin hcl ............ 95TARCEVA ............... 18TARGRETIN ............. 18taron a prenatal. .......... 87taron-bc ................. 87taron-c dha .............. 87taron-crystals. ............ 95taron-duo ec ............. 87taron-ec cal .............. 87taron ec calcium .......... 87taron-prex prenatal ........ 87TASIGNA. ............... 18TASMAR ................ 28TAZORAC ............... 37taztia xt. ................. 33TECHLITE AST LANCETS . 71TECHLITE BLOODLANCET ............... 71TEGRETOL XR 100 MGTABLET. ............... 23TEKAMLO ............... 35TEKTURNA. ............. 35TEKTURNA HCT ......... 35TELCARE CONTROLSOLUTION ............ 71temazepam .............. 29TEMODAR CAPSULE. .... 19TEMODAR INJECTION. ... 19TENIVAC ................ 49terazosin 1 mg capsule, -5 mgcapsule ................ 36terazosin 2 mg capsule, -10 mgcapsule ................ 36terbinafine hcl tablet ....... 10terbutaline sulfate injection,-tablet ................. 93terconazole .............. 15TERUMO INS SYR 0.3 ML29GX1/2 .............. 71TERUMO INS SYRINGE U100-1/2 ML ................ 71TERUMO INS SYRINGE U100-1/3 ML ................ 71TERUMO INS SYRINGE U100-1 ML .................. 71TERUMO INS SYRNG U100-1/2 ML ................ 71TERUMO SURGUARD SYR28G-1/2 ML. ........... 71TERUMO SURGUARD SYR28G-1 ML. ............. 71TERUMO SURGUARD SYR29G-0.3 ML ............ 72TERUMO SURGUARD SYR29G-1/2 ML. ........... 72TERUMO SURGUARD SYRN29G-1 ML. ............. 72TESTIM ................. 83testosterone cypionateinjection ............... 83testosterone enanthateinjection ............... 83TETANUS-DIPHTERIA-DECAVAC ............. 49TETANUS DIPHTHERIATOXOIDS .............. 49tetanus toxoid adsorbed. ... 49tetracycline hcl capsule .... 14THALOMID .............. 40theochron. ............... 93theophylline .............. 93theophylline anhydrous tabletsustained action. ........ 93THERACYS. ............. 19thermazene .............. 14THIN LANCET ........... 72THINLETS 28G(T)LANCETS. ............. 72THINLETS GP LANCETS .. 72THINPRO INS SYRIN U100-0.3ML. ................... 72THINPRO INS SYRIN U100-0.5ML. ................... 72THINPRO INS SYRIN U100-1ML. ................... 72thioridazine hcl ........... 21thiotepa injection. ......... 19thiothixene ............... 21tiagabine tablet ........... 27ticlopidine hcl ............ 78TIKOSYN. ............... 34tilia fe ................... 84timolol maleate ophth drops 90timolol maleate tablet ...... 32tinidazole tablet. ........... 7tizanidine hcl capsule, -tablet 76tl-assure one ............. 87tl-select ................. 87TOBI..................... 7TOBI PODHALER ......... 7tobramycin. ............... 7tobramycin-dexamethasone . 90tobramycin sulfate ophthdrops. ................. 91TODAY’S HEALTH SUPERTHIN 30G ............. 72TODAY’S HLTH PN NEEDLE6MM 31G. ............. 72TODAY’S HLTH PN NEEDLE8MM 31G. ............. 72TODAY’S HLTH ULTRA THINLANCET ............... 72TODAY’S HLT PN NEEDLE12MM 29G ............ 72tolazamide ............... 44124

tolbutamide . . . . . . . . . . . . . . 44tolmetin sodium. .......... 78tolterodine tartrate ........ 95TOPCARE CLICKFINE 31G X1/4. ................... 72TOPCARE CLICKFINE 31G X5/16 .................. 72TOPCARE ULTRA COMFORTSYRINGE. ............. 72TOPCARE UNIVERSAL1 THINLANCET ............... 72topiragen ................ 27topiramate sprinkle, -tablet. . 27toposar. ................. 19topotecan hcl ............ 19TORISEL. ............... 19torsemide injection ........ 34torsemide tablet .......... 34TRACLEER .............. 36tramadol hcl. ............. 20tramadol hcl-acetaminophen 20tramadol hcl er ........... 20trandolapril. .............. 31tranexamic acid ........... 40tranexamic tab. ........... 40TRANSDERM-SCOP ..... 22tranylcypromine sulfate. .... 26TRAVATAN Z ............. 90travoprost ophth drops. .... 90trazodone hcl tablet ....... 28TREANDA 25 MG VIAL. ... 19TREANDA 100 MG VIAL .. 19TRECATOR. .............. 9TRELSTAR .............. 19TRELSTAR DEPOT ....... 19TRELSTAR LA. ........... 19tretinoin capsule . . . . . . . . . . 19tretinoin cream, -gel ....... 37trezix. ................... 25triadvance ............... 87triamcinolone acetonide cream,-lotion, -oint. ............ 39triamcinolone acetonide nasalinhaled steroids ......... 41triamcinolone acetonidepaste .................. 41triamterene-hctz .......... 36triamterenehydrochlorothiazid....... 36trianex. .................. 39triazolam. ................ 29tricitrates ................ 95triderm .................. 39trifluoperazine hcl ......... 21trifluridine ophth drops ..... 92trihexyphenidyl hcl elix ..... 20trihexyphenidyl hcl tablet ... 20TRIHIBIT ................ 49tri-legest fe. .............. 84TRILEPTAL SUSPENSION. 23trilyte with flavor packets ... 47trimesis rx. ............... 87trimethobenzamide hcl capsule,-injection ............... 22trimethoprim ............. 14trimipramine maleate capsule 30trinatal gt ................ 87trinatal rx 1. .............. 87trinatal ultra .............. 87trinate. .................. 87trinessa ................. 84TRIPEDIA ............... 49tri-previfem. .............. 84tri rx .................... 87TRISENOX .............. 19tri-sprintec ............... 84triveen-duo dha ........... 87triveen-one. .............. 87triveen-prx rnf. ............ 87triveen-ten ............... 87triveen-u ................. 87tri-vitamin with fluoride . . . . . 80trivora-28 ................ 84TRIZIVIR ................. 8trospium chloride ......... 95TRUECONTROL GLUCOSESOLUTION ............ 72TRUEPLUS 33G LANCETS 72TRUEPLUS LANCETS 28G 72TRUEPLUS SUPER THIN 28GLANCET ............... 72TRUEPLUS SYR 0.3ML29GX1/2 .............. 72TRUEPLUS SYR 0.3ML30GX5/16 ............. 72TRUEPLUS SYR 0.3ML31GX5/16 ............. 72TRUEPLUS SYR 0.5ML28GX1/2 .............. 72TRUEPLUS SYR 0.5ML29GX1/2 .............. 72TRUEPLUS SYR 0.5ML30GX5/16 ............. 72TRUEPLUS SYR 0.5ML31GX5/16 ............. 72TRUEPLUS SYR 1ML28GX1/2 .............. 72TRUEPLUS SYR 1ML29GX1/2 .............. 72TRUEPLUS SYR 1ML30GX5/16 ............. 72TRUEPLUS SYR 1ML31GX5/16 ............. 72TRUEPLUS ULTRA THIN 30GLANCET ............... 72TRUETEST CONTROL SOLNHIGH ................. 72TRUETEST CONTROL SOLNNORMAL . . . . . . . . . . . . . . 72TRUETEST CONTROLSOLUTION LOW ....... 72TRUETRACK GLUCOSECONTROL. ............ 72TRUVADA ................ 8TUDORZA .............. 94TWINRIX. ............... 49TWIST LANCETS. ........ 72TYGACIL ................ 10TYKERB ................ 19TYPHIM VI. .............. 49TYSABRI ................ 19TYVASO ................ 36TYZEKA. ................ 12TYZINE ................. 41Uu-kera e urea emollient ..... 39ULESFIA . . . . . . . . . . . . . . . . 38ULORIC. ................ 77ULTCARE INS SYR 1 ML30GX5/16 ............. 73ULTCARE INS SYR 1 ML31GX5/16 ............. 73125

ULT CFT 0.3 ML 29GX1/2(1/2) .................. 72ULT CFT 0.3 ML 30GX5/16(1/2) .................. 72ULT CFT 0.3 ML 31GX5/16(1/2) .................. 72ULTICARE 30GX0.3 MLSYRINGE. ............. 73ULTICARE 30GX0.5 MLSYRINGE. ............. 73ULTICARE 30GX1 MLSYRINGE. ............. 73ULTICARE 31GX0.3 MLSYRINGE. ............. 73ULTICARE 31GX0.5 MLSYRINGE. ............. 73ULTICARE 31GX1 MLSYRINGE. ............. 73ULTICARE INS 0.5 ML29GX1/2 .............. 73ULTICARE INS SYR 1 ML28GX1/2 .............. 73ULTICARE INS SYR 1 ML29GX1/2 .............. 73ULTICARE INSULIN SYR U1001 ML .................. 73ULTICARE INSUL SYR U1000.3 ML ................ 73ULTICARE INSUL SYR U1000.5 ML ................ 73ULTICARE PEN NEEDLES4MM 32G. ............. 73ULTICARE PEN NEEDLES 6MM 31 G .............. 73ULTICARE PEN NEEDLES6MM 31G. ............. 73ULTICARE PEN NEEDLES 8MM 31 G .............. 73ULTICARE PEN NEEDLES8MM 31G. ............. 73ULTICARE PEN NEEDLES12MM 29G ............ 73ULTICARE SYR 0.3 ML31GX5/16 ............. 73ULTICARE SYR 0.5 ML30GX5/16 ............. 73ULTICARE SYR 0.5 ML31GX5/16 ............. 73ULTICARE SYRIN 0.3 ML29GX1/2 .............. 73ULTICARE SYRIN 0.5 ML28GX1/2 .............. 73ULTICARE THIN 28GLANCETS. ............. 73ULTICARE THIN 30GLANCETS. ............. 73ULTICARE U100 0.3 ML30GX5/16 ............. 73ULTICARE U100 0.5 ML29GX1/2 .............. 73ULTI-LANCE AUTO-ADDEVICE ............... 73ULTILET 28G LANCETS ... 73ULTILET 30G LANCETS ... 73ULTILET ALCOHOL STERLSWAB. ................ 73ULTILET ALCOHOL SWAB 73ULTILET BASIC 30GLANCETS. ............. 73ULTILET CLASSIC 26GLANCETS. ............. 73ULTILET CLASSIC 28GLANCETS. ............. 73ULTILET CLASSIC 30GLANCETS. ............. 73ULTILET INSULIN SYRINGE0.3 ML ................ 73ULTILET INSULIN SYRINGE0.5 ML ................ 73ULTILET INSULIN SYRINGE 1ML. ................... 73ULTILET LANCETS ....... 73ULTILET SAFETY LANCETS 73ultimatecare advantage .... 87ultimatecare one .......... 87ultimatecare one nf ........ 88ultimate ob dha ........... 87ULTRA COMFORT 0.3 ML29GX1/2 .............. 73ULTRA COMFORT 0.3 MLSYRINGE. ............. 73ULTRA COMFORT 0.5 ML28GX1/2 .............. 73ULTRA COMFORT 0.5 ML29GX1/2 .............. 73ULTRA COMFORT 0.5 ML30GX5/16 ............. 73ULTRA COMFORT 0.5 ML31GX5/16 ............. 73ULTRA COMFORT 0.5 MLSYRINGE. ............. 73ULTRA COMFORT 1 ML28GX1/2 .............. 74ULTRA COMFORT 1 ML29GX1/2 .............. 74ULTRA COMFORT 1 ML30GX5/16 ............. 74ULTRA COMFORT 1 ML31GX5/16 ............. 74ULTRA COMFORT 1 MLSYRINGE. ............. 74ULTRA COMFORT 3/10 MLSYR................... 74ULTRACOMFORT 30GX0.5 MLSYR................... 74ULTRACOMFORT 30GX1 MLSYRINGE. ............. 74ULTRACOMFORT 31GX0.5 MLSYR................... 74ULTRACOMFORT 31GX1 MLSYRINGE. ............. 74ULTRACOMFORT INSULINSYR 1 ML. ............. 74ULTRACOMFORT INSUL SYR0.5 ML ................ 74ULTRACOMFORT PENNEEDLES 6MM ........ 74ULTRACOMFORT PENNEEDLES 8MM ........ 74ULTRALANCE 26GLANCETS. ............. 74ULTRALANCE 28GLANCETS. ............. 74ULTRA THIN 28 G LANCET 74ULTRA THIN 28GLANCETS. ............. 74ULTRA THIN 31GLANCETS. ............. 74ULTRA THIN 33GLANCETS. ............. 74ULTRA-THIN II 26GLANCET ............... 74126

ULTRA-THIN II 28GLANCETS. ............. 74ULTRA-THIN II 30GLANCETS. ............. 74ULTRA-THIN II 31G SHORTNEEDLE. .............. 74ULTRA-THIN II INS 0.3 ML29G. .................. 74ULTRA-THIN II INS 0.3 ML30G. .................. 74ULTRA-THIN II INS 0.3 ML31G. .................. 74ULTRA-THIN II INS 0.5 ML29G. .................. 74ULTRA-THIN II INS 0.5 ML30G. .................. 74ULTRA-THIN II INS 0.5 ML31G. .................. 74ULTRA-THIN II INS SYR 1 ML29G. .................. 74ULTRA-THIN II INS SYR 1 ML30G. .................. 74ULTRA-THIN II PEN NDL29GX1/2 .............. 74ULTRA-THIN II PEN NDL31GX5/16 ............. 74ULTRA THIN LANCETS. ... 74ULTRATRAK CONTROL SOLNORMAL . . . . . . . . . . . . . . 74ULTRATRAK CONTROLSOLUTION ............ 74ULTRATRAK PRO CNTRLSOLUTION ............ 74ULTRATRAK ULTIMATE CNTRLSOLN . . . . . . . . . . . . . . . . . 74UNIFINE PENTIP 0.5CCNEEDLE. .............. 74UNIFINE PENTIPNEEDLES ............. 74UNIFINE PENTIPS 6MM31G. .................. 74UNIFINE PENTIPS 6MMNEEDLE. .............. 75UNIFINE PENTIPS 6MMNEEDLES ............. 75UNIFINE PENTIPS 8MM31G. .................. 75UNIFINE PENTIPS 8MMNEEDLE. .............. 75UNIFINE PENTIPS 8MMNEEDLES ............. 75UNIFINE PENTIPS 12MM29G. .................. 74UNIFINE PENTIPS 12MMNEEDLE. .............. 74UNIFINE PENTIPS31GX3/16 ............. 74UNIFINE PENTIPS32GX5/32 ............. 74UNIFINE PENTIPS NEEDLES29G. .................. 75UNIFINE PENTIPS NEEDLES31G. .................. 75UNILET COMFORTOUCH 26GLANCETS. ............. 75UNILET COMFORTOUCHLANCET ............... 75UNILET EXCELITE IILANCET ............... 75UNILET EXCELITE LANCET 75UNILET GP LANCET. ..... 75UNILET GP LANCETSUPERLITE ............ 75UNILET LANCET . . . . . . . . . 75UNILET LANCET 28G. .... 75UNILET LANCETSUPERLITE ............ 75UNILET SUPER THIN 30GLANCETS. ............. 75UNILET ULTRA THIN 28GLANCETS. ............. 75UNISTIK 3 COMFORTLANCET ............... 75UNISTIK 3 EXTRA 21GLANCETS. ............. 75UNISTIK 3 NORMAL 23GLANCETS. ............. 75UNISTIK 3 SAFETY 21GLANCETS. ............. 75UNISTIK CZT COMFORTLANCET ............... 75UNISTIK CZT NORMAL 23GLANCETS. ............. 75unithroid. ................ 45UNIVERSAL 1 33GLANCETS. ............. 75urea 39% cream, -45% lotion,-40% nail film susp ...... 39urea 40% cream, -45% cream,-50% cream, -foam (noncontraceptive),-gel, -40%lotion, -soln, top, -50%emulsion, -50% topicalsuspension ............. 40urogesic-blue. ............ 14ursodiol capsule, -tablet. ... 47UVADEX ................ 19VVAGIFEM ............... 85valacyclovir .............. 12VALCYTE. ............... 12valproate sodium injection .. 31valproic acid capsule, -syrup 31valsartan-hctz ............ 35VALSTAR ................ 19VALUE PLUS STANDARDLANCETS. ............. 75VALUE PLUS SUPER THINLANCETS. ............. 75VALUEPLUS SYR 0.3 ML29GX1/2 .............. 75VALUE PLUS THINLANCETS. ............. 75VANCOMYCIN-D5W ..... 11vancomycin hcl capsule .... 11vancomycin vial ........... 10vandazole. ............... 85VANDETANIB ............ 19VANISHPOINT 0.5 ML30GX1/2 SY ........... 75VANISHPOINT U-100 29X1/2SYR................... 75VANTAS. ................ 19VAQTA .................. 49VARIVAX VACCINE ....... 49VECTIBIX ............... 19VELCADE ............... 19veletri . . . . . . . . . . . . . . . . . . . 36velivet ................... 84vemavite-prx 2 ............ 88vena-bal dha ............. 88venatal complete dha ...... 88venatal-fa ................ 88127

venlafaxine hcl ............ 28venlafaxine hcl er 37.5 mg cap,-75 mg cap, -37.5 mg tab, -75mg tab. ................ 28venlafaxine hcl er 150 mg cap,-150 mg tab ............ 28VENLAFAXINE HCL ER 225MG TAB (BRAND) ...... 28venlafaxine hcl er 225 mg tab(generic) ............... 28VENTAVIS ............... 36verapamil er 120 mg tablet, -180mg tablet, -240 mg tablet . 33verapamil er pm. .......... 33verapamil hcl capsule sustainedaction, -tablet, -er 120 mgtablet, -er 240 mg tablet .. 33verapamil injection ........ 33veripred 20 .............. 42vestura .................. 85VFEND SUSPENSION. ... 10VH INS SYR 0.5 ML29GX1/2 .............. 75VH INS SYR 1 ML 29GX1/2 75VIBATIV 250 MG VIAL. .... 11VIBATIV 750 MG VIAL. .... 11VICTORY HIGH-LOWCONTROL SOLN. ...... 75VICTOZA 2-PAK .......... 42VICTOZA 3-PAK .......... 42VICTRELIS ............... 8VIDAZA ................. 19VIDEX ................... 8VIIBRYD 10 MG TABLET,-20 MG TABLET, -40 MGTABLET. ............... 30VIIBRYD TITRATION PACK 30VIMPAT INJECTION. ...... 27VIMPAT SOLUTION,-TABLET ............... 27vinacal .................. 88vinate az. ................ 88vinate az extra ............ 88vinate c. ................. 88vinate calcium . . . . . . . . . . . . 88vinate care ............... 88vinate gt ................. 88vinate ic ................. 88vinate ii. ................. 88vinate-m ................. 88vinate one ............... 88vinate pn care ............ 88vinate ultra ............... 88vinblastine ............... 19vincasar pfs .............. 19vincristine. ............... 19vinorelbine ............... 19viorele. .................. 85VIRACEPT 625 MG TABLET 8VIRACEPT POWDER, -250 MGTABLET. ................ 8VIRAMUNE ORAL SUSP ... 8VIRAMUNE XR. ........... 8VIREAD .................. 8virt-bal dha. .............. 88virt-pn ................... 88virt-pn dha ............... 88VISICOL ................ 47vitafol-ob ................ 88vitafol-pn ................ 88VITALET 23 GAUGELANCET ............... 75VITALET PRO LANCETS. .. 75VITALET PRO PLUSLANCETS. ............. 75VITALET THIN 26GAUGELANCET ............... 75vitaspire ................. 88vitazol ................... 37vol-nate ................. 88vol-plus. ................. 88vol-tab rx ................ 88VORAXAZE. ............. 19voriconazole. ............. 12voriconazole 50 mg tablet . . 10voriconazole 200 mg tablet . 10VOTRIENT. .............. 19vp-ch-pnv ................ 88vp-era ob plus ............ 88vp-ggr-b6. ............... 88VUMON. ................ 19WWALGREENS LANCETS .. 75WALGREENS THINLANCETS. ............. 75WALGREENS ULTRA THINLANCETS. ............. 75warfarin sodium tablet ..... 82WAVESENSE CONTROLSOLN NORMAL ........ 76WDMEDIC INS SYR 1 ML30GX5/16 ............. 76WD MEDIC SYR 0.3 ML30GX5/16 ............. 76WD MEDIC SYR 0.5 ML29GX1/2 .............. 76WD MEDIC SYR 0.5 ML30GX5/16 ............. 76WD MEDIC SYR 1 ML29GX1/2 .............. 76WDMEDIC SYRING 0.3 ML29GX1/2 .............. 76WEBCOL ALCOHOLPREPS ................ 76WELCHOL .............. 33W & F 26G LANCETS. .... 75W & F COLORED 21GLANCETS. ............. 75W&F COLORED LANCETS 75W&F THIN LANCETS ..... 75XXALKORI. ............... 19XARELTO ............... 82XELODA ................ 19XENAZINE .............. 29XEOMIN ................ 76XGEVA. ................. 45XOLAIR ................. 94XOPENEX. .............. 93XPRES CONTROL SOLUTIONNORMAL . . . . . . . . . . . . . . 76XTANDI ................. 19x-viate. .................. 40XYREM ................. 29YYERVOY ................ 19YF-VAX ................. 49Zzafirlukast. ............... 94zaleplon ................. 29ZALTRAP ................ 19zamicet. ................. 25128

ZANOSAR .............. 19zarah. ................... 85zatean-ch ................ 88zatean-pn ................ 88zatean-pn dha ............ 88zatean-pn plus. ........... 88ZAVESCA . . . . . . . . . . . . . . . 45ZELAPAR ............... 28ZELBORAF. ............. 19ZEMPLAR CAPSULE ..... 83ZEMPLAR INJECTION .... 83zenchent ................ 85zenchent fe .............. 85ZENPEP ................ 47zeosa ................... 85ZETIA. .................. 33ZIAGEN SOLUTION ....... 8zidovudine ................ 9ziprasidone hcl ........... 21ZIRGAN. ................ 92ZITHRANOL-RR. ......... 37zoden pd ................ 92ZOLADEX ............... 19zoledronic acid ........... 45ZOLINZA. ............... 19zolpidem tartrate .......... 29zolpidem tartrate er. ....... 29ZOMETA . . . . . . . . . . . . . . . . 45ZOMIG NASAL DROPS/SPRAYS ............... 26ZONALON .............. 40zonisamide. .............. 27ZORBTIVE .............. 47ZORTRESS 0.5 MG TABLET,-0.75 MG TABLET. ...... 19ZORTRESS 0.25 MGTABLET. ............... 19ZOSTAVAX .............. 49zovia 1-35e .............. 85zovia 1-50e .............. 85ZOVIRAX CREAM, -OINT. . 12ZYCLARA ............... 40ZYPREXA RELPREVV .... 21ZYTIGA ................. 19ZYVOX IV SOLUTION. .... 11ZYVOX ORAL SUSP,-TABLET ............... 11129

®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. ®´, TM Registered Marks andTrademarks of the medications listed are the property of their respective manufacturers. © 2013 Blue Cross andBlue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.128866M55-0392 (8/13) PDF