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Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100 MG Acarbose Oral Tablet 25 MG Acarbose Oral Tablet 50 MG Acetaminophen-Codeine #2 Oral Tablet 300-15 MG Acetaminophen-Codeine #3 Oral Tablet 300-30 MG Acetaminophen-Codeine #4 Oral Tablet 300-60 MG Acetaminophen-Codeine Oral Solution 120-12 MG/5ML Active-Pac/Gabapentin Combination Therapy Pack 300 & 4-1 MG & % Acyclovir External Cream 5 % Acyclovir External Ointment 5 % Acyclovir Oral Capsule 200 MG Acyclovir Oral Suspension 200 MG/5ML Acyclovir Oral Tablet 400 MG Acyclovir Oral Tablet 800 MG Acyclovir Sodium Intravenous Solution 50 MG/ML Allopurinol Oral Tablet 100 MG Allopurinol Oral Tablet 300 MG Allopurinol Sodium Intravenous Solution Reconstituted 500 MG Alogliptin-metFORMIN HCl Oral Tablet 12.5-1000 MG Alogliptin-metFORMIN HCl Oral Tablet 12.5-500 MG Alogliptin-Pioglitazone Oral Tablet 12.5-15 MG Alogliptin-Pioglitazone Oral Tablet 12.5-30 MG Alogliptin-Pioglitazone Oral Tablet 12.5-45 MG Alogliptin-Pioglitazone Oral Tablet 25-15 MG Alogliptin-Pioglitazone Oral Tablet 25-30 MG Alogliptin-Pioglitazone Oral Tablet 25-45 MG ALPRAZolam ER Oral Tablet Extended Release 24 Hour 0.5 MG ALPRAZolam ER Oral Tablet Extended Release 24 Hour 1 MG ALPRAZolam ER Oral Tablet Extended Release 24 Hour 2 MG ALPRAZolam ER Oral Tablet Extended Release 24 Hour 3 MG ALPRAZolam Intensol Oral Concentrate 1 MG/ML ALPRAZolam Oral Tablet 0.25 MG ALPRAZolam Oral Tablet 0.5 MG ALPRAZolam Oral Tablet 1 MG ALPRAZolam Oral Tablet 2 MG ALPRAZolam Oral Tablet Disintegrating 0.25 MG ALPRAZolam Oral Tablet Disintegrating 0.5 MG ALPRAZolam Oral Tablet Disintegrating 1 MG ALPRAZolam Oral Tablet Disintegrating 2 MG Altavera Oral Tablet 0.15-30 MG-MCG aMILoride-hydroCHLOROthiazide Oral Tablet 5-50 MG Amiodarone HCl in Dextrose Intravenous Solution 150-5 MG/100ML-% Amiodarone HCl in Dextrose Intravenous Solution 450-5 MG/250ML-% Amiodarone HCl in Dextrose Intravenous Solution 750-5 MG/500ML-% The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

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Page 1: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Tier 1 (Generics) - $10 or LessAcarbose Oral Tablet 100 MGAcarbose Oral Tablet 25 MGAcarbose Oral Tablet 50 MGAcetaminophen-Codeine #2 Oral Tablet 300-15 MGAcetaminophen-Codeine #3 Oral Tablet 300-30 MGAcetaminophen-Codeine #4 Oral Tablet 300-60 MGAcetaminophen-Codeine Oral Solution 120-12 MG/5MLActive-Pac/Gabapentin Combination Therapy Pack 300 & 4-1 MG & %Acyclovir External Cream 5 %Acyclovir External Ointment 5 %Acyclovir Oral Capsule 200 MGAcyclovir Oral Suspension 200 MG/5MLAcyclovir Oral Tablet 400 MGAcyclovir Oral Tablet 800 MGAcyclovir Sodium Intravenous Solution 50 MG/MLAllopurinol Oral Tablet 100 MGAllopurinol Oral Tablet 300 MGAllopurinol Sodium Intravenous Solution Reconstituted 500 MGAlogliptin-metFORMIN HCl Oral Tablet 12.5-1000 MGAlogliptin-metFORMIN HCl Oral Tablet 12.5-500 MGAlogliptin-Pioglitazone Oral Tablet 12.5-15 MGAlogliptin-Pioglitazone Oral Tablet 12.5-30 MGAlogliptin-Pioglitazone Oral Tablet 12.5-45 MGAlogliptin-Pioglitazone Oral Tablet 25-15 MGAlogliptin-Pioglitazone Oral Tablet 25-30 MGAlogliptin-Pioglitazone Oral Tablet 25-45 MGALPRAZolam ER Oral Tablet Extended Release 24 Hour 0.5 MGALPRAZolam ER Oral Tablet Extended Release 24 Hour 1 MGALPRAZolam ER Oral Tablet Extended Release 24 Hour 2 MGALPRAZolam ER Oral Tablet Extended Release 24 Hour 3 MGALPRAZolam Intensol Oral Concentrate 1 MG/MLALPRAZolam Oral Tablet 0.25 MGALPRAZolam Oral Tablet 0.5 MGALPRAZolam Oral Tablet 1 MGALPRAZolam Oral Tablet 2 MGALPRAZolam Oral Tablet Disintegrating 0.25 MGALPRAZolam Oral Tablet Disintegrating 0.5 MGALPRAZolam Oral Tablet Disintegrating 1 MGALPRAZolam Oral Tablet Disintegrating 2 MGAltavera Oral Tablet 0.15-30 MG-MCGaMILoride-hydroCHLOROthiazide Oral Tablet 5-50 MGAmiodarone HCl in Dextrose Intravenous Solution 150-5 MG/100ML-%Amiodarone HCl in Dextrose Intravenous Solution 450-5 MG/250ML-%Amiodarone HCl in Dextrose Intravenous Solution 750-5 MG/500ML-%

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 2: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Amiodarone HCl in Dextrose Intravenous Solution 900-5 MG/500ML-%Amiodarone HCl Intravenous Solution 150 MG/3MLAmiodarone HCl Intravenous Solution 450 MG/9MLAmiodarone HCl Intravenous Solution 900 MG/18MLAmiodarone HCl Oral Tablet 100 MGAmiodarone HCl Oral Tablet 200 MGAmiodarone HCl Oral Tablet 400 MGAmitriptyline HCl Oral Tablet 10 MGAmitriptyline HCl Oral Tablet 100 MGAmitriptyline HCl Oral Tablet 150 MGAmitriptyline HCl Oral Tablet 25 MGAmitriptyline HCl Oral Tablet 50 MGAmitriptyline HCl Oral Tablet 75 MGamLODIPine Besy-Benazepril HCl Oral Capsule 10-20 MGamLODIPine Besy-Benazepril HCl Oral Capsule 10-40 MGamLODIPine Besy-Benazepril HCl Oral Capsule 2.5-10 MGamLODIPine Besy-Benazepril HCl Oral Capsule 5-10 MGamLODIPine Besy-Benazepril HCl Oral Capsule 5-20 MGamLODIPine Besy-Benazepril HCl Oral Capsule 5-40 MGamLODIPine Besylate Oral Tablet 10 MGamLODIPine Besylate Oral Tablet 2.5 MGamLODIPine Besylate Oral Tablet 5 MGamLODIPine Besylate-Valsartan Oral Tablet 10-160 MGamLODIPine Besylate-Valsartan Oral Tablet 10-320 MGamLODIPine Besylate-Valsartan Oral Tablet 5-160 MGamLODIPine Besylate-Valsartan Oral Tablet 5-320 MGamLODIPine-Atorvastatin Oral Tablet 10-10 MGamLODIPine-Atorvastatin Oral Tablet 10-20 MGamLODIPine-Atorvastatin Oral Tablet 10-40 MGamLODIPine-Atorvastatin Oral Tablet 10-80 MGamLODIPine-Atorvastatin Oral Tablet 2.5-10 MGamLODIPine-Atorvastatin Oral Tablet 2.5-20 MGamLODIPine-Atorvastatin Oral Tablet 2.5-40 MGamLODIPine-Atorvastatin Oral Tablet 5-10 MGamLODIPine-Atorvastatin Oral Tablet 5-20 MGamLODIPine-Atorvastatin Oral Tablet 5-40 MGamLODIPine-Atorvastatin Oral Tablet 5-80 MGamLODIPine-Olmesartan Oral Tablet 10-20 MGamLODIPine-Olmesartan Oral Tablet 10-40 MGamLODIPine-Olmesartan Oral Tablet 5-20 MGamLODIPine-Olmesartan Oral Tablet 5-40 MGamLODIPine-Valsartan-HCTZ Oral Tablet 10-160-12.5 MGamLODIPine-Valsartan-HCTZ Oral Tablet 10-160-25 MGamLODIPine-Valsartan-HCTZ Oral Tablet 10-320-25 MGamLODIPine-Valsartan-HCTZ Oral Tablet 5-160-12.5 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 3: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

amLODIPine-Valsartan-HCTZ Oral Tablet 5-160-25 MGAmoxicillin Oral Capsule 250 MGAmoxicillin Oral Capsule 500 MGAmoxicillin Oral Suspension Reconstituted 125 MG/5MLAmoxicillin Oral Suspension Reconstituted 200 MG/5MLAmoxicillin Oral Suspension Reconstituted 250 MG/5MLAmoxicillin Oral Suspension Reconstituted 400 MG/5MLAmoxicillin Oral Tablet 500 MGAmoxicillin Oral Tablet 875 MGAmoxicillin Oral Tablet Chewable 125 MGAmoxicillin Oral Tablet Chewable 250 MGAmoxicillin-Pot Clavulanate ER Oral Tablet Extended Release 12 Hour 1000-62Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted 200-28.5 MG/5MLAmoxicillin-Pot Clavulanate Oral Suspension Reconstituted 250-62.5 MG/5MLAmoxicillin-Pot Clavulanate Oral Suspension Reconstituted 400-57 MG/5MLAmoxicillin-Pot Clavulanate Oral Suspension Reconstituted 600-42.9 MG/5MLAmoxicillin-Pot Clavulanate Oral Tablet 250-125 MGAmoxicillin-Pot Clavulanate Oral Tablet 500-125 MGAmoxicillin-Pot Clavulanate Oral Tablet 875-125 MGAmoxicillin-Pot Clavulanate Oral Tablet Chewable 200-28.5 MGAmoxicillin-Pot Clavulanate Oral Tablet Chewable 400-57 MGAnastrozole Oral Tablet 1 MGApraclonidine HCl Ophthalmic Solution 0.5 %Atenolol Oral Tablet 100 MGAtenolol Oral Tablet 25 MGAtenolol Oral Tablet 50 MGAtenolol-Chlorthalidone Oral Tablet 100-25 MGAtenolol-Chlorthalidone Oral Tablet 50-25 MGAtorvastatin Calcium Oral Tablet 10 MGAtorvastatin Calcium Oral Tablet 20 MGAtorvastatin Calcium Oral Tablet 40 MGAtorvastatin Calcium Oral Tablet 80 MGAubra EQ Oral Tablet 0.1-20 MG-MCGB Complex-C-Folic Acid Oral Tablet B Complex-Folic Acid Oral Tablet 500-5-200 MCG-MG-MCGB-Complex/Folic Acid/Vitamin C Oral Tablet Extended Release Baclofen Intrathecal Solution 10 MG/20MLBaclofen Intrathecal Solution 20000 MCG/20MLBaclofen Intrathecal Solution 40 MG/20MLBaclofen Oral Tablet 10 MGBaclofen Oral Tablet 20 MGBaclofen Oral Tablet 5 MGBenazepril HCl Oral Tablet 10 MGBenazepril HCl Oral Tablet 20 MGBenazepril HCl Oral Tablet 40 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 4: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Benazepril HCl Oral Tablet 5 MGBenazepril-hydroCHLOROthiazide Oral Tablet 10-12.5 MGBenazepril-hydroCHLOROthiazide Oral Tablet 20-12.5 MGBenazepril-hydroCHLOROthiazide Oral Tablet 20-25 MGBenazepril-hydroCHLOROthiazide Oral Tablet 5-6.25 MGBenzhydrocodone-Acetaminophen Oral Tablet 4.08-325 MGBenzhydrocodone-Acetaminophen Oral Tablet 6.12-325 MGBenzhydrocodone-Acetaminophen Oral Tablet 8.16-325 MGBenzonatate Oral Capsule 100 MGBenzonatate Oral Capsule 150 MGBenzonatate Oral Capsule 200 MGBenztropine Mesylate Injection Solution 1 MG/MLBenztropine Mesylate Oral Tablet 0.5 MGBenztropine Mesylate Oral Tablet 1 MGBenztropine Mesylate Oral Tablet 2 MGBethanechol Chloride Oral Tablet 10 MGBethanechol Chloride Oral Tablet 25 MGBethanechol Chloride Oral Tablet 5 MGBethanechol Chloride Oral Tablet 50 MGBicalutamide Oral Tablet 50 MGBisoprolol-hydroCHLOROthiazide Oral Tablet 10-6.25 MGBisoprolol-hydroCHLOROthiazide Oral Tablet 2.5-6.25 MGBisoprolol-hydroCHLOROthiazide Oral Tablet 5-6.25 MGBlisovi 24 Fe Oral Tablet 1-20 MG-MCG(24)Blisovi Fe 1.5/30 Oral Tablet 1.5-30 MG-MCGBlisovi FE 1/20 Oral Tablet 1-20 MG-MCGbuPROPion HCl ER (Smoking Det) Oral Tablet Extended Release 12 Hour 150 MGbuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 100 MGbuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MGbuPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 200 MGbuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MGbuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 300 MGbuPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 450 MGbuPROPion HCl Oral Tablet 100 MGbuPROPion HCl Oral Tablet 75 MGbusPIRone HCl Oral Tablet 10 MGbusPIRone HCl Oral Tablet 15 MGbusPIRone HCl Oral Tablet 30 MGbusPIRone HCl Oral Tablet 5 MGbusPIRone HCl Oral Tablet 7.5 MGCalcitriol External Ointment 3 MCG/GMCalcitriol Intravenous Solution 1 MCG/MLCalcitriol Oral Capsule 0.25 MCGCalcitriol Oral Capsule 0.5 MCGCalcitriol Oral Solution 1 MCG/ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 5: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Calcium-Folic Acid Plus D Oral Wafer 1342-1 MGCaptopril-hydroCHLOROthiazide Oral Tablet 25-15 MGCaptopril-hydroCHLOROthiazide Oral Tablet 25-25 MGCaptopril-hydroCHLOROthiazide Oral Tablet 50-15 MGCaptopril-hydroCHLOROthiazide Oral Tablet 50-25 MGCarbidopa Oral Tablet 25 MGCarbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MGCarbidopa-Levodopa ER Oral Tablet Extended Release 50-200 MGCarbidopa-Levodopa Oral Tablet 10-100 MGCarbidopa-Levodopa Oral Tablet 25-100 MGCarbidopa-Levodopa Oral Tablet 25-250 MGCarbidopa-Levodopa Oral Tablet Disintegrating 10-100 MGCarbidopa-Levodopa Oral Tablet Disintegrating 25-100 MGCarbidopa-Levodopa Oral Tablet Disintegrating 25-250 MGCarbidopa-Levodopa-Entacapone Oral Tablet 12.5-50-200 MGCarbidopa-Levodopa-Entacapone Oral Tablet 18.75-75-200 MGCarbidopa-Levodopa-Entacapone Oral Tablet 25-100-200 MGCarbidopa-Levodopa-Entacapone Oral Tablet 31.25-125-200 MGCarbidopa-Levodopa-Entacapone Oral Tablet 37.5-150-200 MGCarbidopa-Levodopa-Entacapone Oral Tablet 50-200-200 MGCarisoprodol Oral Tablet 250 MGCarisoprodol Oral Tablet 350 MGCarisoprodol-Aspirin Oral Tablet 200-325 MGCarisoprodol-Aspirin-Codeine Oral Tablet 200-325-16 MGCarvedilol Oral Tablet 12.5 MGCarvedilol Oral Tablet 25 MGCarvedilol Oral Tablet 3.125 MGCarvedilol Oral Tablet 6.25 MGCarvedilol Phosphate ER Oral Capsule Extended Release 24 Hour 10 MGCarvedilol Phosphate ER Oral Capsule Extended Release 24 Hour 20 MGCarvedilol Phosphate ER Oral Capsule Extended Release 24 Hour 40 MGCarvedilol Phosphate ER Oral Capsule Extended Release 24 Hour 80 MGCefadroxil Oral Capsule 500 MGCefadroxil Oral Suspension Reconstituted 250 MG/5MLCefadroxil Oral Suspension Reconstituted 500 MG/5MLCefadroxil Oral Tablet 1 GMCeftibuten Oral Capsule 400 MGCeftibuten Oral Suspension Reconstituted 180 MG/5MLCephalexin Oral Capsule 250 MGCephalexin Oral Capsule 500 MGCephalexin Oral Capsule 750 MGCephalexin Oral Suspension Reconstituted 125 MG/5MLCephalexin Oral Suspension Reconstituted 250 MG/5MLCephalexin Oral Tablet 250 MGCephalexin Oral Tablet 500 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 6: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Childrens Ibuprofen 100 Oral Suspension 100 MG/5MLchlordiazePOXIDE-Amitriptyline Oral Tablet 10-25 MGchlordiazePOXIDE-Amitriptyline Oral Tablet 5-12.5 MGCilostazol Oral Tablet 100 MGCilostazol Oral Tablet 50 MGCiprofloxacin HCl Ophthalmic Solution 0.3 %Ciprofloxacin HCl Oral Tablet 100 MGCiprofloxacin HCl Oral Tablet 250 MGCiprofloxacin HCl Oral Tablet 500 MGCiprofloxacin HCl Oral Tablet 750 MGCiprofloxacin HCl Otic Solution 0.2 %Ciprofloxacin in D5W Intravenous Solution 200 MG/100MLCiprofloxacin in D5W Intravenous Solution 400 MG/200MLCiprofloxacin Intravenous Solution 200 MG/20MLCiprofloxacin Intravenous Solution 400 MG/40MLCiprofloxacin Oral Suspension Reconstituted 250 MG/5ML (5%)Ciprofloxacin Oral Suspension Reconstituted 500 MG/5ML (10%)Ciprofloxacin-Ciproflox HCl ER Oral Tablet Extended Release 24 Hour 1000 MGCiprofloxacin-Ciproflox HCl ER Oral Tablet Extended Release 24 Hour 500 MGCiprofloxacin-Fluocinolone PF Otic Solution 0.3-0.025 %Citalopram Hydrobromide Oral Solution 10 MG/5MLCitalopram Hydrobromide Oral Tablet 10 MGCitalopram Hydrobromide Oral Tablet 20 MGCitalopram Hydrobromide Oral Tablet 40 MGClindamycin HCl Oral Capsule 150 MGClindamycin HCl Oral Capsule 300 MGClindamycin HCl Oral Capsule 75 MGClindamycin Palmitate HCl Oral Solution Reconstituted 75 MG/5MLClindamycin Phos-Benzoyl Perox External Gel 1-5 %Clindamycin Phos-Benzoyl Perox External Gel 1.2-2.5 %Clindamycin Phos-Benzoyl Perox External Gel 1.2-5 %Clindamycin Phosphate External Foam 1 %Clindamycin Phosphate External Gel 1 %Clindamycin Phosphate External Lotion 1 %Clindamycin Phosphate External Solution 1 %Clindamycin Phosphate External Swab 1 %Clindamycin Phosphate in D5W Intravenous Solution 300 MG/50MLClindamycin Phosphate in D5W Intravenous Solution 600 MG/50MLClindamycin Phosphate in D5W Intravenous Solution 900 MG/50MLClindamycin Phosphate in NaCl Intravenous Solution 300-0.9 MG/50ML-%Clindamycin Phosphate in NaCl Intravenous Solution 600-0.9 MG/50ML-%Clindamycin Phosphate in NaCl Intravenous Solution 900-0.9 MG/50ML-%Clindamycin Phosphate Injection Solution 300 MG/2MLClindamycin Phosphate Injection Solution 600 MG/4MLClindamycin Phosphate Injection Solution 9 GM/60ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 7: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Clindamycin Phosphate Injection Solution 900 MG/6MLClindamycin Phosphate Intravenous Solution 300 MG/2MLClindamycin Phosphate Intravenous Solution 600 MG/4MLClindamycin Phosphate Intravenous Solution 900 MG/6MLClindamycin Phosphate Vaginal Cream 2 %Clindamycin-Tretinoin External Gel 1.2-0.025 %clonazePAM Oral Tablet 0.5 MGclonazePAM Oral Tablet 1 MGclonazePAM Oral Tablet 2 MGclonazePAM Oral Tablet Disintegrating 0.125 MGclonazePAM Oral Tablet Disintegrating 0.25 MGclonazePAM Oral Tablet Disintegrating 0.5 MGclonazePAM Oral Tablet Disintegrating 1 MGclonazePAM Oral Tablet Disintegrating 2 MGcloNIDine HCl (Analgesia) Epidural Solution 100 MCG/MLcloNIDine HCl (Analgesia) Epidural Solution 500 MCG/MLcloNIDine HCl ER Oral Tablet Extended Release 12 Hour 0.1 MGcloNIDine HCl Oral Tablet 0.1 MGcloNIDine HCl Oral Tablet 0.2 MGcloNIDine HCl Oral Tablet 0.3 MGcloNIDine Transdermal Patch Weekly 0.1 MG/24HRcloNIDine Transdermal Patch Weekly 0.2 MG/24HRcloNIDine Transdermal Patch Weekly 0.3 MG/24HRClopidogrel Bisulfate Oral Tablet 300 MGClopidogrel Bisulfate Oral Tablet 75 MGCurad Hydrocortisone External Cream 1 %CVS Folic Acid Oral Tablet 800 MCGCVS Hydrocortisone Acetate External Cream 0.5 %CVS Hydrocortisone Anti-Itch External Cream 0.5 %CVS Ibuprofen IB Oral Tablet 200 MGCVS Ibuprofen Infants Oral Suspension 50 MG/1.25MLCVS Ibuprofen Junior Strength Oral Tablet Chewable 100 MGCVS Ibuprofen Oral Capsule 200 MGCVS Ibuprofen PM Oral Tablet 200-38 MGCVS Naproxen Sodium Oral Capsule 220 MGCVS Naproxen Sodium Oral Tablet 220 MGCVS raNITIdine Oral Tablet 75 MGCyclobenzaprine HCl ER Oral Capsule Extended Release 24 Hour 15 MGCyclobenzaprine HCl ER Oral Capsule Extended Release 24 Hour 30 MGCyclobenzaprine HCl Oral Tablet 10 MGCyclobenzaprine HCl Oral Tablet 5 MGCyclobenzaprine HCl Oral Tablet 7.5 MGCyproheptadine HCl Oral Syrup 2 MG/5MLCyproheptadine HCl Oral Tablet 4 MGDeltasone Oral Tablet 20 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 8: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Depo-Estradiol Intramuscular Oil 5 MG/MLDesogestrel-Ethinyl Estradiol Oral Tablet 0.15-0.02/0.01 MG (21/5)Desogestrel-Ethinyl Estradiol Oral Tablet 0.15-30 MG-MCGDesvenlafaxine ER Oral Tablet Extended Release 24 Hour 100 MGDesvenlafaxine ER Oral Tablet Extended Release 24 Hour 50 MGDesvenlafaxine Fumarate ER Oral Tablet Extended Release 24 Hour 100 MGDesvenlafaxine Fumarate ER Oral Tablet Extended Release 24 Hour 50 MGDesvenlafaxine Succinate ER Oral Tablet Extended Release 24 Hour 100 MGDesvenlafaxine Succinate ER Oral Tablet Extended Release 24 Hour 25 MGDesvenlafaxine Succinate ER Oral Tablet Extended Release 24 Hour 50 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 10 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 15 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 20 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 25 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 30 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 35 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 40 MGDexmethylphenidate HCl ER Oral Capsule Extended Release 24 Hour 5 MGDexmethylphenidate HCl Oral Tablet 10 MGDexmethylphenidate HCl Oral Tablet 2.5 MGDexmethylphenidate HCl Oral Tablet 5 MGdiazePAM Injection Solution 5 MG/MLdiazePAM Intensol Oral Concentrate 5 MG/MLdiazePAM Intramuscular Solution Auto-injector 10 MG/2MLdiazePAM Oral Solution 5 MG/5MLdiazePAM Oral Tablet 10 MGdiazePAM Oral Tablet 2 MGdiazePAM Oral Tablet 5 MGdiazePAM Rectal Gel 10 MGdiazePAM Rectal Gel 2.5 MGdiazePAM Rectal Gel 20 MGDibucaine External Ointment 1 %Dibucaine Rectal Ointment 1 %Dicyclomine HCl Intramuscular Solution 10 MG/MLDicyclomine HCl Oral Capsule 10 MGDicyclomine HCl Oral Solution 10 MG/5MLDicyclomine HCl Oral Tablet 20 MGDonepezil HCl Oral Tablet 10 MGDonepezil HCl Oral Tablet 23 MGDonepezil HCl Oral Tablet 5 MGDonepezil HCl Oral Tablet Disintegrating 10 MGDonepezil HCl Oral Tablet Disintegrating 5 MGDoxazosin Mesylate Oral Tablet 1 MGDoxazosin Mesylate Oral Tablet 2 MGDoxazosin Mesylate Oral Tablet 4 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 9: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Doxazosin Mesylate Oral Tablet 8 MGDoxycycline Hyclate Intravenous Solution Reconstituted 100 MGDoxycycline Hyclate Oral Capsule 100 MGDoxycycline Hyclate Oral Capsule 50 MGDoxycycline Hyclate Oral Tablet 100 MGDoxycycline Hyclate Oral Tablet 150 MGDoxycycline Hyclate Oral Tablet 20 MGDoxycycline Hyclate Oral Tablet 50 MGDoxycycline Hyclate Oral Tablet 75 MGDoxycycline Hyclate Oral Tablet Delayed Release 100 MGDoxycycline Hyclate Oral Tablet Delayed Release 150 MGDoxycycline Hyclate Oral Tablet Delayed Release 200 MGDoxycycline Hyclate Oral Tablet Delayed Release 50 MGDoxycycline Hyclate Oral Tablet Delayed Release 75 MGDoxycycline Hyclate Oral Tablet Delayed Release 80 MGDoxycycline Monohydrate Oral Capsule 100 MGDoxycycline Monohydrate Oral Capsule 150 MGDoxycycline Monohydrate Oral Capsule 50 MGDoxycycline Monohydrate Oral Capsule 75 MGDoxycycline Monohydrate Oral Suspension Reconstituted 25 MG/5MLDoxycycline Monohydrate Oral Tablet 100 MGDoxycycline Monohydrate Oral Tablet 150 MGDoxycycline Monohydrate Oral Tablet 50 MGDoxycycline Monohydrate Oral Tablet 75 MGDoxycycline Oral Capsule Delayed Release 40 MGDrospirenone-Ethinyl Estradiol Oral Tablet 3-0.02 MGDrospirenone-Ethinyl Estradiol Oral Tablet 3-0.03 MGDutasteride-Tamsulosin HCl Oral Capsule 0.5-0.4 MGEC-Naproxen Oral Tablet Delayed Release 375 MGEC-Naproxen Oral Tablet Delayed Release 500 MGEnalapril Maleate Oral Tablet 10 MGEnalapril Maleate Oral Tablet 2.5 MGEnalapril Maleate Oral Tablet 20 MGEnalapril Maleate Oral Tablet 5 MGEnalapril-hydroCHLOROthiazide Oral Tablet 10-25 MGEnalapril-hydroCHLOROthiazide Oral Tablet 5-12.5 MGEnalaprilat Intravenous Injectable 1.25 MG/MLEndocet Oral Tablet 10-325 MGEndocet Oral Tablet 2.5-325 MGEndocet Oral Tablet 5-325 MGEndocet Oral Tablet 7.5-325 MGEQ Athletes Foot (Terbinafine) External Cream 1 %Ergocalciferol Oral Capsule 1.25 MG (50000 UT)Ergocalciferol Oral Solution 200 MCG/MLEscitalopram Oxalate Oral Solution 5 MG/5ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 10: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Escitalopram Oxalate Oral Tablet 10 MGEscitalopram Oxalate Oral Tablet 20 MGEscitalopram Oxalate Oral Tablet 5 MGEstradiol Oral Tablet 0.5 MGEstradiol Oral Tablet 1 MGEstradiol Oral Tablet 2 MGEstradiol Transdermal Patch Twice Weekly 0.025 MG/24HREstradiol Transdermal Patch Twice Weekly 0.0375 MG/24HREstradiol Transdermal Patch Twice Weekly 0.05 MG/24HREstradiol Transdermal Patch Twice Weekly 0.075 MG/24HREstradiol Transdermal Patch Twice Weekly 0.1 MG/24HREstradiol Transdermal Patch Weekly 0.025 MG/24HREstradiol Transdermal Patch Weekly 0.0375 MG/24HREstradiol Transdermal Patch Weekly 0.05 MG/24HREstradiol Transdermal Patch Weekly 0.06 MG/24HREstradiol Transdermal Patch Weekly 0.075 MG/24HREstradiol Transdermal Patch Weekly 0.1 MG/24HREstradiol Vaginal Cream 0.1 MG/GMEstradiol Vaginal Tablet 10 MCGEstradiol Valerate Intramuscular Oil 20 MG/MLEstradiol Valerate Intramuscular Oil 40 MG/MLEstradiol-Norethindrone Acet Oral Tablet 0.5-0.1 MGEstradiol-Norethindrone Acet Oral Tablet 1-0.5 MGEthynodiol Diac-Eth Estradiol Oral Tablet 1-35 MG-MCGEthynodiol Diac-Eth Estradiol Oral Tablet 1-50 MG-MCGEtonogestrel-Ethinyl Estradiol Vaginal Ring 0.12-0.015 MG/24HREzetimibe-Simvastatin Oral Tablet 10-10 MGEzetimibe-Simvastatin Oral Tablet 10-20 MGEzetimibe-Simvastatin Oral Tablet 10-40 MGEzetimibe-Simvastatin Oral Tablet 10-80 MGFamotidine in NaCl Intravenous Solution Prefilled Syringe 20-0.9 MG/10ML-%Famotidine in NaCl Intravenous Solution Prefilled Syringe 20-0.9 MG/5ML-%Famotidine Intravenous Solution 20 MG/2MLFamotidine Intravenous Solution 200 MG/20MLFamotidine Intravenous Solution 40 MG/4MLFamotidine Oral Suspension Reconstituted 40 MG/5MLFamotidine Oral Tablet 10 MGFamotidine Oral Tablet 20 MGFamotidine Oral Tablet 40 MGFamotidine Premixed Intravenous Solution 20-0.9 MG/50ML-%Fenofibrate Micronized Oral Capsule 130 MGFenofibrate Micronized Oral Capsule 134 MGFenofibrate Micronized Oral Capsule 200 MGFenofibrate Micronized Oral Capsule 43 MGFenofibrate Micronized Oral Capsule 67 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 11: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Fenofibrate Oral Capsule 150 MGFenofibrate Oral Capsule 50 MGFenofibrate Oral Tablet 120 MGFenofibrate Oral Tablet 145 MGFenofibrate Oral Tablet 160 MGFenofibrate Oral Tablet 40 MGFenofibrate Oral Tablet 48 MGFenofibrate Oral Tablet 54 MGFinasteride Oral Tablet 1 MGFinasteride Oral Tablet 5 MGFlecainide Acetate Oral Tablet 100 MGFlecainide Acetate Oral Tablet 150 MGFlecainide Acetate Oral Tablet 50 MGFLUoxetine HCl (PMDD) Oral Capsule 10 MGFLUoxetine HCl (PMDD) Oral Capsule 20 MGFLUoxetine HCl (PMDD) Oral Tablet 10 MGFLUoxetine HCl (PMDD) Oral Tablet 20 MGFLUoxetine HCl Oral Capsule 10 MGFLUoxetine HCl Oral Capsule 20 MGFLUoxetine HCl Oral Capsule 40 MGFLUoxetine HCl Oral Capsule Delayed Release 90 MGFLUoxetine HCl Oral Solution 20 MG/5MLFLUoxetine HCl Oral Tablet 10 MGFLUoxetine HCl Oral Tablet 20 MGFLUoxetine HCl Oral Tablet 60 MGFolic Acid Injection Solution 5 MG/MLFolic Acid Oral Capsule 0.8 MGFolic Acid Oral Capsule 20 MGFolic Acid Oral Tablet 1 MGFolic Acid Oral Tablet 400 MCGFosinopril Sodium Oral Tablet 10 MGFosinopril Sodium Oral Tablet 20 MGFosinopril Sodium Oral Tablet 40 MGFosinopril Sodium-HCTZ Oral Tablet 10-12.5 MGFosinopril Sodium-HCTZ Oral Tablet 20-12.5 MGFurosemide in Sodium Chloride Intravenous Solution 100-0.9 MG/100ML-%Furosemide Injection Solution 10 MG/MLFurosemide Oral Solution 10 MG/MLFurosemide Oral Solution 8 MG/MLFurosemide Oral Tablet 20 MGFurosemide Oral Tablet 40 MGFurosemide Oral Tablet 80 MGGabapentin Oral Capsule 100 MGGabapentin Oral Capsule 300 MGGabapentin Oral Capsule 400 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 12: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Gabapentin Oral Solution 250 MG/5MLGabapentin Oral Tablet 600 MGGabapentin Oral Tablet 800 MGGemfibrozil Oral Tablet 600 MGGlimepiride Oral Tablet 1 MGGlimepiride Oral Tablet 2 MGGlimepiride Oral Tablet 4 MGglipiZIDE ER Oral Tablet Extended Release 24 Hour 10 MGglipiZIDE ER Oral Tablet Extended Release 24 Hour 2.5 MGglipiZIDE ER Oral Tablet Extended Release 24 Hour 5 MGglipiZIDE Oral Tablet 10 MGglipiZIDE Oral Tablet 5 MGglipiZIDE-metFORMIN HCl Oral Tablet 2.5-250 MGglipiZIDE-metFORMIN HCl Oral Tablet 2.5-500 MGglipiZIDE-metFORMIN HCl Oral Tablet 5-500 MGglyBURIDE Micronized Oral Tablet 1.5 MGglyBURIDE Micronized Oral Tablet 3 MGglyBURIDE Micronized Oral Tablet 6 MGglyBURIDE Oral Tablet 1.25 MGglyBURIDE Oral Tablet 2.5 MGglyBURIDE Oral Tablet 5 MGglyBURIDE-metFORMIN Oral Tablet 1.25-250 MGglyBURIDE-metFORMIN Oral Tablet 2.5-500 MGglyBURIDE-metFORMIN Oral Tablet 5-500 MGGNP Hydrocortisone Max St External Ointment 1 %GNP Hydrocortisone/Aloe External Cream 1 %GNP Ibuprofen Cold/Sinus Oral Tablet 30-200 MGguanFACINE HCl ER Oral Tablet Extended Release 24 Hour 1 MGguanFACINE HCl ER Oral Tablet Extended Release 24 Hour 2 MGguanFACINE HCl ER Oral Tablet Extended Release 24 Hour 3 MGguanFACINE HCl ER Oral Tablet Extended Release 24 Hour 4 MGguanFACINE HCl Oral Tablet 1 MGguanFACINE HCl Oral Tablet 2 MGHematinic/Folic Acid Oral Tablet 324-1 MGhydrALAZINE HCl Injection Solution 20 MG/MLhydrALAZINE HCl Oral Tablet 10 MGhydrALAZINE HCl Oral Tablet 100 MGhydrALAZINE HCl Oral Tablet 25 MGhydrALAZINE HCl Oral Tablet 50 MGhydroCHLOROthiazide Oral Capsule 12.5 MGhydroCHLOROthiazide Oral Tablet 12.5 MGhydroCHLOROthiazide Oral Tablet 25 MGhydroCHLOROthiazide Oral Tablet 50 MGHYDROcodone-Acetaminophen Oral Solution 10-325 MG/15MLHYDROcodone-Acetaminophen Oral Solution 2.5-108 MG/5ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 13: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

HYDROcodone-Acetaminophen Oral Tablet 10-300 MGHYDROcodone-Acetaminophen Oral Tablet 10-325 MGHYDROcodone-Acetaminophen Oral Tablet 2.5-325 MGHYDROcodone-Acetaminophen Oral Tablet 5-300 MGHYDROcodone-Acetaminophen Oral Tablet 5-325 MGHYDROcodone-Acetaminophen Oral Tablet 7.5-300 MGHYDROcodone-Acetaminophen Oral Tablet 7.5-325 MGHYDROcodone-Ibuprofen Oral Tablet 10-200 MGHYDROcodone-Ibuprofen Oral Tablet 5-200 MGHYDROcodone-Ibuprofen Oral Tablet 7.5-200 MGHydrocortisone Ace-Pramoxine External Cream 2.5-1 %Hydrocortisone Ace-Pramoxine Rectal Cream 1-1 %Hydrocortisone Ace-Pramoxine Rectal Cream 2.5-1 %Hydrocortisone Acetate External Ointment 1 %Hydrocortisone Acetate Rectal Suppository 25 MGHydrocortisone Acetate Rectal Suppository 30 MGHydrocortisone Butyr Lipo Base External Cream 0.1 %Hydrocortisone Butyrate External Cream 0.1 %Hydrocortisone Butyrate External Lotion 0.1 %Hydrocortisone Butyrate External Ointment 0.1 %Hydrocortisone Butyrate External Solution 0.1 %Hydrocortisone External Cream 2.5 %Hydrocortisone External Lotion 1 %Hydrocortisone External Lotion 2.5 %Hydrocortisone External Ointment 0.5 %Hydrocortisone External Ointment 2.5 %Hydrocortisone Oral Tablet 10 MGHydrocortisone Oral Tablet 20 MGHydrocortisone Oral Tablet 5 MGHydrocortisone Rectal Cream 1 %Hydrocortisone Rectal Cream 2.5 %Hydrocortisone Rectal Enema 100 MG/60MLHydrocortisone Valerate External Cream 0.2 %Hydrocortisone Valerate External Ointment 0.2 %Hydrocortisone-Acetic Acid Otic Solution 1-2 %Hydrocortisone-Aloe External Cream 0.5 %Hydrocortisone-Iodoquinol External Cream 1-1 %HYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse-Deterrent 12 MGHYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse-Deterrent 16 MGHYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse-Deterrent 32 MGHYDROmorphone HCl ER Oral Tablet ER 24 Hour Abuse-Deterrent 8 MGHYDROmorphone HCl Injection Solution 1 MG/MLHYDROmorphone HCl Injection Solution 2 MG/MLHYDROmorphone HCl Injection Solution 4 MG/MLHYDROmorphone HCl Oral Liquid 1 MG/ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 14: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

HYDROmorphone HCl Oral Tablet 2 MGHYDROmorphone HCl Oral Tablet 4 MGHYDROmorphone HCl Oral Tablet 8 MGHYDROmorphone HCl PF Injection Solution 1 MG/MLHYDROmorphone HCl PF Injection Solution 10 MG/MLHYDROmorphone HCl PF Injection Solution 2 MG/MLHYDROmorphone HCl PF Injection Solution 4 MG/MLHYDROmorphone HCl Rectal Suppository 3 MGHYDROmorphone HCl-NaCl Injection Solution 20-0.9 MG/100ML-%HYDROmorphone HCl-NaCl Intravenous Solution 10-0.9 MG/50ML-%HYDROmorphone HCl-NaCl Intravenous Solution 100-0.9 MG/100ML-%HYDROmorphone HCl-NaCl Intravenous Solution 100-0.9 MG/50ML-%HYDROmorphone HCl-NaCl Intravenous Solution 12-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 15-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 18-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 20-0.9 MG/100ML-%HYDROmorphone HCl-NaCl Intravenous Solution 200-0.9 MG/100ML-%HYDROmorphone HCl-NaCl Intravenous Solution 24-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 25-0.9 MG/50ML-%HYDROmorphone HCl-NaCl Intravenous Solution 250-0.9 MG/250ML-%HYDROmorphone HCl-NaCl Intravenous Solution 3-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 30-0.9 MG/150ML-%HYDROmorphone HCl-NaCl Intravenous Solution 30-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 36-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 40-0.9 MG/200ML-%HYDROmorphone HCl-NaCl Intravenous Solution 50-0.9 MG/100ML-%HYDROmorphone HCl-NaCl Intravenous Solution 50-0.9 MG/250ML-%HYDROmorphone HCl-NaCl Intravenous Solution 50-0.9 MG/50ML-%HYDROmorphone HCl-NaCl Intravenous Solution 6-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution 60-0.9 MG/30ML-%HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 0.5-0.9 MG/MLHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 1-0.9 MG/5ML-HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 1-0.9 MG/ML-%HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 10-0.9 MG/25MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 10-0.9 MG/50MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 12-0.9 MG/30MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 15-0.9 MG/30MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 2-0.9 MG/10MLHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 2-0.9 MG/ML-%HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 2.5-0.9 MG/25HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 25-0.9 MG/25MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 25-0.9 MG/50MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 30-0.9 MG/30MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 4-0.9 MG/ML-%HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 5-0.9 MG/25ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 15: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

HYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 50-0.9 MG/50MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 55-0.9 MG/55MHYDROmorphone HCl-NaCl Intravenous Solution Prefilled Syringe 6-0.9 MG/30MLHYDROmorphone-Bupivacaine-NaCl Epidural Solution 4-0.125-0.9 MG/200ML-%HYDROmorphone-Ropivacaine-NaCl Epidural Solution 2-0.1-0.9 MG/250ML-%hydrOXYzine HCl Intramuscular Solution 25 MG/MLhydrOXYzine HCl Intramuscular Solution 50 MG/MLhydrOXYzine HCl Oral Syrup 10 MG/5MLhydrOXYzine HCl Oral Tablet 10 MGhydrOXYzine HCl Oral Tablet 25 MGhydrOXYzine HCl Oral Tablet 50 MGhydrOXYzine Pamoate Oral Capsule 100 MGhydrOXYzine Pamoate Oral Capsule 25 MGhydrOXYzine Pamoate Oral Capsule 50 MGIBU Oral Tablet 400 MGIBU Oral Tablet 600 MGIBU Oral Tablet 800 MGIbuprofen Comfort Pac Combination Kit 800 MGIbuprofen Lysine Intravenous Solution 10 MG/MLIbuprofen PM Oral Capsule 200-25 MGIbutilide Fumarate Intravenous Solution 1 MG/10MLImipramine HCl Oral Tablet 10 MGImipramine HCl Oral Tablet 25 MGImipramine HCl Oral Tablet 50 MGImipramine Pamoate Oral Capsule 100 MGImipramine Pamoate Oral Capsule 125 MGImipramine Pamoate Oral Capsule 150 MGImipramine Pamoate Oral Capsule 75 MGIndapamide Oral Tablet 1.25 MGIndapamide Oral Tablet 2.5 MGIndomethacin ER Oral Capsule Extended Release 75 MGIndomethacin Oral Capsule 25 MGIndomethacin Oral Capsule 50 MGIndomethacin Sodium Intravenous Solution Reconstituted 1 MGIodoquinol-Hydrocortisone-Aloe External Cream 1-1.9 %Irbesartan Oral Tablet 150 MGIrbesartan Oral Tablet 300 MGIrbesartan Oral Tablet 75 MGIrbesartan-hydroCHLOROthiazide Oral Tablet 150-12.5 MGIrbesartan-hydroCHLOROthiazide Oral Tablet 300-12.5 MGJantoven Oral Tablet 1 MGJantoven Oral Tablet 10 MGJantoven Oral Tablet 2 MGJantoven Oral Tablet 2.5 MGJantoven Oral Tablet 3 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 16: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Jantoven Oral Tablet 4 MGJantoven Oral Tablet 5 MGJantoven Oral Tablet 6 MGJantoven Oral Tablet 7.5 MGLabetalol HCl Intravenous Solution 5 MG/MLLabetalol HCl Intravenous Solution Prefilled Syringe 20 MG/4MLLabetalol HCl Intravenous Solution Prefilled Syringe 25 MG/5MLLabetalol HCl Intravenous Solution Prefilled Syringe 50 MG/10MLLabetalol HCl Oral Tablet 100 MGLabetalol HCl Oral Tablet 200 MGLabetalol HCl Oral Tablet 300 MGLabetalol HCl-Dextrose Intravenous Solution 200-5 MG/200ML-%Levocetirizine Dihydrochloride Oral Solution 2.5 MG/5MLLevocetirizine Dihydrochloride Oral Tablet 5 MGlevoFLOXacin in D5W Intravenous Solution 250 MG/50MLlevoFLOXacin in D5W Intravenous Solution 500 MG/100MLlevoFLOXacin in D5W Intravenous Solution 750 MG/150MLlevoFLOXacin Intravenous Solution 25 MG/MLlevoFLOXacin Ophthalmic Solution 0.5 %levoFLOXacin Oral Solution 25 MG/MLlevoFLOXacin Oral Tablet 250 MGlevoFLOXacin Oral Tablet 500 MGlevoFLOXacin Oral Tablet 750 MGLidocaine-Hydrocortisone Ace Rectal Cream 3-0.5 %Lidocaine-Hydrocortisone Ace Rectal Gel 2.8-0.55 %Lidocaine-Hydrocortisone Ace Rectal Kit 2-2 %Lidocaine-Hydrocortisone Ace Rectal Kit 3-0.5 %Lidocaine-Hydrocortisone Ace Rectal Kit 3-1 %Lidocaine-Hydrocortisone Ace Rectal Kit 3-2.5 %Lisinopril Oral Tablet 10 MGLisinopril Oral Tablet 2.5 MGLisinopril Oral Tablet 20 MGLisinopril Oral Tablet 30 MGLisinopril Oral Tablet 40 MGLisinopril Oral Tablet 5 MGLisinopril-hydroCHLOROthiazide Oral Tablet 10-12.5 MGLisinopril-hydroCHLOROthiazide Oral Tablet 20-12.5 MGLisinopril-hydroCHLOROthiazide Oral Tablet 20-25 MGLithium Carbonate ER Oral Tablet Extended Release 300 MGLithium Carbonate ER Oral Tablet Extended Release 450 MGLithium Carbonate Oral Capsule 150 MGLithium Carbonate Oral Capsule 300 MGLithium Carbonate Oral Capsule 600 MGLithium Carbonate Oral Tablet 300 MGLORazepam Injection Solution 2 MG/ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 17: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

LORazepam Injection Solution 4 MG/MLLORazepam Intensol Oral Concentrate 2 MG/MLLORazepam Oral Tablet 0.5 MGLORazepam Oral Tablet 1 MGLORazepam Oral Tablet 2 MGLORazepam-Dextrose Intravenous Solution 100-5 MG/100ML-%LORazepam-Sodium Chloride Intravenous Solution 100-0.9 MG/100ML-%Losartan Potassium Oral Tablet 100 MGLosartan Potassium Oral Tablet 25 MGLosartan Potassium Oral Tablet 50 MGLosartan Potassium-HCTZ Oral Tablet 100-12.5 MGLosartan Potassium-HCTZ Oral Tablet 100-25 MGLosartan Potassium-HCTZ Oral Tablet 50-12.5 MGLovastatin Oral Tablet 10 MGLovastatin Oral Tablet 20 MGLovastatin Oral Tablet 40 MGMegestrol Acetate Oral Suspension 40 MG/MLMegestrol Acetate Oral Suspension 625 MG/5MLMegestrol Acetate Oral Tablet 20 MGMegestrol Acetate Oral Tablet 40 MGMeloxicam Comfort Pac Combination Kit 15 MGMeloxicam Oral Tablet 15 MGMeloxicam Oral Tablet 7.5 MGMemantine HCl ER Oral Capsule Extended Release 24 Hour 14 MGMemantine HCl ER Oral Capsule Extended Release 24 Hour 21 MGMemantine HCl ER Oral Capsule Extended Release 24 Hour 28 MGMemantine HCl ER Oral Capsule Extended Release 24 Hour 7 MGMemantine HCl Oral Solution 10 MG/5MLMemantine HCl Oral Tablet 10 MGMemantine HCl Oral Tablet 28 x 5 MG & 21 x 10 MGMemantine HCl Oral Tablet 5 MGmetFORMIN HCl ER (MOD) Oral Tablet Extended Release 24 Hour 1000 MGmetFORMIN HCl ER (MOD) Oral Tablet Extended Release 24 Hour 500 MGmetFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 1000 MGmetFORMIN HCl ER (OSM) Oral Tablet Extended Release 24 Hour 500 MGmetFORMIN HCl ER Oral Tablet Extended Release 24 Hour 500 MGmetFORMIN HCl ER Oral Tablet Extended Release 24 Hour 750 MGmetFORMIN HCl Oral Solution 500 MG/5MLmetFORMIN HCl Oral Tablet 1000 MGmetFORMIN HCl Oral Tablet 500 MGmetFORMIN HCl Oral Tablet 850 MGMethadone HCl Injection Solution 10 MG/MLMethadone HCl Intensol Oral Concentrate 10 MG/MLMethadone HCl Oral Solution 10 MG/5MLMethadone HCl Oral Solution 5 MG/5ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 18: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Methadone HCl Oral Tablet 10 MGMethadone HCl Oral Tablet 5 MGMethadone HCl Oral Tablet Soluble 40 MGmethIMAzole Oral Tablet 10 MGmethIMAzole Oral Tablet 5 MGMethocarbamol Injection Solution 1000 MG/10MLMethocarbamol Oral Tablet 500 MGMethocarbamol Oral Tablet 750 MGMethyldopa-hydroCHLOROthiazide Oral Tablet 250-15 MGMethyldopa-hydroCHLOROthiazide Oral Tablet 250-25 MGMethylphenidate HCl ER (CD) Oral Capsule Extended Release 10 MGMethylphenidate HCl ER (CD) Oral Capsule Extended Release 20 MGMethylphenidate HCl ER (CD) Oral Capsule Extended Release 30 MGMethylphenidate HCl ER (CD) Oral Capsule Extended Release 40 MGMethylphenidate HCl ER (CD) Oral Capsule Extended Release 50 MGMethylphenidate HCl ER (CD) Oral Capsule Extended Release 60 MGMethylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 10 MGMethylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 20 MGMethylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 30 MGMethylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 40 MGMethylphenidate HCl ER (LA) Oral Capsule Extended Release 24 Hour 60 MGMethylphenidate HCl ER Oral Tablet Extended Release 10 MGMethylphenidate HCl ER Oral Tablet Extended Release 18 MGMethylphenidate HCl ER Oral Tablet Extended Release 20 MGMethylphenidate HCl ER Oral Tablet Extended Release 24 Hour 18 MGMethylphenidate HCl ER Oral Tablet Extended Release 24 Hour 27 MGMethylphenidate HCl ER Oral Tablet Extended Release 24 Hour 36 MGMethylphenidate HCl ER Oral Tablet Extended Release 24 Hour 54 MGMethylphenidate HCl ER Oral Tablet Extended Release 27 MGMethylphenidate HCl ER Oral Tablet Extended Release 36 MGMethylphenidate HCl ER Oral Tablet Extended Release 54 MGMethylphenidate HCl ER Oral Tablet Extended Release 72 MGMethylphenidate HCl Oral Solution 10 MG/5MLMethylphenidate HCl Oral Solution 5 MG/5MLMethylphenidate HCl Oral Tablet 10 MGMethylphenidate HCl Oral Tablet 20 MGMethylphenidate HCl Oral Tablet 5 MGMethylphenidate HCl Oral Tablet Chewable 10 MGMethylphenidate HCl Oral Tablet Chewable 2.5 MGMethylphenidate HCl Oral Tablet Chewable 5 MGMetoclopramide HCl Injection Solution 5 MG/MLMetoclopramide HCl Oral Solution 10 MG/10MLMetoclopramide HCl Oral Tablet 10 MGMetoclopramide HCl Oral Tablet 5 MGMetoclopramide HCl Oral Tablet Disintegrating 10 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 19: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Metoclopramide HCl Oral Tablet Disintegrating 5 MGMetoprolol Tartrate Intravenous Solution 5 MG/5MLMetoprolol Tartrate Intravenous Solution Cartridge 5 MG/5MLMetoprolol Tartrate Oral Tablet 100 MGMetoprolol Tartrate Oral Tablet 25 MGMetoprolol Tartrate Oral Tablet 37.5 MGMetoprolol Tartrate Oral Tablet 50 MGMetoprolol Tartrate Oral Tablet 75 MGMetoprolol-hydroCHLOROthiazide Oral Tablet 100-25 MGMetoprolol-hydroCHLOROthiazide Oral Tablet 100-50 MGMetoprolol-hydroCHLOROthiazide Oral Tablet 50-25 MGmetroNIDAZOLE External Cream 0.75 %metroNIDAZOLE External Gel 0.75 %metroNIDAZOLE External Gel 1 %metroNIDAZOLE External Lotion 0.75 %metroNIDAZOLE in NaCl Intravenous Solution 5-0.79 MG/ML-%metroNIDAZOLE in NaCl Intravenous Solution 500-0.74 MG/100ML-%metroNIDAZOLE Intravenous Solution 5 MG/MLmetroNIDAZOLE Oral Capsule 375 MGmetroNIDAZOLE Oral Tablet 250 MGmetroNIDAZOLE Oral Tablet 500 MGmetroNIDAZOLE Vaginal Gel 0.75 %Midazolam-Ketamine-Ondansetron Mouth/Throat Troche 3-25-2 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 105 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 115 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 135 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 45 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 55 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 65 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 80 MGMinocycline HCl ER Oral Tablet Extended Release 24 Hour 90 MGMinocycline HCl Oral Capsule 100 MGMinocycline HCl Oral Capsule 50 MGMinocycline HCl Oral Capsule 75 MGMinocycline HCl Oral Tablet 100 MGMinocycline HCl Oral Tablet 50 MGMinocycline HCl Oral Tablet 75 MGMinoxidil for Men External Foam 5 %Minoxidil for Men External Solution 2 %Minoxidil for Men External Solution 5 %Minoxidil Oral Tablet 10 MGMinoxidil Oral Tablet 2.5 MGMirtazapine Oral Tablet 15 MGMirtazapine Oral Tablet 30 MGMirtazapine Oral Tablet 45 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 20: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Mirtazapine Oral Tablet 7.5 MGMirtazapine Oral Tablet Disintegrating 15 MGMirtazapine Oral Tablet Disintegrating 30 MGMirtazapine Oral Tablet Disintegrating 45 MGMoexipril-hydroCHLOROthiazide Oral Tablet 15-12.5 MGMoexipril-hydroCHLOROthiazide Oral Tablet 15-25 MGMoexipril-hydroCHLOROthiazide Oral Tablet 7.5-12.5 MGMontelukast Sodium Oral Packet 4 MGMontelukast Sodium Oral Tablet 10 MGMontelukast Sodium Oral Tablet Chewable 4 MGMontelukast Sodium Oral Tablet Chewable 5 MGMynate 90 Plus Oral Tablet Extended Release Nabumetone Oral Tablet 500 MGNabumetone Oral Tablet 750 MGNaproxen Comfort Pac Combination Kit 500 MGNaproxen Kit Oral Tablet 500 MGNaproxen Oral Suspension 125 MG/5MLNaproxen Oral Tablet 250 MGNaproxen Oral Tablet 375 MGNaproxen Sodium ER Oral Tablet Extended Release 24 Hour 375 MGNaproxen Sodium ER Oral Tablet Extended Release 24 Hour 500 MGNaproxen Sodium Oral Tablet 275 MGNaproxen Sodium Oral Tablet 550 MGNizatidine Oral Capsule 150 MGNizatidine Oral Capsule 300 MGNizatidine Oral Solution 15 MG/MLNorethin-Eth Estradiol-Fe Oral Tablet Chewable 0.4-35 MG-MCGNorethin-Eth Estradiol-Fe Oral Tablet Chewable 0.8-25 MG-MCGNorethindrone-Eth Estradiol Oral Tablet 0.5-2.5 MG-MCGNorethindrone-Eth Estradiol Oral Tablet 1-5 MG-MCGNorgestim-Eth Estrad Triphasic Oral Tablet 0.18/0.215/0.25 MG-25 MCGNorgestim-Eth Estrad Triphasic Oral Tablet 0.18/0.215/0.25 MG-35 MCGNorgestimate-Eth Estradiol Oral Tablet 0.25-35 MG-MCGNortriptyline HCl Oral Capsule 10 MGNortriptyline HCl Oral Capsule 25 MGNortriptyline HCl Oral Capsule 50 MGNortriptyline HCl Oral Capsule 75 MGNortriptyline HCl Oral Solution 10 MG/5MLOLANZapine Intramuscular Solution Reconstituted 10 MGOLANZapine Oral Tablet 10 MGOLANZapine Oral Tablet 15 MGOLANZapine Oral Tablet 2.5 MGOLANZapine Oral Tablet 20 MGOLANZapine Oral Tablet 5 MGOLANZapine Oral Tablet 7.5 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 21: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

OLANZapine Oral Tablet Disintegrating 10 MGOLANZapine Oral Tablet Disintegrating 15 MGOLANZapine Oral Tablet Disintegrating 20 MGOLANZapine Oral Tablet Disintegrating 5 MGOLANZapine-FLUoxetine HCl Oral Capsule 12-25 MGOLANZapine-FLUoxetine HCl Oral Capsule 12-50 MGOLANZapine-FLUoxetine HCl Oral Capsule 3-25 MGOLANZapine-FLUoxetine HCl Oral Capsule 6-25 MGOLANZapine-FLUoxetine HCl Oral Capsule 6-50 MGOlmesartan-amLODIPine-HCTZ Oral Tablet 20-5-12.5 MGOlmesartan-amLODIPine-HCTZ Oral Tablet 40-10-12.5 MGOlmesartan-amLODIPine-HCTZ Oral Tablet 40-10-25 MGOlmesartan-amLODIPine-HCTZ Oral Tablet 40-5-12.5 MGOlmesartan-amLODIPine-HCTZ Oral Tablet 40-5-25 MGOndansetron HCl Injection Solution 4 MG/2MLOndansetron HCl Injection Solution 40 MG/20MLOndansetron HCl Oral Solution 4 MG/5MLOndansetron HCl Oral Tablet 24 MGOndansetron HCl Oral Tablet 4 MGOndansetron HCl Oral Tablet 8 MGOndansetron HCl-Dextrose Intravenous Solution 8-5 MG/50ML-%Ondansetron HCl-NaCl Intravenous Solution 8-0.9 MG/50ML-%Ondansetron Oral Tablet Disintegrating 4 MGOndansetron Oral Tablet Disintegrating 8 MGOpurity B12/Folic Acid Oral Tablet 1000-200 MCGOXcarbazepine Oral Suspension 300 MG/5MLOXcarbazepine Oral Tablet 150 MGOXcarbazepine Oral Tablet 300 MGOXcarbazepine Oral Tablet 600 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 10 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 15 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 20 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 30 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 40 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 60 MGoxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 80 MGoxyCODONE HCl Oral Capsule 5 MGoxyCODONE HCl Oral Concentrate 10 MG/0.5MLoxyCODONE HCl Oral Solution 5 MG/5MLoxyCODONE HCl Oral Tablet 10 MGoxyCODONE HCl Oral Tablet 15 MGoxyCODONE HCl Oral Tablet 20 MGoxyCODONE HCl Oral Tablet 30 MGoxyCODONE HCl Oral Tablet 5 MGoxyCODONE-Acetaminophen Oral Solution 5-325 MG/5ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 22: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

oxyCODONE-Aspirin Oral Tablet 4.8355-325 MGoxyCODONE-Ibuprofen Oral Tablet 5-400 MGPARoxetine HCl ER Oral Tablet Extended Release 24 Hour 12.5 MGPARoxetine HCl ER Oral Tablet Extended Release 24 Hour 25 MGPARoxetine HCl ER Oral Tablet Extended Release 24 Hour 37.5 MGPARoxetine HCl Oral Tablet 10 MGPARoxetine HCl Oral Tablet 20 MGPARoxetine HCl Oral Tablet 30 MGPARoxetine HCl Oral Tablet 40 MGPARoxetine Mesylate Oral Capsule 7.5 MGPenicillin G Pot in Dextrose Intravenous Solution 20000 UNIT/MLPenicillin G Pot in Dextrose Intravenous Solution 40000 UNIT/MLPenicillin G Pot in Dextrose Intravenous Solution 60000 UNIT/MLPenicillin G Potassium Injection Solution Reconstituted 20000000 UNITPenicillin G Potassium Injection Solution Reconstituted 5000000 UNITPenicillin G Procaine Intramuscular Suspension 600000 UNIT/MLPenicillin G Sodium Injection Solution Reconstituted 5000000 UNITPenicillin V Potassium Oral Solution Reconstituted 125 MG/5MLPenicillin V Potassium Oral Solution Reconstituted 250 MG/5MLPenicillin V Potassium Oral Tablet 250 MGPenicillin V Potassium Oral Tablet 500 MGPerphenazine-Amitriptyline Oral Tablet 2-10 MGPerphenazine-Amitriptyline Oral Tablet 2-25 MGPerphenazine-Amitriptyline Oral Tablet 4-10 MGPerphenazine-Amitriptyline Oral Tablet 4-25 MGPerphenazine-Amitriptyline Oral Tablet 4-50 MGPhendimetrazine Tartrate ER Oral Capsule Extended Release 24 Hour 105 MGPhendimetrazine Tartrate Oral Tablet 35 MGPhentermine HCl Oral Capsule 15 MGPhentermine HCl Oral Capsule 30 MGPhentermine HCl Oral Capsule 37.5 MGPhentermine HCl Oral Tablet 37.5 MGPioglitazone HCl Oral Tablet 15 MGPioglitazone HCl Oral Tablet 30 MGPioglitazone HCl Oral Tablet 45 MGPioglitazone HCl-Glimepiride Oral Tablet 30-2 MGPioglitazone HCl-Glimepiride Oral Tablet 30-4 MGPioglitazone HCl-metFORMIN HCl Oral Tablet 15-500 MGPioglitazone HCl-metFORMIN HCl Oral Tablet 15-850 MGPolymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 UNIT/ML-%Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 0.375 MPramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 0.75 MGPramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 1.5 MGPramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 2.25 MGPramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 3 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 23: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Pramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 3.75 MGPramipexole Dihydrochloride ER Oral Tablet Extended Release 24 Hour 4.5 MGPramipexole Dihydrochloride Oral Tablet 0.125 MGPramipexole Dihydrochloride Oral Tablet 0.25 MGPramipexole Dihydrochloride Oral Tablet 0.5 MGPramipexole Dihydrochloride Oral Tablet 0.75 MGPramipexole Dihydrochloride Oral Tablet 1 MGPramipexole Dihydrochloride Oral Tablet 1.5 MGPravastatin Sodium Oral Tablet 10 MGPravastatin Sodium Oral Tablet 20 MGPravastatin Sodium Oral Tablet 40 MGPravastatin Sodium Oral Tablet 80 MGpredniSONE Intensol Oral Concentrate 5 MG/MLpredniSONE Oral Solution 5 MG/5MLpredniSONE Oral Tablet 1 MGpredniSONE Oral Tablet 10 MGpredniSONE Oral Tablet 2.5 MGpredniSONE Oral Tablet 5 MGpredniSONE Oral Tablet 50 MGpredniSONE Oral Tablet Therapy Pack 10 MG (21)predniSONE Oral Tablet Therapy Pack 10 MG (48)predniSONE Oral Tablet Therapy Pack 5 MG (21)predniSONE Oral Tablet Therapy Pack 5 MG (48)Primidone Oral Tablet 250 MGPrimidone Oral Tablet 50 MGProchlorperazine Maleate Oral Tablet 10 MGProchlorperazine Maleate Oral Tablet 5 MGPromethazine HCl Injection Solution 25 MG/MLPromethazine HCl Injection Solution 50 MG/MLPromethazine HCl Oral Solution 6.25 MG/5MLPromethazine HCl Oral Tablet 12.5 MGPromethazine HCl Oral Tablet 25 MGPromethazine HCl Oral Tablet 50 MGPromethazine HCl Rectal Suppository 12.5 MGPromethazine HCl Rectal Suppository 25 MGPromethazine HCl Rectal Suppository 50 MGPromethazine VC Oral Syrup 6.25-5 MG/5MLPromethazine VC/Codeine Oral Syrup 6.25-5-10 MG/5MLPromethazine-Codeine Oral Solution 6.25-10 MG/5MLPromethazine-DM Oral Solution 6.25-15 MG/5MLPropafenone HCl ER Oral Capsule Extended Release 12 Hour 225 MGPropafenone HCl ER Oral Capsule Extended Release 12 Hour 325 MGPropafenone HCl ER Oral Capsule Extended Release 12 Hour 425 MGPropafenone HCl Oral Tablet 150 MGPropafenone HCl Oral Tablet 225 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 24: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Propafenone HCl Oral Tablet 300 MGPropranolol HCl ER Oral Capsule Extended Release 24 Hour 120 MGPropranolol HCl ER Oral Capsule Extended Release 24 Hour 160 MGPropranolol HCl ER Oral Capsule Extended Release 24 Hour 60 MGPropranolol HCl ER Oral Capsule Extended Release 24 Hour 80 MGPropranolol HCl Intravenous Solution 1 MG/MLPropranolol HCl Oral Solution 20 MG/5MLPropranolol HCl Oral Solution 40 MG/5MLPropranolol HCl Oral Tablet 10 MGPropranolol HCl Oral Tablet 20 MGPropranolol HCl Oral Tablet 40 MGPropranolol HCl Oral Tablet 60 MGPropranolol HCl Oral Tablet 80 MGPropranolol-HCTZ Oral Tablet 40-25 MGPropranolol-HCTZ Oral Tablet 80-25 MGQUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MGQUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 200 MGQUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 300 MGQUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 400 MGQUEtiapine Fumarate ER Oral Tablet Extended Release 24 Hour 50 MGQUEtiapine Fumarate Oral Tablet 100 MGQUEtiapine Fumarate Oral Tablet 200 MGQUEtiapine Fumarate Oral Tablet 25 MGQUEtiapine Fumarate Oral Tablet 300 MGQUEtiapine Fumarate Oral Tablet 400 MGQUEtiapine Fumarate Oral Tablet 50 MGQuinapril HCl Oral Tablet 10 MGQuinapril HCl Oral Tablet 20 MGQuinapril HCl Oral Tablet 40 MGQuinapril HCl Oral Tablet 5 MGQuinapril-hydroCHLOROthiazide Oral Tablet 10-12.5 MGQuinapril-hydroCHLOROthiazide Oral Tablet 20-12.5 MGQuinapril-hydroCHLOROthiazide Oral Tablet 20-25 MGRamipril Oral Capsule 1.25 MGRamipril Oral Capsule 10 MGRamipril Oral Capsule 2.5 MGRamipril Oral Capsule 5 MGraNITIdine 150 Max Strength Oral Tablet 150 MGraNITIdine HCl Injection Solution 1000 MG/40MLraNITIdine HCl Injection Solution 150 MG/6MLraNITIdine HCl Injection Solution 50 MG/2MLraNITIdine HCl Oral Capsule 150 MGraNITIdine HCl Oral Capsule 300 MGraNITIdine HCl Oral Syrup 15 MG/MLraNITIdine HCl Oral Tablet 300 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 25: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Repaglinide Oral Tablet 0.5 MGRepaglinide Oral Tablet 1 MGRepaglinide Oral Tablet 2 MGRepaglinide-metFORMIN HCl Oral Tablet 1-500 MGRepaglinide-metFORMIN HCl Oral Tablet 2-500 MGrisperiDONE Oral Solution 1 MG/MLrisperiDONE Oral Tablet 0.25 MGrisperiDONE Oral Tablet 0.5 MGrisperiDONE Oral Tablet 1 MGrisperiDONE Oral Tablet 2 MGrisperiDONE Oral Tablet 3 MGrisperiDONE Oral Tablet 4 MGrisperiDONE Oral Tablet Disintegrating 0.25 MGrisperiDONE Oral Tablet Disintegrating 0.5 MGrisperiDONE Oral Tablet Disintegrating 1 MGrisperiDONE Oral Tablet Disintegrating 2 MGrisperiDONE Oral Tablet Disintegrating 3 MGrisperiDONE Oral Tablet Disintegrating 4 MGrOPINIRole HCl ER Oral Tablet Extended Release 24 Hour 12 MGrOPINIRole HCl ER Oral Tablet Extended Release 24 Hour 2 MGrOPINIRole HCl ER Oral Tablet Extended Release 24 Hour 4 MGrOPINIRole HCl ER Oral Tablet Extended Release 24 Hour 6 MGrOPINIRole HCl ER Oral Tablet Extended Release 24 Hour 8 MGrOPINIRole HCl Oral Tablet 0.25 MGrOPINIRole HCl Oral Tablet 0.5 MGrOPINIRole HCl Oral Tablet 1 MGrOPINIRole HCl Oral Tablet 2 MGrOPINIRole HCl Oral Tablet 3 MGrOPINIRole HCl Oral Tablet 4 MGrOPINIRole HCl Oral Tablet 5 MGRopiv-cloNIDine-Ketorolac Periarticular Solution Prefilled Syringe 123-0.04Sertraline HCl Oral Concentrate 20 MG/MLSertraline HCl Oral Tablet 100 MGSertraline HCl Oral Tablet 25 MGSertraline HCl Oral Tablet 50 MGSildenafil Citrate Intravenous Solution 10 MG/12.5MLSildenafil Citrate Oral Suspension Reconstituted 10 MG/MLSildenafil Citrate Oral Tablet 100 MGSildenafil Citrate Oral Tablet 20 MGSildenafil Citrate Oral Tablet 25 MGSildenafil Citrate Oral Tablet 50 MGSimvastatin Oral Tablet 10 MGSimvastatin Oral Tablet 20 MGSimvastatin Oral Tablet 40 MGSimvastatin Oral Tablet 5 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 26: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Simvastatin Oral Tablet 80 MGSM Ibuprofen Jr Oral Tablet 100 MGSpironolactone Oral Tablet 100 MGSpironolactone Oral Tablet 25 MGSpironolactone Oral Tablet 50 MGSpironolactone-HCTZ Oral Tablet 25-25 MGSulfamethoxazole-Trimethoprim Intravenous Solution 400-80 MG/5MLSulfamethoxazole-Trimethoprim Oral Suspension 200-40 MG/5MLSulfamethoxazole-Trimethoprim Oral Tablet 400-80 MGSulfamethoxazole-Trimethoprim Oral Tablet 800-160 MGsulfaSALAzine Oral Tablet 500 MGsulfaSALAzine Oral Tablet Delayed Release 500 MGSulindac Oral Tablet 150 MGSulindac Oral Tablet 200 MGSUMAtriptan-Naproxen Sodium Oral Tablet 85-500 MGTamsulosin HCl Oral Capsule 0.4 MGTelmisartan-amLODIPine Oral Tablet 40-10 MGTelmisartan-amLODIPine Oral Tablet 40-5 MGTelmisartan-amLODIPine Oral Tablet 80-10 MGTelmisartan-amLODIPine Oral Tablet 80-5 MGTemazepam Oral Capsule 15 MGTemazepam Oral Capsule 22.5 MGTemazepam Oral Capsule 30 MGTemazepam Oral Capsule 7.5 MGTerazosin HCl Oral Capsule 1 MGTerazosin HCl Oral Capsule 10 MGTerazosin HCl Oral Capsule 2 MGTerazosin HCl Oral Capsule 5 MGTerbinafine HCl Oral Tablet 250 MGtiZANidine Comfort Pac Combination Miscellaneous 4 MGtiZANidine HCl Oral Capsule 2 MGtiZANidine HCl Oral Capsule 4 MGtiZANidine HCl Oral Capsule 6 MGtiZANidine HCl Oral Tablet 2 MGtiZANidine HCl Oral Tablet 4 MGTopiramate ER Oral Capsule ER 24 Hour Sprinkle 100 MGTopiramate ER Oral Capsule ER 24 Hour Sprinkle 150 MGTopiramate ER Oral Capsule ER 24 Hour Sprinkle 200 MGTopiramate ER Oral Capsule ER 24 Hour Sprinkle 25 MGTopiramate ER Oral Capsule ER 24 Hour Sprinkle 50 MGTopiramate Oral Capsule Sprinkle 15 MGTopiramate Oral Capsule Sprinkle 25 MGTopiramate Oral Tablet 100 MGTopiramate Oral Tablet 200 MGTopiramate Oral Tablet 25 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 27: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Topiramate Oral Tablet 50 MGTorsemide Oral Tablet 10 MGTorsemide Oral Tablet 100 MGTorsemide Oral Tablet 20 MGTorsemide Oral Tablet 5 MGtraMADol HCl ER (Biphasic) Oral Tablet Extended Release 24 Hour 100 MGtraMADol HCl ER (Biphasic) Oral Tablet Extended Release 24 Hour 200 MGtraMADol HCl ER (Biphasic) Oral Tablet Extended Release 24 Hour 300 MGtraMADol HCl ER Oral Capsule Extended Release 24 Hour 100 MGtraMADol HCl ER Oral Capsule Extended Release 24 Hour 150 MGtraMADol HCl ER Oral Capsule Extended Release 24 Hour 200 MGtraMADol HCl ER Oral Capsule Extended Release 24 Hour 300 MGtraMADol HCl ER Oral Tablet Extended Release 24 Hour 100 MGtraMADol HCl ER Oral Tablet Extended Release 24 Hour 200 MGtraMADol HCl ER Oral Tablet Extended Release 24 Hour 300 MGtraMADol HCl Oral Tablet 50 MGtraMADol-Acetaminophen Oral Tablet 37.5-325 MGTrandolapril Oral Tablet 1 MGTrandolapril Oral Tablet 2 MGTrandolapril Oral Tablet 4 MGTrandolapril-Verapamil HCl ER Oral Tablet Extended Release 1-240 MGTrandolapril-Verapamil HCl ER Oral Tablet Extended Release 2-180 MGTrandolapril-Verapamil HCl ER Oral Tablet Extended Release 2-240 MGTrandolapril-Verapamil HCl ER Oral Tablet Extended Release 4-240 MGtraZODone HCl Oral Tablet 100 MGtraZODone HCl Oral Tablet 150 MGtraZODone HCl Oral Tablet 300 MGtraZODone HCl Oral Tablet 50 MGTriamterene Oral Capsule 100 MGTriamterene Oral Capsule 50 MGTriamterene-HCTZ Oral Capsule 37.5-25 MGTriamterene-HCTZ Oral Capsule 50-25 MGTriamterene-HCTZ Oral Tablet 37.5-25 MGTriamterene-HCTZ Oral Tablet 75-50 MGTrimethoprim Oral Tablet 100 MGTrimipramine Maleate Oral Capsule 100 MGTrimipramine Maleate Oral Capsule 25 MGTrimipramine Maleate Oral Capsule 50 MGvalACYclovir HCl Oral Tablet 1 GMvalACYclovir HCl Oral Tablet 500 MGValproic Acid Oral Capsule 250 MGValproic Acid Oral Solution 250 MG/5MLValsartan-hydroCHLOROthiazide Oral Tablet 160-12.5 MGValsartan-hydroCHLOROthiazide Oral Tablet 160-25 MGValsartan-hydroCHLOROthiazide Oral Tablet 320-12.5 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 28: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Valsartan-hydroCHLOROthiazide Oral Tablet 320-25 MGValsartan-hydroCHLOROthiazide Oral Tablet 80-12.5 MGVenlafaxine HCl ER Oral Capsule Extended Release 24 Hour 150 MGVenlafaxine HCl ER Oral Capsule Extended Release 24 Hour 37.5 MGVenlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MGVenlafaxine HCl ER Oral Tablet Extended Release 24 Hour 150 MGVenlafaxine HCl ER Oral Tablet Extended Release 24 Hour 225 MGVenlafaxine HCl ER Oral Tablet Extended Release 24 Hour 37.5 MGVenlafaxine HCl ER Oral Tablet Extended Release 24 Hour 75 MGVenlafaxine HCl Oral Tablet 100 MGVenlafaxine HCl Oral Tablet 25 MGVenlafaxine HCl Oral Tablet 37.5 MGVenlafaxine HCl Oral Tablet 50 MGVenlafaxine HCl Oral Tablet 75 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 100 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 120 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 180 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 200 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 240 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 300 MGVerapamil HCl ER Oral Capsule Extended Release 24 Hour 360 MGVerapamil HCl ER Oral Tablet Extended Release 120 MGVerapamil HCl ER Oral Tablet Extended Release 180 MGVerapamil HCl ER Oral Tablet Extended Release 240 MGVerapamil HCl Intravenous Solution 2.5 MG/MLVerapamil HCl Oral Tablet 120 MGVerapamil HCl Oral Tablet 40 MGVerapamil HCl Oral Tablet 80 MGVitamin D (Ergocalciferol) Oral Capsule 50 MCG (2000 UT)West-Vite w/Folic Acid Oral Tablet 0.8 MGZaleplon Oral Capsule 10 MGZaleplon Oral Capsule 5 MGZolpidem Tartrate ER Oral Tablet Extended Release 12.5 MGZolpidem Tartrate ER Oral Tablet Extended Release 6.25 MGZolpidem Tartrate Oral Tablet 10 MGZolpidem Tartrate Oral Tablet 5 MGZolpidem Tartrate Sublingual Tablet Sublingual 1.75 MGZolpidem Tartrate Sublingual Tablet Sublingual 3.5 MGZonisamide Oral Capsule 100 MGZonisamide Oral Capsule 25 MGZonisamide Oral Capsule 50 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 29: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Tier 2 (Generics) - $25 or LessAbacavir Sulfate-lamiVUDine Oral Tablet 600-300 MGAbacavir-lamiVUDine-Zidovudine Oral Tablet 300-150-300 MGacetaZOLAMIDE ER Oral Capsule Extended Release 12 Hour 500 MGacetaZOLAMIDE Oral Tablet 125 MGacetaZOLAMIDE Oral Tablet 250 MGacetaZOLAMIDE Sodium Injection Solution Reconstituted 500 MGAlendronate Sodium Oral Solution 70 MG/75MLAlendronate Sodium Oral Tablet 10 MGAlendronate Sodium Oral Tablet 35 MGAlendronate Sodium Oral Tablet 40 MGAlendronate Sodium Oral Tablet 5 MGAlendronate Sodium Oral Tablet 70 MGAlyacen 1/35 Oral Tablet 1-35 MG-MCGAlyacen 7/7/7 Oral Tablet 0.5/0.75/1-35 MG-MCGAmantadine HCl Oral Capsule 100 MGAmantadine HCl Oral Syrup 50 MG/5MLAmantadine HCl Oral Tablet 100 MGAmethia Lo Oral Tablet 0.1-0.02 & 0.01 MGAmethia Oral Tablet 0.15-0.03 &0.01 MGAmphetamine-Dextroamphetamine Oral Tablet 10 MGAmphetamine-Dextroamphetamine Oral Tablet 12.5 MGAmphetamine-Dextroamphetamine Oral Tablet 15 MGAmphetamine-Dextroamphetamine Oral Tablet 20 MGAmphetamine-Dextroamphetamine Oral Tablet 30 MGAmphetamine-Dextroamphetamine Oral Tablet 5 MGAmphetamine-Dextroamphetamine Oral Tablet 7.5 MGAranelle Oral Tablet 0.5/1/0.5-35 MG-MCGArmodafinil Oral Tablet 150 MGArmodafinil Oral Tablet 200 MGArmodafinil Oral Tablet 250 MGArmodafinil Oral Tablet 50 MGazaTHIOprine Oral Tablet 50 MGazaTHIOprine Sodium Injection Solution Reconstituted 100 MGAzithromycin Intravenous Solution Reconstituted 500 MGAzithromycin Oral Packet 1 GMAzithromycin Oral Suspension Reconstituted 100 MG/5MLAzithromycin Oral Suspension Reconstituted 200 MG/5MLAzithromycin Oral Tablet 250 MGAzithromycin Oral Tablet 500 MGAzithromycin Oral Tablet 600 MGBacitra-Neomycin-Polymyxin-HC Ophthalmic Ointment 1 %Bacitracin-Neomycin-Polymyxin External Ointment 400-5-5000 Balsalazide Disodium Oral Capsule 750 MGBalziva Oral Tablet 0.4-35 MG-MCG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 30: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Bumetanide Injection Solution 0.25 MG/MLBumetanide Oral Tablet 0.5 MGBumetanide Oral Tablet 1 MGBumetanide Oral Tablet 2 MGButalbital-Acetaminophen Oral Capsule 50-300 MGButalbital-Acetaminophen Oral Tablet 50-300 MGButalbital-Acetaminophen Oral Tablet 50-325 MGButalbital-APAP-Caff-Cod Oral Capsule 50-300-40-30 MGButalbital-APAP-Caff-Cod Oral Capsule 50-325-40-30 MGButalbital-APAP-Caffeine Oral Capsule 50-300-40 MGButalbital-APAP-Caffeine Oral Capsule 50-325-40 MGButalbital-APAP-Caffeine Oral Tablet 50-325-40 MGButalbital-ASA-Caff-Codeine Oral Capsule 50-325-40-30 MGButalbital-ASA-Caffeine Oral Capsule 50-325-40 MGButalbital-Aspirin-Caffeine Oral Tablet 50-325-40 MGCandesartan Cilexetil Oral Tablet 16 MGCandesartan Cilexetil Oral Tablet 32 MGCandesartan Cilexetil Oral Tablet 4 MGCandesartan Cilexetil Oral Tablet 8 MGCandesartan Cilexetil-HCTZ Oral Tablet 16-12.5 MGCandesartan Cilexetil-HCTZ Oral Tablet 32-12.5 MGCandesartan Cilexetil-HCTZ Oral Tablet 32-25 MGCaptopril Oral Tablet 100 MGCaptopril Oral Tablet 12.5 MGCaptopril Oral Tablet 25 MGCaptopril Oral Tablet 50 MGcarBAMazepine ER Oral Capsule Extended Release 12 Hour 100 MGcarBAMazepine ER Oral Capsule Extended Release 12 Hour 200 MGcarBAMazepine ER Oral Capsule Extended Release 12 Hour 300 MGcarBAMazepine ER Oral Tablet Extended Release 12 Hour 100 MGcarBAMazepine ER Oral Tablet Extended Release 12 Hour 200 MGcarBAMazepine ER Oral Tablet Extended Release 12 Hour 400 MGcarBAMazepine Oral Suspension 100 MG/5MLcarBAMazepine Oral Tablet 200 MGcarBAMazepine Oral Tablet Chewable 100 MGCarbinoxamine Maleate Oral Solution 4 MG/5MLCarbinoxamine Maleate Oral Tablet 4 MGCarbinoxamine Maleate Oral Tablet 6 MGCefdinir Oral Capsule 300 MGCefdinir Oral Suspension Reconstituted 125 MG/5MLCefdinir Oral Suspension Reconstituted 250 MG/5MLCefprozil Oral Suspension Reconstituted 125 MG/5MLCefprozil Oral Suspension Reconstituted 250 MG/5MLCefprozil Oral Tablet 250 MGCefprozil Oral Tablet 500 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 31: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Cefuroxime Axetil Oral Tablet 250 MGCefuroxime Axetil Oral Tablet 500 MGCefuroxime Sodium Injection Solution Reconstituted 7.5 GMCefuroxime Sodium Injection Solution Reconstituted 750 MGCefuroxime Sodium Intravenous Solution Reconstituted 1.5 GMCefuroxime Sodium-NaCl Intravitreal Solution 10-0.9 MG/ML-%Celecoxib Oral Capsule 100 MGCelecoxib Oral Capsule 200 MGCelecoxib Oral Capsule 400 MGCelecoxib Oral Capsule 50 MGCentratex Oral Capsule 106-1 MGCevimeline HCl Oral Capsule 30 MGChlorothiazide Oral Tablet 250 MGChlorothiazide Oral Tablet 500 MGChlorothiazide Sodium Intravenous Solution Reconstituted 500 MGChlorthalidone Oral Tablet 25 MGChlorthalidone Oral Tablet 50 MGClarithromycin ER Oral Tablet Extended Release 24 Hour 500 MGClarithromycin Oral Suspension Reconstituted 125 MG/5MLClarithromycin Oral Suspension Reconstituted 250 MG/5MLClarithromycin Oral Tablet 250 MGClarithromycin Oral Tablet 500 MGClorazepate Dipotassium Oral Tablet 15 MGClorazepate Dipotassium Oral Tablet 3.75 MGClorazepate Dipotassium Oral Tablet 7.5 MGcloZAPine Oral Tablet 100 MGcloZAPine Oral Tablet 200 MGcloZAPine Oral Tablet 25 MGcloZAPine Oral Tablet 50 MGcloZAPine Oral Tablet Disintegrating 100 MGcloZAPine Oral Tablet Disintegrating 12.5 MGcloZAPine Oral Tablet Disintegrating 150 MGcloZAPine Oral Tablet Disintegrating 200 MGcloZAPine Oral Tablet Disintegrating 25 MGCryselle-28 Oral Tablet 0.3-30 MG-MCGcycloSPORINE in Klarity Ophthalmic Emulsion 0.1 %cycloSPORINE Intravenous Solution 50 MG/MLcycloSPORINE Modified Oral Capsule 100 MGcycloSPORINE Modified Oral Capsule 25 MGcycloSPORINE Modified Oral Capsule 50 MGcycloSPORINE Modified Oral Solution 100 MG/MLcycloSPORINE Oral Capsule 100 MGcycloSPORINE Oral Capsule 25 MGDantrolene Sodium Intravenous Solution Reconstituted 20 MGDantrolene Sodium Oral Capsule 100 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 32: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Dantrolene Sodium Oral Capsule 25 MGDantrolene Sodium Oral Capsule 50 MGDapsone External Gel 5 %Dapsone External Gel 7.5 %Dapsone Oral Tablet 100 MGDapsone Oral Tablet 25 MGDesloratadine Oral Tablet 5 MGDesloratadine Oral Tablet Disintegrating 2.5 MGDesloratadine Oral Tablet Disintegrating 5 MGDesmopressin Ace Spray Refrig Nasal Solution 0.01 %Desmopressin Acetate Injection Solution 4 MCG/MLDesmopressin Acetate Oral Tablet 0.1 MGDesmopressin Acetate Oral Tablet 0.2 MGDesmopressin Acetate Spray Nasal Solution 0.01 %Dextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 10 MGDextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 15 MGDextroamphetamine Sulfate ER Oral Capsule Extended Release 24 Hour 5 MGDextroamphetamine Sulfate Oral Solution 5 MG/5MLDextroamphetamine Sulfate Oral Tablet 10 MGDextroamphetamine Sulfate Oral Tablet 5 MGDiclofenac Potassium Oral Tablet 50 MGDiclofenac-miSOPROStol Oral Tablet Delayed Release 50-0.2 MGDiclofenac-miSOPROStol Oral Tablet Delayed Release 75-0.2 MGDigitek Oral Tablet 125 MCGDigitek Oral Tablet 250 MCGdilTIAZem CD Oral Capsule Extended Release 24 Hour 120 MGdilTIAZem CD Oral Capsule Extended Release 24 Hour 180 MGdilTIAZem CD Oral Capsule Extended Release 24 Hour 240 MGdilTIAZem CD Oral Capsule Extended Release 24 Hour 300 MGdilTIAZem HCl ER Beads Oral Capsule Extended Release 24 Hour 120 MGdilTIAZem HCl ER Beads Oral Capsule Extended Release 24 Hour 180 MGdilTIAZem HCl ER Beads Oral Capsule Extended Release 24 Hour 240 MGdilTIAZem HCl ER Beads Oral Capsule Extended Release 24 Hour 300 MGdilTIAZem HCl ER Beads Oral Capsule Extended Release 24 Hour 360 MGdilTIAZem HCl ER Beads Oral Capsule Extended Release 24 Hour 420 MGdilTIAZem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour 360 MGdilTIAZem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 180 MGdilTIAZem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 240 MGdilTIAZem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 300 MGdilTIAZem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 360 MGdilTIAZem HCl ER Coated Beads Oral Tablet Extended Release 24 Hour 420 MGdilTIAZem HCl ER Oral Capsule Extended Release 12 Hour 120 MGdilTIAZem HCl ER Oral Capsule Extended Release 12 Hour 60 MGdilTIAZem HCl ER Oral Capsule Extended Release 12 Hour 90 MGdilTIAZem HCl ER Oral Capsule Extended Release 24 Hour 120 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 33: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

dilTIAZem HCl ER Oral Capsule Extended Release 24 Hour 180 MGdilTIAZem HCl ER Oral Capsule Extended Release 24 Hour 240 MGdilTIAZem HCl Intravenous Solution 125 MG/25MLdilTIAZem HCl Intravenous Solution 25 MG/5MLdilTIAZem HCl Intravenous Solution 50 MG/10MLdilTIAZem HCl Intravenous Solution Reconstituted 100 MGdilTIAZem HCl Oral Tablet 120 MGdilTIAZem HCl Oral Tablet 30 MGdilTIAZem HCl Oral Tablet 60 MGdilTIAZem HCl Oral Tablet 90 MGdilTIAZem HCl-Dextrose Intravenous Solution 100-5 MG/100ML-%dilTIAZem HCl-Dextrose Intravenous Solution 125-5 MG/125ML-%dilTIAZem HCl-Dextrose Intravenous Solution 250-5 MG/250ML-%dilTIAZem HCl-Sodium Chloride Intravenous Solution 100-0.9 MG/100ML-%dilTIAZem HCl-Sodium Chloride Intravenous Solution 125-0.7 MG/125ML-%dilTIAZem HCl-Sodium Chloride Intravenous Solution 125-0.9 MG/125ML-%Diphenoxylate-Atropine Oral Liquid 2.5-0.025 MG/5MLDiphenoxylate-Atropine Oral Tablet 2.5-0.025 MGDisopyramide Phosphate Oral Capsule 100 MGDisopyramide Phosphate Oral Capsule 150 MGDutasteride Oral Capsule 0.5 MGEnpresse-28 Oral Tablet 50-30/75-40/ 125-30 MCGEntacapone Oral Tablet 200 MGEplerenone Oral Tablet 25 MGEplerenone Oral Tablet 50 MGEszopiclone Oral Tablet 1 MGEszopiclone Oral Tablet 2 MGEszopiclone Oral Tablet 3 MGEthambutol HCl Oral Tablet 100 MGEthambutol HCl Oral Tablet 400 MGEthosuximide Oral Capsule 250 MGEthosuximide Oral Solution 250 MG/5MLEtodolac ER Oral Tablet Extended Release 24 Hour 400 MGEtodolac ER Oral Tablet Extended Release 24 Hour 500 MGEtodolac ER Oral Tablet Extended Release 24 Hour 600 MGEtodolac Oral Capsule 200 MGEtodolac Oral Capsule 300 MGEtodolac Oral Tablet 400 MGEtodolac Oral Tablet 500 MGEuthyrox Oral Tablet 100 MCGEuthyrox Oral Tablet 112 MCGEuthyrox Oral Tablet 125 MCGEuthyrox Oral Tablet 137 MCGEuthyrox Oral Tablet 150 MCGEuthyrox Oral Tablet 175 MCG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 34: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Euthyrox Oral Tablet 200 MCGEuthyrox Oral Tablet 25 MCGEuthyrox Oral Tablet 50 MCGEuthyrox Oral Tablet 75 MCGEuthyrox Oral Tablet 88 MCGFamciclovir Oral Tablet 125 MGFamciclovir Oral Tablet 250 MGFamciclovir Oral Tablet 500 MGFluconazole in Dextrose Intravenous Solution 200 MG/100MLFluconazole in Dextrose Intravenous Solution 400 MG/200MLFluconazole in Sodium Chloride Intravenous Solution 100-0.9 MG/50ML-%Fluconazole in Sodium Chloride Intravenous Solution 200-0.9 MG/100ML-%Fluconazole in Sodium Chloride Intravenous Solution 400-0.9 MG/200ML-%Fluconazole Oral Suspension Reconstituted 10 MG/MLFluconazole Oral Suspension Reconstituted 40 MG/MLFluconazole Oral Tablet 100 MGFluconazole Oral Tablet 150 MGFluconazole Oral Tablet 200 MGFluconazole Oral Tablet 50 MGFludrocortisone Acetate Oral Tablet 0.1 MGFlutamide Oral Capsule 125 MGfluvoxaMINE Maleate ER Oral Capsule Extended Release 24 Hour 100 MGfluvoxaMINE Maleate ER Oral Capsule Extended Release 24 Hour 150 MGfluvoxaMINE Maleate Oral Tablet 100 MGfluvoxaMINE Maleate Oral Tablet 25 MGfluvoxaMINE Maleate Oral Tablet 50 MGFosphenytoin Sodium Injection Solution 100 MG PE/2MLFosphenytoin Sodium Injection Solution 500 MG PE/10MLGalantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 16 MGGalantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 24 MGGalantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 8 MGGalantamine Hydrobromide Oral Solution 4 MG/MLGalantamine Hydrobromide Oral Tablet 12 MGGalantamine Hydrobromide Oral Tablet 4 MGGalantamine Hydrobromide Oral Tablet 8 MGHaloperidol Decanoate Intramuscular Solution 100 MG/MLHaloperidol Decanoate Intramuscular Solution 50 MG/MLHaloperidol Lactate Injection Solution 5 MG/MLHaloperidol Lactate Oral Concentrate 2 MG/MLHaloperidol Oral Tablet 0.5 MGHaloperidol Oral Tablet 1 MGHaloperidol Oral Tablet 10 MGHaloperidol Oral Tablet 2 MGHaloperidol Oral Tablet 20 MGHaloperidol Oral Tablet 5 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 35: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Hydroxychloroquine Sulfate Oral Tablet 200 MGHYDROXYprogesterone Caproate Intramuscular Oil 250 MG/MLHYDROXYprogesterone Caproate Intramuscular Solution 1.25 GM/5MLHydroxyurea Oral Capsule 500 MGIntrovale Oral Tablet 0.15-0.03 MGIsosorbide Dinitrate ER Oral Tablet Extended Release 40 MGIsosorbide Dinitrate Oral Tablet 10 MGIsosorbide Dinitrate Oral Tablet 20 MGIsosorbide Dinitrate Oral Tablet 30 MGIsosorbide Dinitrate Oral Tablet 40 MGIsosorbide Dinitrate Oral Tablet 5 MGJunel 1.5/30 Oral Tablet 1.5-30 MG-MCGJunel 1/20 Oral Tablet 1-20 MG-MCGlamiVUDine Oral Solution 10 MG/MLlamiVUDine Oral Tablet 100 MGlamiVUDine Oral Tablet 150 MGlamiVUDine Oral Tablet 300 MGlamiVUDine-Zidovudine Oral Tablet 150-300 MGlamoTRIgine ER Oral Tablet Extended Release 24 Hour 100 MGlamoTRIgine ER Oral Tablet Extended Release 24 Hour 200 MGlamoTRIgine ER Oral Tablet Extended Release 24 Hour 25 MGlamoTRIgine ER Oral Tablet Extended Release 24 Hour 250 MGlamoTRIgine ER Oral Tablet Extended Release 24 Hour 300 MGlamoTRIgine ER Oral Tablet Extended Release 24 Hour 50 MGlamoTRIgine Oral Kit 21 x 25 MG & 7 x 50 MGlamoTRIgine Oral Kit 25 & 50 & 100 MGlamoTRIgine Oral Kit 42 x 50 MG & 14x100 MGlamoTRIgine Oral Tablet 100 MGlamoTRIgine Oral Tablet 150 MGlamoTRIgine Oral Tablet 200 MGlamoTRIgine Oral Tablet 25 MGlamoTRIgine Oral Tablet Chewable 25 MGlamoTRIgine Oral Tablet Chewable 5 MGlamoTRIgine Oral Tablet Disintegrating 100 MGlamoTRIgine Oral Tablet Disintegrating 200 MGlamoTRIgine Oral Tablet Disintegrating 25 MGlamoTRIgine Oral Tablet Disintegrating 50 MGlamoTRIgine Starter Kit-Blue Oral Kit 35 x 25 MGlamoTRIgine Starter Kit-Green Oral Kit 84 x 25 MG & 14x100 MGlamoTRIgine Starter Kit-Orange Oral Kit 42 x 25 MG & 7 x 100 MGLetrozole Oral Tablet 2.5 MGlevETIRAcetam ER Oral Tablet Extended Release 24 Hour 500 MGlevETIRAcetam ER Oral Tablet Extended Release 24 Hour 750 MGlevETIRAcetam in NaCl Intravenous Solution 1000 MG/100MLlevETIRAcetam in NaCl Intravenous Solution 1500 MG/100ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 36: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

levETIRAcetam in NaCl Intravenous Solution 500 MG/100MLlevETIRAcetam Intravenous Solution 500 MG/5MLlevETIRAcetam Oral Solution 100 MG/MLlevETIRAcetam Oral Tablet 1000 MGlevETIRAcetam Oral Tablet 250 MGlevETIRAcetam Oral Tablet 500 MGlevETIRAcetam Oral Tablet 750 MGLiothyronine Sodium Intravenous Solution 10 MCG/MLLiothyronine Sodium Oral Tablet 25 MCGLiothyronine Sodium Oral Tablet 5 MCGLiothyronine Sodium Oral Tablet 50 MCGLoxapine Succinate Oral Capsule 10 MGLoxapine Succinate Oral Capsule 25 MGLoxapine Succinate Oral Capsule 5 MGLoxapine Succinate Oral Capsule 50 MGmedroxyPROGESTERone Acetate Intramuscular Suspension 150 MG/MLmedroxyPROGESTERone Acetate Intramuscular Suspension Prefilled Syringe 150 medroxyPROGESTERone Acetate Oral Tablet 10 MGmedroxyPROGESTERone Acetate Oral Tablet 2.5 MGmedroxyPROGESTERone Acetate Oral Tablet 5 MGMeperidine HCl Injection Solution 10 MG/MLMeperidine HCl Injection Solution 100 MG/MLMeperidine HCl Injection Solution 25 MG/MLMeperidine HCl Injection Solution 50 MG/MLMeperidine HCl Oral Solution 50 MG/5MLMeperidine HCl Oral Tablet 100 MGMeperidine HCl Oral Tablet 50 MGMeperidine HCl-Sodium Chloride Intravenous Solution 500-0.9 MG/50ML-%Mercaptopurine Oral Tablet 50 MGMetaxall Oral Tablet 800 MGMethenamine Hippurate Oral Tablet 1 GMMethenamine Mandelate Oral Tablet 0.5 GMMethenamine Mandelate Oral Tablet 1 GMMethotrexate Oral Tablet 2.5 MGMethotrexate Sodium (PF) Injection Solution 1 GM/40MLMethotrexate Sodium (PF) Injection Solution 100 MG/4MLMethotrexate Sodium (PF) Injection Solution 200 MG/8MLMethotrexate Sodium (PF) Injection Solution 250 MG/10MLMethotrexate Sodium (PF) Injection Solution 50 MG/2MLMethotrexate Sodium Injection Solution 250 MG/10MLMethotrexate Sodium Injection Solution 50 MG/2MLMethotrexate Sodium Injection Solution Reconstituted 1 GMmethylPREDNISolone Acetate Injection Suspension 40 MG/MLmethylPREDNISolone Acetate Injection Suspension 50 MG/MLmethylPREDNISolone Acetate Injection Suspension 80 MG/ML

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 37: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

methylPREDNISolone Oral Tablet 16 MGmethylPREDNISolone Oral Tablet 32 MGmethylPREDNISolone Oral Tablet 4 MGmethylPREDNISolone Oral Tablet 8 MGmethylPREDNISolone Oral Tablet Therapy Pack 4 MGmethylPREDNISolone Sodium Succ Injection Solution Reconstituted 1000 MGmethylPREDNISolone Sodium Succ Injection Solution Reconstituted 125 MGmethylPREDNISolone Sodium Succ Injection Solution Reconstituted 40 MGmethylPREDNISolone Sodium Succ Injection Solution Reconstituted 500 MGmethylPREDNISolone-Bupivacaine Injection Suspension 40-5 MG/MLmethylPREDNISolone-Bupivacaine Injection Suspension 80-5 MG/MLMidodrine HCl Oral Tablet 10 MGMidodrine HCl Oral Tablet 2.5 MGMidodrine HCl Oral Tablet 5 MGmiSOPROStol Oral Tablet 100 MCGmiSOPROStol Oral Tablet 200 MCGModafinil Oral Tablet 100 MGModafinil Oral Tablet 200 MGMycophenolate Mofetil HCl Intravenous Solution Reconstituted 500 MGMycophenolate Mofetil Oral Capsule 250 MGMycophenolate Mofetil Oral Suspension Reconstituted 200 MG/MLMycophenolate Mofetil Oral Tablet 500 MGMycophenolate Sodium Oral Tablet Delayed Release 180 MGMycophenolate Sodium Oral Tablet Delayed Release 360 MGNaltrexone HCl Oral Tablet 50 MGNateglinide Oral Tablet 120 MGNateglinide Oral Tablet 60 MGNecon 0.5/35 (28) Oral Tablet 0.5-35 MG-MCGNecon 1/50 (28) Oral Tablet 1-50 MG-MCGNecon 10/11 (28) Oral Tablet 35 MCGNeomycin Sulfate Oral Tablet 500 MGNeomycin-Bacitracin Zn-Polymyx Ophthalmic Ointment 3.5-400-10000 Neomycin-Polymyxin B GU Irrigation Solution 40-200000 Neomycin-Polymyxin-Dexameth Ophthalmic Ointment 3.5-10000-0.1 Neomycin-Polymyxin-Dexameth Ophthalmic Suspension 0.1 %Neomycin-Polymyxin-Gramicidin Ophthalmic Solution 1.75-10000-.025 Neomycin-Polymyxin-HC Ophthalmic Suspension 3.5-10000-1 Neomycin-Polymyxin-HC Otic Solution 1 %Neomycin-Polymyxin-HC Otic Suspension 3.5-10000-1 NIFEdipine ER Oral Tablet Extended Release 24 Hour 30 MGNIFEdipine ER Oral Tablet Extended Release 24 Hour 60 MGNIFEdipine ER Oral Tablet Extended Release 24 Hour 90 MGNIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 30 MGNIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 60 MGNIFEdipine ER Osmotic Release Oral Tablet Extended Release 24 Hour 90 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 38: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

NIFEdipine Oral Capsule 10 MGNIFEdipine Oral Capsule 20 MGNitrofurantoin Macrocrystal Oral Capsule 100 MGNitrofurantoin Macrocrystal Oral Capsule 25 MGNitrofurantoin Macrocrystal Oral Capsule 50 MGNitrofurantoin Monohyd Macro Oral Capsule 100 MGNitrofurantoin Oral Suspension 25 MG/5MLNorethindrone Acet-Ethinyl Est Oral Tablet Chewable 1-20 MG-MCG(24)Norethindrone Acetate Oral Tablet 5 MGNorethindrone Oral Tablet 0.35 MGNystatin External Cream 100000 UNIT/GMNystatin External Ointment 100000 UNIT/GMNystatin External Powder 100000 UNIT/GMNystatin Mouth/Throat Suspension 100000 UNIT/MLNystatin Oral Powder Nystatin Oral Tablet 500000 UNITNystatin-Triamcinolone External Cream 100000-0.1 UNIT/GM-%Nystatin-Triamcinolone External Ointment 100000-0.1 UNIT/GM-%Olmesartan Medoxomil Oral Tablet 20 MGOlmesartan Medoxomil Oral Tablet 40 MGOlmesartan Medoxomil Oral Tablet 5 MGOlmesartan Medoxomil-HCTZ Oral Tablet 20-12.5 MGOlmesartan Medoxomil-HCTZ Oral Tablet 40-12.5 MGOlmesartan Medoxomil-HCTZ Oral Tablet 40-25 MGOmega-3-acid Ethyl Esters Oral Capsule 1 GMOxaprozin Oral Tablet 600 MGOxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 10 MGOxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 15 MGOxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MGOxybutynin Chloride Oral Syrup 5 MG/5MLOxybutynin Chloride Oral Tablet 5 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 10 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 15 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 20 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 30 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 40 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 5 MGoxyMORphone HCl ER Oral Tablet Extended Release 12 Hour 7.5 MGoxyMORphone HCl Oral Tablet 10 MGoxyMORphone HCl Oral Tablet 5 MGPerphenazine Oral Tablet 16 MGPerphenazine Oral Tablet 2 MGPerphenazine Oral Tablet 4 MGPerphenazine Oral Tablet 8 MGPhenytoin Infatabs Oral Tablet Chewable 50 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 39: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Phenytoin Oral Suspension 125 MG/5MLPhenytoin Sodium Extended Oral Capsule 100 MGPhenytoin Sodium Extended Oral Capsule 200 MGPhenytoin Sodium Extended Oral Capsule 300 MGPhenytoin Sodium Injection Solution 50 MG/MLPilocarpine HCl Ophthalmic Solution 1 %Pilocarpine HCl Ophthalmic Solution 2 %Pilocarpine HCl Ophthalmic Solution 4 %Pilocarpine HCl Oral Tablet 5 MGPilocarpine HCl Oral Tablet 7.5 MGPindolol Oral Tablet 10 MGPindolol Oral Tablet 5 MGPiroxicam Oral Capsule 10 MGPiroxicam Oral Capsule 20 MGPrazosin HCl Oral Capsule 1 MGPrazosin HCl Oral Capsule 2 MGPrazosin HCl Oral Capsule 5 MGProgesterone Intramuscular Oil 50 MG/MLProgesterone Micronized Oral Capsule 100 MGProgesterone Micronized Oral Capsule 200 MGPyridostigmine Bromide ER Oral Tablet Extended Release 180 MGPyridostigmine Bromide Oral Solution 60 MG/5MLPyridostigmine Bromide Oral Tablet 30 MGPyridostigmine Bromide Oral Tablet 60 MGRaloxifene HCl Oral Tablet 60 MGReadySharp methylPREDNISolone Injection Kit 80 MG/MLrifAMPin Intravenous Solution Reconstituted 600 MGrifAMPin Oral Capsule 150 MGrifAMPin Oral Capsule 300 MGRiluzole Oral Tablet 50 MGRivastigmine Tartrate Oral Capsule 1.5 MGRivastigmine Tartrate Oral Capsule 3 MGRivastigmine Tartrate Oral Capsule 4.5 MGRivastigmine Tartrate Oral Capsule 6 MGRivastigmine Transdermal Patch 24 Hour 13.3 MG/24HRRivastigmine Transdermal Patch 24 Hour 4.6 MG/24HRRivastigmine Transdermal Patch 24 Hour 9.5 MG/24HRRizatriptan Benzoate Oral Tablet 10 MGRizatriptan Benzoate Oral Tablet 5 MGRizatriptan Benzoate Oral Tablet Disintegrating 10 MGRizatriptan Benzoate Oral Tablet Disintegrating 5 MGRosuvastatin Calcium Oral Tablet 10 MGRosuvastatin Calcium Oral Tablet 20 MGRosuvastatin Calcium Oral Tablet 40 MGRosuvastatin Calcium Oral Tablet 5 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 40: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

SUMAtriptan Nasal Solution 20 MG/ACTSUMAtriptan Nasal Solution 5 MG/ACTSUMAtriptan Succinate Oral Tablet 100 MGSUMAtriptan Succinate Oral Tablet 25 MGSUMAtriptan Succinate Oral Tablet 50 MGSUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 4 MG/0.5MLSUMAtriptan Succinate Refill Subcutaneous Solution Cartridge 6 MG/0.5MLSUMAtriptan Succinate Subcutaneous Solution 6 MG/0.5MLSUMAtriptan Succinate Subcutaneous Solution Auto-injector 4 MG/0.5MLSUMAtriptan Succinate Subcutaneous Solution Auto-injector 6 MG/0.5MLSUMAtriptan Succinate Subcutaneous Solution Prefilled Syringe 6 MG/0.5MLTacrolimus External Ointment 0.03 %Tacrolimus External Ointment 0.1 %Tacrolimus Oral Capsule 0.5 MGTacrolimus Oral Capsule 1 MGTacrolimus Oral Capsule 5 MGTamoxifen Citrate Oral Tablet 10 MGTamoxifen Citrate Oral Tablet 20 MGTelmisartan Oral Tablet 20 MGTelmisartan Oral Tablet 40 MGTelmisartan Oral Tablet 80 MGTelmisartan-HCTZ Oral Tablet 40-12.5 MGTelmisartan-HCTZ Oral Tablet 80-12.5 MGTelmisartan-HCTZ Oral Tablet 80-25 MGTolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 2 MGTolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 4 MGTolterodine Tartrate Oral Tablet 1 MGTolterodine Tartrate Oral Tablet 2 MGTrimethobenzamide HCl Oral Capsule 300 MGTrospium Chloride ER Oral Capsule Extended Release 24 Hour 60 MGTrospium Chloride Oral Tablet 20 MGUrsodiol Oral Capsule 300 MGUrsodiol Oral Tablet 250 MGUrsodiol Oral Tablet 500 MGValsartan Oral Tablet 160 MGValsartan Oral Tablet 320 MGValsartan Oral Tablet 40 MGValsartan Oral Tablet 80 MGZiprasidone HCl Oral Capsule 20 MGZiprasidone HCl Oral Capsule 40 MGZiprasidone HCl Oral Capsule 60 MGZiprasidone HCl Oral Capsule 80 MG

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 41: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Tier 3 (Brands) - $50 or LessADACEL INJAFLURIA QUAD INJ 2019-20ALBUTEROL AER HFAAMPICILLIN CAP 500MGARMOUR THYRO TAB 60MGATROPINE SUL SOL 1% OPAZITHROMYCIN POW 1GM PAKBACLOFEN TAB 5MGBOOSTRIX INJBYSTOLIC TAB 10MGCHLORZOXAZON TAB 500MGCLOMIPHENE TAB 50MGCODEINE SULF TAB 30MGCOLCHICINE TAB 0.6MGDEXAMETHASON TAB 1MGDILT-XR CAP 240MGELLA TAB 30MGFLUBLOK QUAD INJ 2019-20FLUCLVX QUAD INJ 2019-20FLURBIPROFEN SOL 0.03% OPFLUZONE HD INJ PF 19-20FLUZONE QUAD INJ 2019-20FREESTYLE TES PREC NEOGOLYTELY SOLHYDROXYZ PAM CAP 100MGHYOPHEN TABKAPSPARGO CAP 50MGLITHIUM CARB CAP 600MGMEFLOQUINE TAB 250MGOGESTREL TABPOT CHLORIDE TAB 20MEQ ERPOT CHLORIDE TAB 8MEQ ERPREDNISOLONE SOL 15MG/5MLPREDNISOLONE SOL 25MG/5MLPREDNISOLONE SUS 1% OPPREDNISONE PAK 10MGPREDNISONE PAK 5MGPREDNISONE SOL 5MG/5MLPREDNISONE TAB 50MGPRENATAL TAB 27-0.8MGPREVDNT 5000 PST 1.1-5%PREVDNT 5000 PST 1.1%PREVIDENT SOL 0.2%PROMETHAZINE SYP DM

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 42: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

PROPRANOLOL SOL 20MG/5MLSOLU-CORTEF INJ 100MGSULF/PRED NA SOL OPSUPRAX CAP 400MGSYNTHROID TAB 100MCGSYNTHROID TAB 112MCGSYNTHROID TAB 125MCGSYNTHROID TAB 137MCGSYNTHROID TAB 150MCGSYNTHROID TAB 175MCGSYNTHROID TAB 200MCGSYNTHROID TAB 25MCGSYNTHROID TAB 50MCGSYNTHROID TAB 75MCGSYNTHROID TAB 88MCGTERCONAZOLE CRE 0.8%

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.

Page 43: Tier 1 (Generics) - $10 or Less Acarbose Oral Tablet 100

Tier 4 (Brands) -$75 or LessCEPHALEXIN TAB 500MGCLOMIPHENE TAB 50MGDEXAMETH PHO SOL 0.1% OPENGERIX-B INJ 20MCG/MLFLUAD INJ 2019-20FLUNISOLIDE SPR 0.025%HAVRIX INJ 1440UNITNADOLOL/BEND TAB 40-5MGONETOUCH TES ULTRA BLPROAIR HFA AERPROAIR RESPI AERTRADJENTA TAB 5MGVOLTAREN GEL 1%XOPENEX HFA AER

The pricing and inclusion of any prescription drug within this list is subject to change and is not guaranteed.