Tricare Uniform Formulary

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 Formulary: Tricare Uniform Formulary available at Retail
   Global Sort:
   NDC             Product Name                           Form         Strength           Cost


   (10:00) Antineoplastics
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00054413025     CYCLOPHOSPHAMIDE                       TABS         50MG        T1

   00054412925     CYCLOPHOSPHAMIDE                       TABS         25MG        T1

   00378326694     ETOPOSIDE                              CAPS         50MG        T1

   00172496058     FLUTAMIDE                              CAPS         125MG       T1

   00555088202     HYDROXYUREA                            CAPS         500MG       T1

   00703402419     LEUPROLIDE ACETATE                     SOLN         1MG/0.2ML   T1

   00185740085     LEUPROLIDE ACETATE                     KIT          1MG/0.2ML   T1

   49884090738     MEGESTROL ACETATE                      SUSP         40MG/ML     T1

   00555060702     MEGESTROL ACETATE                      TABS         40MG        T1

   49884028901     MEGESTROL ACETATE                      TABS         20MG        T1

   00054458111     MERCAPTOPURINE                         TABS         50MG        T1

   00555057202     METHOTREXATE                           TABS         2.5MG       T1

   55390003110     METHOTREXATE SODIUM                    SOLN         25MG/ML     T1

   61703035038     METHOTREXATE SODIUM                    SOLN         25MG/ML     T1

   00555044609     TAMOXIFEN CITRATE                      TABS         10MG        T1

   00093078256     TAMOXIFEN CITRATE                      TABS         20MG        T1

   00555080802     TRETINOIN                              CAPS         10MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   59572030250     ALKERAN                                TABS         2MG         T2

   00310020130     ARIMIDEX                               TABS         1MG         T2

   00009766304     AROMASIN                               TABS         25MG        T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 1 of 285
   00310070530     CASODEX                                TABS         50MG         T2

   00015303020     CEENU                                  CAPS         10MG         T2

   00015303410     CEENU                                  CAPS         300MG        T2

   00015303120     CEENU                                  CAPS         40MG         T2

   00015303220     CEENU                                  CAPS         100MG        T2

   00003633517     DROXIA                                 CAPS         200MG        T2

   00003633617     DROXIA                                 CAPS         300MG        T2

   00003633717     DROXIA                                 CAPS         400MG        T2

   00024060545     ELIGARD                                KIT          45MG         T2

   00024022205     ELIGARD                                KIT          22.5MG       T2

   00024061030     ELIGARD                                KIT          30MG         T2

   00013013202     EMCYT                                  CAPS         140MG        T2

   11399000530     FARESTON                               TABS         60MG         T2

   00310072050     FASLODEX                               SOLN         250MG/5ML    T2

   00078024915     FEMARA                                 TABS         2.5MG        T2

   00078043815     GLEEVEC                                TABS         400MG        T2   QL (30.00 days supply per dispensing)


   00078040134     GLEEVEC                                TABS         100MG        T2   QL (30.00 days supply per dispensing)


   58063000170     HEXALEN                                CAPS         50MG         T2

   00085113301     INTRON-A                               SOLN         10MU/ML      T2

   00085116801     INTRON-A                               SOLN         6000000UNIT/ T2
                                                                       ML
   00085123501     INTRON-A                               KIT          5MU/0.2ML    T2

   00085124201     INTRON-A                               KIT          3MU/0.2ML    T2

   00085125401     INTRON-A                               KIT          10MU/0.2ML   T2

   00085057102     INTRON-A W/DILUENT                     SOLR         10MU         T2

   00085053901     INTRON-A W/DILUENT                     SOLR         50MU         T2

   00085111001     INTRON-A W/DILUENT                     SOLR         18MU         T2

   00310048230     IRESSA                                 TABS         250MG        T2   QL (30.00 per 30 days)


   00173063535     LEUKERAN                               TABS         2MG          T2

   00300334601     LUPRON DEPOT                           KIT          22.5MG       T2

   00300364201     LUPRON DEPOT                           KIT          7.5MG        T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 2 of 285
   00300366301     LUPRON DEPOT                           KIT          11.25MG     T2

   00300364101     LUPRON DEPOT                           KIT          3.75MG      T2

   00300368301     LUPRON DEPOT                           KIT          30MG        T2

   00300210801     LUPRON DEPOT-PED                       KIT          7.5MG       T2

   00300228201     LUPRON DEPOT-PED                       KIT          11.25MG     T2

   00300244001     LUPRON DEPOT-PED                       KIT          15MG        T2

   00015308060     LYSODREN                               TABS         500MG       T2

   54482005301     MATULANE                               CAPS         50MG        T2

   67386091151     MUSTARGEN                              SOLR         10MG        T2

   00173071325     MYLERAN                                TABS         2MG         T2

   00026848858     NEXAVAR                                TABS         200MG       T2   QL (120.00 per 30 days)


   00088111114     NILANDRON                              TABS         150MG       T2

   67253058046     RHEUMATREX                             TABS         2.5MG       T2

   00004201509     ROFERON-A                              KIT          3MU/0.5ML   T2

   00004201709     ROFERON-A                              KIT          9MU/0.5ML   T2

   00003052711     SPRYCEL                                TABS         20MG        T2   QL (120.00 per 30 days)


   00003052411     SPRYCEL                                TABS         70MG        T2   QL (60.00 per 30 days)


   00003052811     SPRYCEL                                TABS         50MG        T2   QL (120.00 per 30 days)


   00069098038     SUTENT                                 CAPS         50MG        T2   QL (30.00 per 30 days)


   00069055038     SUTENT                                 CAPS         12.5MG      T2   QL (120.00 per 30 days)


   00069077038     SUTENT                                 CAPS         25MG        T2   QL (60.00 per 30 days)


   00173088025     TABLOID                                TABS         40MG        T2

   50242006201     TARCEVA                                TABS         25MG        T2   QL (30.00 days supply per dispensing)


   50242006301     TARCEVA                                TABS         100MG       T2   QL (30.00 days supply per dispensing)


   50242006401     TARCEVA                                TABS         150MG       T2   QL (30.00 days supply per dispensing)


   62856060210     TARGRETIN                              CAPS         75MG        T2

   00085136602     TEMODAR                                CAPS         100MG       T2

   00085124801     TEMODAR                                CAPS         5MG         T2

   00085142502     TEMODAR                                CAPS         140MG       T2

   00085141701     TEMODAR                                CAPS         250MG       T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 3 of 285
   00085143001     TEMODAR                                CAPS         180MG      T2

   00085151901     TEMODAR                                CAPS         20MG       T2

   00003069050     TESLAC                                 TABS         50MG       T2

   52544015476     TRELSTAR LA                            SUSR         11.25MG    T2

   51285036701     TREXALL                                TABS         7.5MG      T2

   51285036801     TREXALL                                TABS         10MG       T2

   51285036901     TREXALL                                TABS         15MG       T2

   51285036601     TREXALL                                TABS         5MG        T2

   00173075200     TYKERB                                 TABS         250MG      T2            QL (150.00 per 30 days)


   00004110020     XELODA                                 TABS         150MG      T2

   00004110150     XELODA                                 TABS         500MG      T2

   00310095036     ZOLADEX                                IMPL         3.6MG      T2

   00310095130     ZOLADEX                                IMPL         10.8MG     T2

   00006056840     ZOLINZA                                CAPS         100MG      T2            QL (120.00 per 30 days)




   (12:04) Autonomic Drugs » Cholinergics
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   50111032301     BETHANECHOL CHLORIDE                   TABS         5MG        T1

   50111032501     BETHANECHOL CHLORIDE                   TABS         25MG       T1

   50111032401     BETHANECHOL CHLORIDE                   TABS         10MG       T1

   50111032601     BETHANECHOL CHLORIDE                   TABS         50MG       T1

   00228283711     PILOCARPINE HCL                        TABS         7.5MG      T1

   00781510001     PILOCARPINE HYDROCHLORIDE              TABS         5MG        T1

   00555013302     PYRIDOSTIGMINE BROMIDE                 TABS         60MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   62856024530     ARICEPT                                TABS         5MG        T2

   62856024630     ARICEPT                                TABS         10MG       T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 4 of 285
   62856083230     ARICEPT ODT                            TBDP         10MG         T2

   62856083130     ARICEPT ODT                            TBDP         5MG          T2

   63395020113     EVOXAC                                 CAPS         30MG         T2

   00078050115     EXELON                                 PT24         4.6MG/24HR   T2

   00078032444     EXELON                                 CAPS         3MG          T2

   00078050215     EXELON                                 PT24         9.5MG/24HR   T2

   00078032544     EXELON                                 CAPS         4.5MG        T2

   00078032644     EXELON                                 CAPS         6MG          T2

   00078033931     EXELON                                 SOLN         2MG/ML       T2

   00078032344     EXELON                                 CAPS         1.5MG        T2

   00187301220     MESTINON                               SYRP         60MG/5ML     T2

   00187301330     MESTINON TIMESPAN                      TBCR         180MG        T2

   00187310010     PROSTIGMIN                             TABS         15MG         T2

   50458039760     RAZADYNE                               TABS         8MG          T2

   50458039860     RAZADYNE                               TABS         12MG         T2

   50458049010     RAZADYNE                               SOLN         4MG/ML       T2

   50458039660     RAZADYNE                               TABS         4MG          T2

   50458038730     RAZADYNE ER                            CP24         8MG          T2

   50458038830     RAZADYNE ER                            CP24         16MG         T2

   50458038930     RAZADYNE ER                            CP24         24MG         T2


   Tier: T3
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   59630019012     COGNEX                                 CAPS         10MG         T3            MN


   59630019112     COGNEX                                 CAPS         20MG         T3            MN


   59630019212     COGNEX                                 CAPS         30MG         T3            MN


   59630019312     COGNEX                                 CAPS         40MG         T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 5 of 285
   (12:08.08) Autonomic Drugs » Anticholinergics » Antimuscarinics/Antispasmodics
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   00574704512     BELLADONNA & OPIUM                     SUPP         16.2MG; 30MG T1

   00574704012     BELLADONNA ALKALOIDS & OPIUM           SUPP         16.2MG; 60MG T1

   00603103058     BELLADONNA ALKALOIDS/PHENOBARBITAL     ELIX         0.0194MG/5ML T1
                                                                       ;
                                                                       0.1037MG/5ML
                                                                       ; 16.2MG/5ML;
                                                                       0.0065MG/5ML
   00603241832     BELLADONNA ALKALOIDS/PHENOBARBITAL     TABS         0.0194MG;     T1
                                                                       0.1037MG;
                                                                       16.2MG;
                                                                       0.0065MG
   00603271421     CHLORDIAZEPOXIDE /CLIDINIUM            CAPS         5MG; 2.5MG    T1

   55390006610     DICYCLOMINE HCL                        SOLN         10MG/ML       T1

   00603116158     DICYCLOMINE HCL                        SOLN         10MG/5ML      T1

   00591079401     DICYCLOMINE HCL                        CAPS         10MG          T1

   00591079501     DICYCLOMINE HCL                        TABS         20MG          T1

   12830084001     DISPAS                                 TBDP         0.25MG        T1

   64980013101     GLYCOPYRROLATE                         TABS         1MG           T1

   10019001681     GLYCOPYRROLATE                         SOLN         0.2MG/ML      T1

   64980013201     GLYCOPYRROLATE                         TABS         2MG           T1

   66993040202     HYOSCYAMINE                            TABS         0.15MG        T1

   58177042304     HYOSCYAMINE SULFATE                    TBDP         0.125MG       T1

   60258080116     HYOSCYAMINE SULFATE                    ELIX         0.125MG/5ML   T1

   60258080215     HYOSCYAMINE SULFATE                    SOLN         0.125MG/ML    T1

   58177025504     HYOSCYAMINE SULFATE                    SUBL         0.125MG       T1

   58177027404     HYOSCYAMINE SULFATE                    TABS         0.125MG       T1

   58177001704     HYOSCYAMINE SULFATE ER                 CP12         0.375MG       T1

   58177023704     HYOSCYAMINE SULFATE ER                 TB12         0.375MG       T1

   49502068526     IPRATROPIUM BROMIDE                    SOLN         0.02%         T1            QL (180.00 per 30 days)


   18754006101     METHSCOPOLAMINE BROMIDE                TABS         2.5MG         T1

   64376060406     METHSCOPOLAMINE BROMIDE                TABS         5MG           T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                           Page 6 of 285
   00054472125     PROPANTHELINE BROMIDE                  TABS         15MG         T1

   60267074230     SAL-TROPINE                            TABS         0.4MG        T1

   63323026801     SCOPOLAMINE HYDROBROMIDE               SOLN         0.4MG/ML     T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details         Comment

   00597008717     ATROVENT HFA                           AERS         17MCG/ACT    T2            QL (2.00 per 30 days)


   00068003701     CANTIL                                 TABS         25MG         T2

   00187410010     LIBRAX                                 CAPS         5MG; 2.5MG   T2

   00597007541     SPIRIVA HANDIHALER                     CAPS         18MCG        T2            QL (30.00 per 30 days)


   64543011890     SYMAX DUOTAB                           TBCR         0.375MG      T2




   (12:12.04) Autonomic Drugs » Adrenergics » a-Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details         Comment

   00378190201     MIDODRINE HCL                          TABS         5MG          T1

   00378190101     MIDODRINE HCL                          TABS         2.5MG        T1

   00378190301     MIDODRINE HCL                          TABS         10MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details         Comment

   59196001704     AH-CHEW D                              SUSP         10MG/5ML     T2

   66992014616     LUSONAL                                LIQD         7.5MG/5ML    T2

   63717026001     NASOP                                  TBDP         10MG         T2

   63717026104     NASOP                                  SUSP         7.5MG/5ML    T2

   63717025901     NASOP12                                CHEW         10MG         T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 7 of 285
   (12:12.08.12) Autonomic Drugs » Adrenergics » ß-Agonists » ß-2 Selective Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details          Comment

   17270072101     ALBUTEROL                              AERS         90MCG/ACT    T1            QL (2.00 per 30 days)


   00378057201     ALBUTEROL SULFATE                      TABS         4MG          T1

   00487990130     ALBUTEROL SULFATE                      NEBU         0.5%         T1            QL (200.00 per 30 days)


   50383074120     ALBUTEROL SULFATE                      NEBU         0.5%         T1            QL (3.00 per 30 days)


   00378025501     ALBUTEROL SULFATE                      TABS         2MG          T1

   00487990401     ALBUTEROL SULFATE                      NEBU         1.25MG/3ML   T1            QL (200.00 per 30 days)


   00093066116     ALBUTEROL SULFATE                      SYRP         2MG/5ML      T1

   49502069724     ALBUTEROL SULFATE                      NEBU         0.083%       T1            QL (200.00 per 30 days)


   00378412401     ALBUTEROL SULFATE ER                   TB12         8MG          T1

   00378412201     ALBUTEROL SULFATE ER                   TB12         4MG          T1

   00185732230     ALBUTEROL SULFATE/IPRATROPIUM          SOLN         2.5MG/3ML;   T1            QL (180.00 per 30 days)
                   BROMIDE                                             0.5MG/3ML
   00603142258     METAPROTERENOL SULFATE                 SYRP         10MG/5ML     T1

   49884025801     METAPROTERENOL SULFATE                 TABS         10MG         T1

   49884025901     METAPROTERENOL SULFATE                 TABS         20MG         T1

   49502067624     METAPROTERENOL SULFATE                 NEBU         0.6%         T1            QL (200.00 per 30 days)


   49502067824     METAPROTERENOL SULFATE                 NEBU         0.4%         T1            QL (200.00 per 30 days)


   00115262201     TERBUTALINE SULFATE                    TABS         5MG          T1

   00115261101     TERBUTALINE SULFATE                    TABS         2.5MG        T1

   00703127104     TERBUTALINE SULFATE                    SOLN         1MG/ML       T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details          Comment

   49502069203     ACCUNEB                                NEBU         0.63MG/3ML   T2            QL (200.00 per 30 days)


   00173069500     ADVAIR DISKUS                          MISC         100MCG/DOSE T2             QL (1.00 per 30 days)
                                                                       ; 50MCG/DOSE
   00173069600     ADVAIR DISKUS                          MISC         250MCG/DOSE T2             QL (1.00 per 30 days)
                                                                       ; 50MCG/DOSE
   00173069700     ADVAIR DISKUS                          MISC         500MCG/DOSE T2             QL (1.00 per 30 days)
                                                                       ; 50MCG/DOSE



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                          Page 8 of 285
   00173071700     ADVAIR HFA                             AERO         230MCG/ACT;   T2
                                                                       21MCG/ACT
   00173071500     ADVAIR HFA                             AERO         45MCG/ACT;    T2
                                                                       21MCG/ACT
   00173071600     ADVAIR HFA                             AERO         115MCG/ACT;   T2
                                                                       21MCG/ACT
   00597007017     ALUPENT                                AERP         0.65MG/ACT    T2            QL (2.00 per 30 days)


   63402091130     BROVANA                                NEBU         15MCG/2ML     T2            QL (60.00 per 30 days)


   00597001314     COMBIVENT                              AERO         103MCG/ACT;   T2
                                                                       18MCG/ACT
   00085140101     FORADIL AEROLIZER                      CAPS         12MCG         T2            QL (1.00 per 30 days)


   00089081521     MAXAIR AUTOHALER                       AERB         200MCG/INH    T2            QL (1.00 per 30 days)


   49502060561     PERFOROMIST                            NEBU         20MCG/2ML     T2            QL (60.00 per 30 days)


   59310057920     PROAIR HFA                             AERS         108MCG/ACT    T2            QL (2.00 per 30 days)


   00173052100     SEREVENT DISKUS                        AEPB         50MCG/DOSE    T2            QL (1.00 per 30 days)


   63402051224     XOPENEX                                NEBU         0.63MG/3ML    T2            QL (120.00 per 30 days)


   63402051324     XOPENEX                                NEBU         1.25MG/3ML    T2            QL (120.00 per 30 days)


   63402051124     XOPENEX                                NEBU         0.31MG/3ML    T2            QL (120.00 per 30 days)


   63402051530     XOPENEX CONCENTRATE                    NEBU         1.25MG/0.5ML T2             QL (120.00 per 30 days)


   63402051001     XOPENEX HFA                            AERO         45MCG/ACT     T2




   (12:12.12) Autonomic Drugs » Adrenergics » a & ß Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   14629020101     EXTENDRYL PSE                          TB12         2.5MG; 120MG T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   66813055516     ENTEX                                  SUSP         22.5MG/5ML    T2

   49502050001     EPIPEN                                 DEVI         1:1000        T2

   49502050102     EPIPEN-JR 2-PAK                        DEVI         1:2000        T2

   63717026504     NASOFED                                SUSP         50MG/5ML      T2

   13436070002     TWINJECT                               DEVI         0.3MG/DOSE    T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                           Page 9 of 285
   13436070102     TWINJECT                               DEVI         0.15MG/DOSE   T2




   (12:16) Autonomic Drugs » Adrenergic Blockers
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   53489028101     ERGOLOID MESYLATES                     TABS         1MG           T1

   55390011301     PHENTOLAMINE MESYLATE                  SOLR         5MG           T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   65197000101     DIBENZYLINE                            CAPS         10MG          T2




   (12:20.04) Autonomic Drugs » Skeletal Muscle Relaxants » Centrally Acting Skeletal Muscle Relaxants
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00603258228     CARISOPRODOL                           TABS         350MG         T1

   00185074901     CARISOPRODOL /ASPIRIN /CODEINE         TABS         325MG;        T1
                                                                       200MG; 16MG
   00185072401     CARISOPRODOL/ASPIRIN                   TABS         325MG; 200MG T1

   00555058502     CHLORZOXAZONE                          TABS         500MG         T1

   50111056303     CYCLOBENZAPRINE HCL                    TABS         10MG          T1

   00378077101     CYCLOBENZAPRINE HCL                    TABS         5MG           T1

   00603448521     METHOCARBAMOL                          TABS         500MG         T1

   00603448621     METHOCARBAMOL                          TABS         750MG         T1

   55111018015     TIZANIDINE HCL                         TABS         4MG           T1

   55111017915     TIZANIDINE HCL                         TABS         2MG           T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00095030006     AMRIX                                  CP24         30MG          T2

   63459070060     AMRIX                                  CP24         15MG          T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 10 of 285
   68453095010     FEXMID                                 TABS         7.5MG      T2

   60977015071     ROBAXIN                                SOLN         100MG/ML   T2

   60793013601     SKELAXIN                               TABS         800MG      T2

   00037225010     SOMA                                   TABS         250MG      T2

   10144060215     ZANAFLEX                               CAPS         2MG        T2

   10144060415     ZANAFLEX                               CAPS         4MG        T2

   10144060615     ZANAFLEX                               CAPS         6MG        T2




   (12:20.08) Autonomic Drugs » Skeletal Muscle Relaxants » Direct-acting Skeletal Muscle Relaxants
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00115442201     DANTROLENE SODIUM                      CAPS         50MG       T1

   00115443301     DANTROLENE SODIUM                      CAPS         100MG      T1

   00115441101     DANTROLENE SODIUM                      CAPS         25MG       T1




   (12:20.12) Autonomic Drugs » Skeletal Muscle Relaxants » GABA-derivative Skeletal Muscle Relaxants
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00172409660     BACLOFEN                               TABS         10MG       T1

   00832102500     BACLOFEN                               TABS         20MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   58281056102     LIORESAL INTRATHECAL                   KIT          10MG/5ML   T2




   (12:20.92) Autonomic Drugs » Skeletal Muscle Relaxants » Skeletal Muscle Relaxants, Miscellaneous
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00591322247     ORPHENADRINE CITRATE                   SOLN         30MG/ML    T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 11 of 285
   55390005910     ORPHENADRINE CITRATE                   SOLN         30MG/ML       T1

   00185002201     ORPHENADRINE CITRATE ER                TB12         100MG         T1




   (12:92) Autonomic Drugs » Autonomic Drugs, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00069047197     CHANTIX                                MISC         0             T2

   00069046856     CHANTIX                                TABS         0.5MG         T2

   00069046997     CHANTIX                                TABS         1MG           T2

   00009540001     NICOTROL INHALER                       INHA         10MG          T2




   (20:04.04) Blood Regulators » Antianemia » Iron Preparations
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00485006501     ED CYTE F                              TABS         50MG; 324MG; T1
                                                                       1MG
   64376080201     FE C PLUS                              TABS         250MG;        T1
                                                                       25MCG; 1MG;
                                                                       100MG
   51991019811     FERREX 150 FORTE                       CAPS         25MCG; 1MG;   T1
                                                                       150MG
   53879020110     FERRO-PLEX HEMATINIC                   TABS         600MG;       T1
                                                                       25MCG; 50MG;
                                                                       345MG; 1MG;
                                                                       75MG; 30UNIT
   60258018901     FERROGELS FORTE                        CAPS         60MG; 10MCG; T1
                                                                       460MG; 1MG
   00536589001     FERROUS SULFATE                        TABS         325MG         T1

   00574060810     FERROUS SULFATE                        TBEC         324MG         T1

   00603076358     FERROUS SULFATE                        ELIX         220MG/5ML     T1

   10892011410     FETRIN                                 CPCR         60MG; 5MCG;   T1
                                                                       200MG; 0
   64980010503     FOLITAB                                TBCR         500MG;       T1
                                                                       525MG; 0.8MG
   00185538076     FOLTRIN                                CAPS         75MG; 15MCG; T1
                                                                       110MG;
                                                                       0.5MG; 240MG

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 12 of 285
   00277018101     FUMATINIC                              CPCR         60MG; 5MCG;   T1
                                                                       200MG; 0
   60258018001     HEMATINIC PLUS VITAMINS/MINERALS       TABS         10MG; 0.8MG; T1
                                                                       15MCG;
                                                                       324MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG; 5MG;
                                                                       6MG; 200MG;
                                                                       10MG; 18.2MG
   60258018101     HEMATINIC/FOLIC ACID                   TABS         324MG; 1MG    T1

   63044063119     HEMATOGEN                              CAPS         250MG;       T1
                                                                       10MCG;
                                                                       200MG; 100MG
   63044063217     HEMATOGEN FA                           CAPS         250MG;        T1
                                                                       10MCG;
                                                                       200MG; 1MG
   63044020361     IFEREX 150                             CAPS         150MG         T1

   51991012611     MULTIFOL                               TABS         60MG; 125MG; T1
                                                                       5MCG; 65MG;
                                                                       1MG; 15MG;
                                                                       2.5MG; 1.8MG;
                                                                       1.1MG;
                                                                       6000UNIT;
                                                                       400UNIT;
                                                                       30UNIT
   52152004814     MULTIRET FOLIC-500                     TBCR         500MG;       T1
                                                                       25MCG;
                                                                       525MG;
                                                                       0.8MG; 30MG;
                                                                       10MG; 5MG;
                                                                       6MG; 6MG
   59528445601     NEPHRON FA                             TABS         40MG;        T1
                                                                       300MCG;
                                                                       6MCG; 75MG;
                                                                       200MG; 1MG;
                                                                       20MG; 10MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG
   00642007416     VITAFOL                                SYRP         8.34MCG/5ML; T1
                                                                       100MG/5ML;
                                                                       0.25MG/5ML;
                                                                       13.3MG/5ML;
                                                                       2MG/5ML


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   64011019826     CHROMAGEN                              TABS         150MG; 2MG; T2
                                                                       10MCG; 50MG;
                                                                       70MG; 75MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 13 of 285
   64011019926     CHROMAGEN FA                           TABS         150MG; 2MG; T2
                                                                       10MCG; 70MG;
                                                                       1MG; 75MG
   64011019726     CHROMAGEN FORTE                        TABS         60MG; 0.8MG; T2
                                                                       10MCG; 50MG;
                                                                       101MG; 1MG;
                                                                       50MG
   11026275509     HEMATRON-AF                            TBCR         500MG;       T2
                                                                       150MCG;
                                                                       5MCG; 3MG;
                                                                       60MCG; 50MG;
                                                                       1MG; 75MG;
                                                                       150MG;
                                                                       150MCG;
                                                                       30UNIT
   52747080060     HEMOCYTE PLUS                          CAPS         10MG; 0.8MG; T2
                                                                       15MCG;
                                                                       324MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG; 5MG;
                                                                       6MG; 200MG;
                                                                       10MG; 18.2MG
   63717011201     ICAR-C PLUS SR                         CPCR         320MG;        T2
                                                                       25MCG; 1MG;
                                                                       100MG
   52544093102     INFED                                  SOLN         50MG/ML       T2

   52041004533     IROFOL                                 LIQD         1MG/5ML;      T2
                                                                       100MG/5ML
   52041004515     IROFOL                                 TABS         1MG; 150MG    T2

   64011016226     NIFEREX GOLD                           TABS         60MG; 0.8MG; T2
                                                                       25MCG; 50MG;
                                                                       50MG; 1MG;
                                                                       150MG; 50MG;
                                                                       10MG
   64011016326     NIFEREX-150                            CAPS         50MG; 0;      T2
                                                                       150MG; 0;
                                                                       50MG; 0
   64011016426     NIFEREX-150 FORTE                      CAPS         60MG; 0.8MG; T2
                                                                       25MCG; 50MG;
                                                                       1MG; 100MG;
                                                                       50MG
   67181021690     PROFERRIN-FORTE                        TABS         1MG; 12MG     T2

   64011020734     REPLIVA 21/7                           TABS         140MG; 60MG; T2
                                                                       0.8MG;
                                                                       10MCG; 70MG;
                                                                       81MG; 1MG;
                                                                       150MG
   52747090090     TANDEM                                 CAPS         162MG;        T2
                                                                       115.2MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 14 of 285
   52747090160     TANDEM F                               CAPS         162MG; 1MG;   T2
                                                                       115.2MG
   52747090260     TANDEM PLUS                            CAPS         10MG; 0.8MG; T2
                                                                       15MCG;
                                                                       162MG; 1MG;
                                                                       1.3MG; 30MG;
                                                                       115.2MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG;
                                                                       18.2MG




   (20:12.04.08) Blood Regulators » Antithrombotics » Anticoagulants » Coumarin Derivatives
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00555083202     WARFARIN SODIUM                        TABS         2.5MG         T1

   00555083102     WARFARIN SODIUM                        TABS         1MG           T1

   00555083302     WARFARIN SODIUM                        TABS         5MG           T1

   00555086902     WARFARIN SODIUM                        TABS         2MG           T1

   00555083502     WARFARIN SODIUM                        TABS         10MG          T1

   00555092502     WARFARIN SODIUM                        TABS         3MG           T1

   00555083402     WARFARIN SODIUM                        TABS         7.5MG         T1

   00555087402     WARFARIN SODIUM                        TABS         4MG           T1

   00555092602     WARFARIN SODIUM                        TABS         6MG           T1




   (20:12.04.16) Blood Regulators » Antithrombotics » Anticoagulants » Heparins
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   63323001710     HEP FLUSH-10                           SOLN         10UNIT/ML     T1

   00409115170     HEPARIN LOCK                           SOLN         10UNIT/ML     T1

   00409115278     HEPARIN LOCK                           SOLN         100UNIT/ML    T1

   68883001003     HEPARIN LOCK FLUSH                     SOLN         10UNIT/ML     T1

   68883010005     HEPARIN LOCK FLUSH                     SOLN         100UNIT/ML    T1

   00641039125     HEPARIN SODIUM                         SOLN         1000UNIT/ML   T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 15 of 285
   00641040025     HEPARIN SODIUM                         SOLN         5000UNIT/ML    T1

   00641041025     HEPARIN SODIUM                         SOLN         10000UNIT/ML T1

   63323091501     HEPARIN SODIUM DCU                     SOLN         20000UNIT/ML T1

   08290042005     HEPARIN SODIUM LOCK FLUSH              KIT          100UNIT/ML;    T1
                                                                       0.9%
   17474012505     MONOJECT PREFILL HEPARIN SODIUM LOCK SOLN           100UNIT/ML     T1
                   FLUSH


   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   62856010110     FRAGMIN                                INJ          10000UNIT/ML T2

   62856015010     FRAGMIN                                INJ          15000UNIT/0.6 T2
                                                                       ML
   62856025101     FRAGMIN                                INJ          25000UNIT/ML T2

   62856010201     FRAGMIN                                INJ          10000UNIT/ML T2

   62856025010     FRAGMIN                                INJ          2500UNIT/0.2   T2
                                                                       ML
   62856018010     FRAGMIN                                INJ          18000UNT/0.7 T2
                                                                       2ML
   62856050010     FRAGMIN                                INJ          5000UNIT/0.2   T2
                                                                       ML
   62856012510     FRAGMIN                                INJ          12500UNIT/0.5 T2
                                                                       ML
   62856075010     FRAGMIN                                INJ          7500UNIT/0.3   T2
                                                                       ML
   00409140231     HEPARIN SODIUM                         SOLN         5000UNIT/ML    T2

   67211034208     INNOHEP                                SOLN         20000UNIT/ML T2

   00075062430     LOVENOX                                SOLN         30MG/0.3ML     T2

   00075291201     LOVENOX                                SOLN         120MG/0.8ML    T2

   00075291501     LOVENOX                                SOLN         150MG/ML       T2

   00075062280     LOVENOX                                SOLN         80MG/0.8ML     T2

   00075062040     LOVENOX                                SOLN         40MG/0.4ML     T2

   00075062300     LOVENOX                                SOLN         100MG/ML       T2

   00075062160     LOVENOX                                SOLN         60MG/0.6ML     T2

   00075062603     LOVENOX                                SOLN         300MG/3ML      T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 16 of 285
   (20:12.04.92) Blood Regulators » Antithrombotics » Anticoagulants » Anticoagulants, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00007323211     ARIXTRA                                SOLN         5MG/0.4ML     T2

   00007323411     ARIXTRA                                SOLN         7.5MG/0.6ML   T2

   00007323611     ARIXTRA                                SOLN         10MG/0.8ML    T2

   00007323011     ARIXTRA                                SOLN         2.5MG/0.5ML   T2




   (20:12.18) Blood Regulators » Antithrombotics » Platelet-Aggregation Inhibitors
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00172524060     ANAGRELIDE HYDROCHLORIDE               CAPS         1MG           T1

   00172524160     ANAGRELIDE HYDROCHLORIDE               CAPS         0.5MG         T1

   00093723006     CILOSTAZOL                             TABS         50MG          T1

   00093723106     CILOSTAZOL                             TABS         100MG         T1

   00093015401     TICLOPIDINE HCL                        TABS         250MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00597000160     AGGRENOX                               CP12         25MG; 200MG   T2

   63653117106     PLAVIX                                 TABS         75MG          T2




   (20:16) Blood Regulators » Hematopoietics
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   55513000504     ARANESP ALBUMIN FREE                   SOLN         100MCG/ML     T2

   55513000601     ARANESP ALBUMIN FREE                   SOLN         200MCG/ML     T2

   55513003201     ARANESP ALBUMIN FREE                   SOLN         500MCG/ML     T2

   55513002704     ARANESP ALBUMIN FREE                   SOLN         150MCG/0.3ML T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 17 of 285
   55513002801     ARANESP ALBUMIN FREE                   SOLN         200MCG/0.4ML T2

   55513005304     ARANESP ALBUMIN FREE                   SOLN         150MCG/0.75M T2
                                                                       L
   55513005704     ARANESP ALBUMIN FREE                   SOLN         25MCG/0.42ML T2

   55513000204     ARANESP ALBUMIN FREE                   SOLN         25MCG/ML      T2

   55513000304     ARANESP ALBUMIN FREE                   SOLN         40MCG/ML      T2

   55513000404     ARANESP ALBUMIN FREE                   SOLN         60MCG/ML      T2

   55513002104     ARANESP ALBUMIN FREE                   SOLN         40MCG/0.4ML   T2

   55513002304     ARANESP ALBUMIN FREE                   SOLN         60MCG/0.3ML   T2

   55513002504     ARANESP ALBUMIN FREE                   SOLN         100MCG/0.5ML T2

   55513011001     ARANESP ALBUMIN FREE                   SOLN         300MCG/ML     T2

   55513011101     ARANESP ALBUMIN FREE                   SOLN         300MCG/0.6ML T2

   55513009201     ARANESP ALBUMIN FREE SURECLICK         SOLN         60MCG/0.3ML   T2

   55513009501     ARANESP ALBUMIN FREE SURECLICK         SOLN         200MCG/0.4ML T2

   55513009701     ARANESP ALBUMIN FREE SURECLICK         SOLN         500MCG/ML     T2

   55513009101     ARANESP ALBUMIN FREE SURECLICK         SOLN         40MCG/0.4ML   T2

   55513009401     ARANESP ALBUMIN FREE SURECLICK         SOLN         150MCG/0.3ML T2

   55513009001     ARANESP ALBUMIN FREE SURECLICK         SOLN         25MCG/0.42ML T2

   55513009301     ARANESP ALBUMIN FREE SURECLICK         SOLN         100MCG/0.5ML T2

   55513009601     ARANESP ALBUMIN FREE SURECLICK         SOLN         300MCG/0.6ML T2

   50419000233     LEUKINE                                SOLR         250MCG        T2

   50419059505     LEUKINE                                SOLN         500MCG/ML     T2

   55513019001     NEULASTA                               SOLN         6MG/0.6ML     T2   QL (0.60 per 21 days)


   58394000401     NEUMEGA                                SOLR         5MG           T2

   55513053010     NEUPOGEN                               SOLN         300MCG/ML     T2

   55513092410     NEUPOGEN                               SOLN         300MCG/0.5ML T2

   55513020910     NEUPOGEN                               SOLN         480MCG/0.8ML T2

   55513054610     NEUPOGEN                               SOLN         480MCG/1.6ML T2

   59676030201     PROCRIT                                SOLN         2000UNIT/ML   T2

   59676030401     PROCRIT                                SOLN         4000UNIT/ML   T2

   59676034001     PROCRIT                                SOLN         40000UNIT/ML T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 18 of 285
   59676031001     PROCRIT                                SOLN         10000UNIT/ML T2

   59676031201     PROCRIT                                SOLN         10000UNIT/ML T2

   59676030301     PROCRIT                                SOLN         3000UNIT/ML   T2

   59676032001     PROCRIT                                SOLN         20000UNIT/ML T2




   (20:24) Blood Regulators » Hemorrheologics
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093511601     PENTOXIFYLLINE ER                      TBCR         400MG         T1




   (20:28.16) Blood Regulators » Antihemorrhagics » Hemostatics
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   61748004416     AMINOCAPROIC ACID                      SYRP         25%           T1

   61748004501     AMINOCAPROIC ACID                      TABS         500MG         T1

   00026378660     KOGENATE FS                            KIT          2000UNIT      T1

   58394000502     REFACTO                                KIT          1000UNIT      T1

   58394000602     REFACTO                                KIT          500UNIT       T1

   52604710502     THROMBIN-JMI W/DIL SPRAY PUMP          KIT          20000UNIT     T1
                   ACTUATOR


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00944294210     ADVATE                                 SOLR         500UNIT       T2

   00944294310     ADVATE                                 SOLR         1000UNIT      T2

   00944294110     ADVATE                                 SOLR         250UNIT       T2

   00944294410     ADVATE                                 SOLR         1500UNIT      T2

   00944294610     ADVATE                                 SOLR         3000UNIT      T2

   00944294510     ADVATE                                 SOLR         2000UNIT      T2

   68516460002     ALPHANATE                              SOLR         1000-1500     T2
                                                                       UNIT


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 19 of 285
   66479002282     AMICAR                                 TABS         1000MG         T2

   64193024402     BEBULIN VH                             SOLR         200-1200 UNIT T2

   58394000106     BENEFIX                                SOLR         1000UNIT       T2

   58394000301     BENEFIX                                SOLR         250UNIT        T2

   58394000206     BENEFIX                                SOLR         500UNIT        T2

   58394000802     BENEFIX                                SOLR         2000UNIT       T2

   64193022204     FEIBA VH IMMUNO                        SOLR         0              T2

   64193022205     FEIBA VH IMMUNO                        SOLR         0              T2

   00009032301     GELFOAM SPONGE                         MISC         0              T2

   00944293503     HEMOFIL M                              SOLR         801-1700 UNIT T2

   00053761505     HUMATE-P                               SOLR         250UNIT;       T2
                                                                       600UNIT
   00053761520     HUMATE-P                               SOLR         1000UNIT;      T2
                                                                       2400UNIT
   00053762010     HUMATE-P                               SOLR         1000UNIT       T2

   00053761510     HUMATE-P                               SOLR         500UNIT;       T2
                                                                       1200UNIT
   00169706201     NOVOSEVEN                              SOLR         4800MCG        T2

   00169706001     NOVOSEVEN                              SOLR         1200MCG        T2

   00169706101     NOVOSEVEN                              SOLR         2400MCG        T2

   00944293801     RECOMBINATE                            SOLR         220-400 UNIT   T2

   00944293802     RECOMBINATE                            SOLR         401-800 UNIT   T2

   00944293803     RECOMBINATE                            SOLR         801-1240 UNIT T2

   58394001102     REFACTO                                KIT          2000UNIT       T2




   (24:04.04.04) Cardiovasculars » Cardiac Drugs » Antiarrhythmics » Antiarrhythmics Class Ia
   Tier: T1
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00591556001     DISOPYRAMIDE PHOSPHATE                 CAPS         100MG          T1

   00591556101     DISOPYRAMIDE PHOSPHATE                 CAPS         150MG          T1

   58177000204     DISOPYRAMIDE PHOSPHATE ER              CP12         150MG          T1

   00003077550     PRONESTYL SR                           TBCR         500MG          T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 20 of 285
   53489014101     QUINIDINE GLUCONATE CR                 TBCR         324MG      T1

   00591545401     QUINIDINE SULFATE                      TABS         300MG      T1

   00591543801     QUINIDINE SULFATE                      TABS         200MG      T1

   00093917501     QUINIDINE SULFATE ER                   TBCR         300MG      T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00025273231     NORPACE CR                             CP12         100MG      T2

   61570007101     PROCANBID                              TB12         1000MG     T2

   61570006901     PROCANBID                              TB12         500MG      T2

   00003075850     PRONESTYL                              CAPS         250MG      T2




   (24:04.04.08) Cardiovasculars » Cardiac Drugs » Antiarrhythmics » Antiarrhythmics Class Ib
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093873901     MEXILETINE HCL                         CAPS         150MG      T1

   00093874001     MEXILETINE HCL                         CAPS         200MG      T1

   00093874101     MEXILETINE HCL                         CAPS         250MG      T1




   (24:04.04.12) Cardiovasculars » Cardiac Drugs » Antiarrhythmics » Antiarrhythmics Class Ic
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00378850501     FLECAINIDE ACETATE                     TABS         50MG       T1

   00378851501     FLECAINIDE ACETATE                     TABS         150MG      T1

   00378851001     FLECAINIDE ACETATE                     TABS         100MG      T1

   00591058201     PROPAFENONE HCL                        TABS         150MG      T1

   00591058301     PROPAFENONE HCL                        TABS         225MG      T1

   58177033304     PROPAFENONE HCL                        TABS         300MG      T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 21 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   65726026115     RYTHMOL SR                             CP12         225MG       T2

   65726026215     RYTHMOL SR                             CP12         325MG       T2

   65726026315     RYTHMOL SR                             CP12         425MG       T2




   (24:04.04.20) Cardiovasculars » Cardiac Drugs » Antiarrhythmics » Antiarrhythmics Class III
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00185014460     AMIODARONE HCL                         TABS         200MG       T1

   51672405706     AMIODARONE HCL                         TABS         400MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00245014430     PACERONE                               TABS         100MG       T2

   00069581060     TIKOSYN                                CAPS         250MCG      T2

   00069580060     TIKOSYN                                CAPS         125MCG      T2

   00069582060     TIKOSYN                                CAPS         500MCG      T2




   (24:04.08) Cardiovasculars » Cardiac Drugs » Cardiotonics
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   62794014601     DIGITEK                                TABS         0.25MG      T1

   62794014510     DIGITEK                                TABS         0.125MG     T1

   00054005746     DIGOXIN                                SOLN         0.05MG/ML   T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 22 of 285
   (24:04.92) Cardiovasculars » Cardiac Drugs » Cardiac Drugs, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   67159011203     RANEXA                                 TB12         500MG       T2

   67159011403     RANEXA                                 TB12         1000MG      T2




   (24:06.04) Cardiovasculars » Antilipemics » Bile Acid Sequestrants
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00185094098     CHOLESTYRAMINE                         PACK         4GM         T1

   00185093998     CHOLESTYRAMINE LIGHT                   PACK         4GM         T1

   00115521116     COLESTIPOL HCL                         TABS         1GM         T1

   00115521302     COLESTIPOL HCL                         GRAN         5GM         T1

   00115521218     COLESTIPOL HCL FOR ORAL SUSPENSION     PACK         5GM         T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00009037003     COLESTID FLAVORED                      PACK         5GM/7.5GM   T2


   Tier: T3
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   65597070118     WELCHOL                                TABS         625MG       T3            MN




   (24:06.05) Cardiovasculars » Antilipemics » Cholesterol Absorption Inhib
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   66582041431     ZETIA                                  TABS         10MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 23 of 285
   (24:06.06) Cardiovasculars » Antilipemics » Fibric Acid Derivatives
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00115053301     FENOFIBRATE                            CAPS         200MG      T1

   63304090090     FENOFIBRATE                            TABS         54MG       T1

   63304090190     FENOFIBRATE                            TABS         160MG      T1

   00115051101     FENOFIBRATE                            CAPS         67MG       T1

   00115052201     FENOFIBRATE                            CAPS         134MG      T1

   00093067005     GEMFIBROZIL                            TABS         600MG      T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   66869014720     LIPOFEN                                CAPS         150MG      T2

   59630048030     TRIGLIDE                               TABS         50MG       T2

   59630048530     TRIGLIDE                               TABS         160MG      T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   67707004330     ANTARA                                 CAPS         43MG       T3            MN


   67707013030     ANTARA                                 CAPS         130MG      T3            MN


   00074612290     TRICOR                                 TABS         48MG       T3            MN


   00074612390     TRICOR                                 TABS         145MG      T3            MN




   (24:06.08) Cardiovasculars » Antilipemics » Statins
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00228263306     LOVASTATIN                             TABS         10MG       T1

   00228263406     LOVASTATIN                             TABS         20MG       T1

   00093092806     LOVASTATIN                             TABS         40MG       T1

   00093720198     PRAVASTATIN SODIUM                     TABS         20MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 24 of 285
   00378828077     PRAVASTATIN SODIUM                     TABS         80MG          T1

   00093077198     PRAVASTATIN SODIUM                     TABS         10MG          T1

   00093720298     PRAVASTATIN SODIUM                     TABS         40MG          T1

   00093715256     SIMVASTATIN                            TABS         5MG           T1

   00093715698     SIMVASTATIN                            TABS         80MG          T1

   00093715398     SIMVASTATIN                            TABS         10MG          T1

   00093715498     SIMVASTATIN                            TABS         20MG          T1

   00093715598     SIMVASTATIN                            TABS         40MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00074307290     ADVICOR                                TB24         20MG; 750MG   T2

   60598000990     ADVICOR                                TB24         40MG; 1000MG T2

   60598000690     ADVICOR                                TB24         20MG; 500MG   T2

   60598000890     ADVICOR                                TB24         20MG; 1000MG T2

   59630063030     ALTOPREV                               TB24         60MG          T2

   59630062830     ALTOPREV                               TB24         20MG          T2

   59630062930     ALTOPREV                               TB24         40MG          T2

   00078017605     LESCOL                                 CAPS         20MG          T2

   00078023405     LESCOL                                 CAPS         40MG          T2

   00078035405     LESCOL XL                              TB24         80MG          T2

   00071015623     LIPITOR                                TABS         20MG          T2

   00071015523     LIPITOR                                TABS         10MG          T2

   00071015723     LIPITOR                                TABS         40MG          T2

   00071015823     LIPITOR                                TABS         80MG          T2

   66582031231     VYTORIN                                TABS         10MG; 20MG    T2

   66582031331     VYTORIN                                TABS         10MG; 40MG    T2

   66582031531     VYTORIN                                TABS         10MG; 80MG    T2

   66582031131     VYTORIN                                TABS         10MG; 10MG    T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 25 of 285
   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00310075430     CRESTOR                                TABS         40MG          T3            MN


   00310075190     CRESTOR                                TABS         10MG          T3            MN


   00310075290     CRESTOR                                TABS         20MG          T3            MN


   00310075590     CRESTOR                                TABS         5MG           T3            MN




   (24:06.92) Cardiovasculars » Antilipemics » Antilipemic, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00074308090     NIASPAN                                TBCR         1000MG        T2

   00074307990     NIASPAN                                TBCR         750MG         T2

   00074307490     NIASPAN                                TBCR         500MG         T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   65726042515     LOVAZA                                 CAPS         375MG;        T3            MN
                                                                       465MG; 1GM




   (24:08.16) Cardiovasculars » Hypotensives » Central a-Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00378019901     CLONIDINE HCL                          TABS         0.3MG         T1

   00378015210     CLONIDINE HCL                          TABS         0.1MG         T1

   00378018601     CLONIDINE HCL                          TABS         0.2MG         T1

   62794002701     CLORPRES                               TABS         15MG; 0.2MG   T1

   62794007201     CLORPRES                               TABS         15MG; 0.3MG   T1

   62794000101     CLORPRES                               TABS         15MG; 0.1MG   T1

   00172422660     GUANABENZ ACETATE                      TABS         4MG           T1

   00172422760     GUANABENZ ACETATE                      TABS         8MG           T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 26 of 285
   00378116001     GUANFACINE HCL                         TABS         1MG           T1

   00378119001     GUANFACINE HCL                         TABS         2MG           T1

   00378042101     METHYLDOPA                             TABS         500MG         T1

   00378061101     METHYLDOPA                             TABS         250MG         T1

   00378050701     METHYLDOPA /HYDROCHLOROTHIAZIDE        TABS         15MG; 250MG   T1

   00378071101     METHYLDOPA /HYDROCHLOROTHIAZIDE        TABS         25MG; 250MG   T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00597003134     CATAPRES-TTS-1                         PTWK         0.1MG/24HR    T2

   00597003234     CATAPRES-TTS-2                         PTWK         0.2MG/24HR    T2

   00597003334     CATAPRES-TTS-3                         PTWK         0.3MG/24HR    T2




   (24:08.20) Cardiovasculars » Hypotensives » Direct Vasodilators
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   49884014301     HYDRALAZINE /HYDROCHLOROTHIAZIDE       CAPS         25MG; 25MG    T1

   49884014401     HYDRALAZINE /HYDROCHLOROTHIAZIDE       CAPS         50MG; 50MG    T1

   50111039801     HYDRALAZINE HCL                        TABS         10MG          T1

   50111032801     HYDRALAZINE HCL                        TABS         50MG          T1

   50111039701     HYDRALAZINE HCL                        TABS         100MG         T1

   49884002701     HYDRALAZINE HCL                        TABS         25MG          T1

   00591564201     MINOXIDIL                              TABS         2.5MG         T1

   00591564301     MINOXIDIL                              TABS         10MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00575620030     PROGLYCEM                              SUSP         50MG/ML       T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 27 of 285
   (24:08.24.04) Cardiovasculars » Hypotensives » Diuretics » Diuretics - Carb Anhydrase Inhib
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   51672402201     ACETAZOLAMIDE                          TABS         125MG      T1

   51672402301     ACETAZOLAMIDE                          TABS         250MG      T1

   00781107201     METHAZOLAMIDE                          TABS         25MG       T1

   00093942401     METHAZOLAMIDE                          TABS         50MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   51285075402     DIAMOX                                 CP12         500MG      T2




   (24:08.32) Cardiovasculars » Hypotensives » Peripheral Adrenergic Inhib
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00185013401     RESERPINE                              TABS         0.25MG     T1

   00185003201     RESERPINE                              TABS         0.1MG      T1




   (24:08.92) Cardiovasculars » Hypotensives » Hypotensives, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   17205062601     INVERSINE                              TABS         2.5MG      T2

   00078048515     TEKTURNA                               TABS         150MG      T2

   00078048615     TEKTURNA                               TABS         300MG      T2




   (24:12.08) Cardiovasculars » Vasodilators » Nitrates & Nitrites
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00143176501     ISOSORBIDE DINITRATE                   SUBL         2.5MG      T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 28 of 285
   00143176901     ISOSORBIDE DINITRATE                   TABS         5MG         T1

   00143177101     ISOSORBIDE DINITRATE                   TABS         10MG        T1

   00143177210     ISOSORBIDE DINITRATE                   TABS         20MG        T1

   49884000901     ISOSORBIDE DINITRATE                   TABS         30MG        T1

   00143176701     ISOSORBIDE DINITRATE                   SUBL         5MG         T1

   00258361301     ISOSORBIDE DINITRATE ER                TBCR         40MG        T1

   62175010701     ISOSORBIDE MONONITRATE                 TABS         20MG        T1

   62175010601     ISOSORBIDE MONONITRATE                 TABS         10MG        T1

   58177020104     ISOSORBIDE MONONITRATE ER              TB24         120MG       T1

   58177023804     ISOSORBIDE MONONITRATE ER              TB24         60MG        T1

   58177022204     ISOSORBIDE MONONITRATE ER              TB24         30MG        T1

   58177000603     NITROGLYCERIN ER                       CPCR         9MG         T1

   58177000504     NITROGLYCERIN ER                       CPCR         6.5MG       T1

   58177000404     NITROGLYCERIN ER                       CPCR         2.5MG       T1

   00378910493     NITROGLYCERIN TRANSDERMAL              PT24         0.2MG/HR    T1

   00378911693     NITROGLYCERIN TRANSDERMAL              PT24         0.6MG/HR    T1

   00378910293     NITROGLYCERIN TRANSDERMAL              PT24         0.1MG/HR    T1

   00378911293     NITROGLYCERIN TRANSDERMAL              PT24         0.4MG/HR    T1

   58177032418     NITROQUICK                             SUBL         0.4MG       T1

   58177032504     NITROQUICK                             SUBL         0.6MG       T1

   58177032304     NITROQUICK                             SUBL         0.3MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   12948000112     BIDIL                                  TABS         37.5MG; 20MG T2

   00091092001     DILATRATE SR                           CPCR         40MG        T2

   64455019201     ISORDIL TITRADOSE                      TABS         40MG        T2

   00168032660     NITRO-BID                              OINT         2%          T2

   00085331530     NITRO-DUR                              PT24         0.3MG/HR    T2

   00085081930     NITRO-DUR                              PT24         0.8MG/HR    T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 29 of 285
   59630030020     NITROLINGUAL PUMPSPRAY                 SOLN         0.4MG/SPRAY   T2




   (24:12.12) Cardiovasculars » Vasodilators » Phosphodiesterase Inhib
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details                        Comment

   00085192301     LEVITRA                                TABS         2.5MG         T2            PA; GL (m); QL (6.00 per 30 days)


   00085193401     LEVITRA                                TABS         20MG          T2            PA; GL (m); QL (6.00 per 30 days)


   00085194501     LEVITRA                                TABS         5MG           T2            PA; GL (m); QL (6.00 per 30 days)


   00085190101     LEVITRA                                TABS         10MG          T2            PA; GL (m); QL (6.00 per 30 days)


   00069419068     REVATIO                                TABS         20MG          T2            PA




   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details                        Comment

   00002446230     CIALIS                                 TABS         5MG           T3            PA; MN; GL (m); QL (6.00 per 30 days)


   00002446330     CIALIS                                 TABS         10MG          T3            PA; MN; GL (m); QL (6.00 per 30 days)


   00002446430     CIALIS                                 TABS         20MG          T3            PA; MN; GL (m); QL (6.00 per 30 days)


   00069421030     VIAGRA                                 TABS         50MG          T3            PA; MN; GL (m); QL (6.00 per 30 days)


   00069422030     VIAGRA                                 TABS         100MG         T3            PA; MN; GL (m); QL (6.00 per 30 days)


   00069420030     VIAGRA                                 TABS         25MG          T3            PA; MN; GL (m); QL (6.00 per 30 days)




   (24:12.92) Cardiovasculars » Vasodilators » Vasodilators, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details                        Comment

   00009768604     CAVERJECT                              SOLR         40MCG         T1            QL (6.00 per 30 days)


   00555025202     DIPYRIDAMOLE                           TABS         25MG          T1

   00555028602     DIPYRIDAMOLE                           TABS         75MG          T1

   00555028502     DIPYRIDAMOLE                           TABS         50MG          T1

   00781184001     ISOXSUPRINE HCL                        TABS         10MG          T1

   00781184201     ISOXSUPRINE HCL                        TABS         20MG          T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                         Page 30 of 285
   66758001501     PAPAVERINE HCL                         SOLN         30MG/ML     T1

   00185515601     PAPAVERINE HCL CR                      CPCR         150MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   00009370105     CAVERJECT                              SOLR         20MCG       T2            QL (6.00 per 30 days)


   00009518201     CAVERJECT IMPULSE                      KIT          20MCG       T2            QL (6.00 per 30 days)


   00009518101     CAVERJECT IMPULSE                      KIT          10MCG       T2            QL (6.00 per 30 days)


   00091114016     EDEX                                   KIT          40MCG       T2            QL (6.00 per 30 days)


   61958080102     LETAIRIS                               TABS         5MG         T2

   61958080202     LETAIRIS                               TABS         10MG        T2

   62541012006     MUSE                                   PLLT         250MCG      T2            QL (6.00 per 30 days)


   62541014006     MUSE                                   PLLT         1000MCG     T2            QL (6.00 per 30 days)


   62541013006     MUSE                                   PLLT         500MCG      T2            QL (6.00 per 30 days)


   62541011006     MUSE                                   PLLT         125MCG      T2            QL (6.00 per 30 days)


   00009316906     PROSTIN VR PEDIATRIC                   SOLN         500MCG/ML   T2

   66215010206     TRACLEER                               TABS         125MG       T2

   66215010106     TRACLEER                               TABS         62.5MG      T2

   10148010230     VENTAVIS                               SOLN         10MCG/ML    T2

   10148010130     VENTAVIS                               SOLN         10MCG/ML    T2




   (24:20) Cardiovasculars » a-Adrenergic Blockers
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   60505009500     DOXAZOSIN MESYLATE                     TABS         4MG         T1

   60505009300     DOXAZOSIN MESYLATE                     TABS         1MG         T1

   60505009400     DOXAZOSIN MESYLATE                     TABS         2MG         T1

   60505009600     DOXAZOSIN MESYLATE                     TABS         8MG         T1

   00378230201     PRAZOSIN HCL                           CAPS         2MG         T1

   00378110101     PRAZOSIN HCL                           CAPS         1MG         T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 31 of 285
   00378320501     PRAZOSIN HCL                           CAPS         5MG           T1

   00781205201     TERAZOSIN HCL                          CAPS         2MG           T1

   00781205101     TERAZOSIN HCL                          CAPS         1MG           T1

   00781205301     TERAZOSIN HCL                          CAPS         5MG           T1

   00781205401     TERAZOSIN HCL                          CAPS         10MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00049272030     CARDURA XL                             TB24         8MG           T2

   00049271030     CARDURA XL                             TB24         4MG           T2




   (24:24) Cardiovasculars » ß-Adrenergic Blockers
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00378120001     ACEBUTOLOL HCL                         CAPS         200MG         T1

   00378140001     ACEBUTOLOL HCL                         CAPS         400MG         T1

   00781107810     ATENOLOL                               TABS         25MG          T1

   00378075701     ATENOLOL                               TABS         100MG         T1

   00378023110     ATENOLOL                               TABS         50MG          T1

   00378206401     ATENOLOL/CHLORTHALIDONE                TABS         100MG; 25MG   T1

   00378206301     ATENOLOL/CHLORTHALIDONE                TABS         50MG; 25MG    T1

   52152017902     BETAXOLOL HCL                          TABS         10MG          T1

   52152018002     BETAXOLOL HCL                          TABS         20MG          T1

   00185077130     BISOPROLOL FUMARATE                    TABS         5MG           T1

   00185077430     BISOPROLOL FUMARATE                    TABS         10MG          T1

   00378050301     BISOPROLOL                             TABS         5MG; 6.25MG   T1
                   FUMARATE/HYDROCHLOROTHIAZIDE
   00378050501     BISOPROLOL                             TABS         10MG; 6.25MG T1
                   FUMARATE/HYDROCHLOROTHIAZIDE
   00378050101     BISOPROLOL                             TABS         2.5MG;        T1
                   FUMARATE/HYDROCHLOROTHIAZIDE                        6.25MG
   00185001001     LABETALOL HCL                          TABS         100MG         T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 32 of 285
   00185011701     LABETALOL HCL                          TABS         200MG         T1

   00185011801     LABETALOL HCL                          TABS         300MG         T1

   00378042401     METOPROLOL /HYDROCHLOROTHIAZIDE        TABS         25MG; 50MG    T1

   00378043401     METOPROLOL /HYDROCHLOROTHIAZIDE        TABS         25MG; 100MG   T1

   00378044501     METOPROLOL /HYDROCHLOROTHIAZIDE        TABS         50MG; 100MG   T1

   49884040701     METOPROLOL SUCCINATE ER                TB24         200MG         T1

   00185028101     METOPROLOL SUCCINATE ER                TB24         25MG          T1

   49884040501     METOPROLOL SUCCINATE ER                TB24         50MG          T1

   49884040601     METOPROLOL SUCCINATE ER                TB24         100MG         T1

   00378001801     METOPROLOL TARTRATE                    TABS         25MG          T1

   00378003210     METOPROLOL TARTRATE                    TABS         50MG          T1

   00378004710     METOPROLOL TARTRATE                    TABS         100MG         T1

   00378002801     NADOLOL                                TABS         20MG          T1

   00378113201     NADOLOL                                TABS         80MG          T1

   00378117101     NADOLOL                                TABS         40MG          T1

   00378005201     PINDOLOL                               TABS         5MG           T1

   00378012701     PINDOLOL                               TABS         10MG          T1

   00378073101     PROPRANOLOL /HYDROCHLOROTHIAZIDE       TABS         25MG; 40MG    T1

   00378034701     PROPRANOLOL /HYDROCHLOROTHIAZIDE       TABS         25MG; 80MG    T1

   50111047001     PROPRANOLOL HCL                        TABS         60MG          T1

   00591555601     PROPRANOLOL HCL                        TABS         40MG          T1

   00591555401     PROPRANOLOL HCL                        TABS         10MG          T1

   00591555501     PROPRANOLOL HCL                        TABS         20MG          T1

   00591555701     PROPRANOLOL HCL                        TABS         80MG          T1

   49884028201     PROPRANOLOL HCL ER                     CP24         60MG          T1

   49884032801     PROPRANOLOL HCL ER                     CP24         80MG          T1

   49884032901     PROPRANOLOL HCL ER                     CP24         120MG         T1

   49884033001     PROPRANOLOL HCL ER                     CP24         160MG         T1

   00093106301     SOTALOL HCL                            TABS         240MG         T1

   00093106201     SOTALOL HCL                            TABS         160MG         T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 33 of 285
   00185017101     SOTALOL HCL                            TABS         80MG        T1

   00093106001     SOTALOL HCL                            TABS         120MG       T1

   00378005501     TIMOLOL MALEATE                        TABS         5MG         T1

   00378071501     TIMOLOL MALEATE                        TABS         20MG        T1

   00378022101     TIMOLOL MALEATE                        TABS         10MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00007414220     COREG                                  TABS         25MG        T2

   00007413920     COREG                                  TABS         3.125MG     T2

   00007414020     COREG                                  TABS         6.25MG      T2

   00007414120     COREG                                  TABS         12.5MG      T2

   00007337113     COREG CR                               CP24         20MG        T2

   00007337213     COREG CR                               CP24         40MG        T2

   00007337313     COREG CR                               CP24         80MG        T2

   00007337013     COREG CR                               CP24         10MG        T2

   60793028301     CORZIDE                                TABS         5MG; 40MG   T2

   60793028401     CORZIDE                                TABS         5MG; 80MG   T2

   65726025010     INNOPRAN XL                            CP24         80MG        T2

   65726025110     INNOPRAN XL                            CP24         120MG       T2

   00091450015     LEVATOL                                TABS         20MG        T2

   00054373063     PROPRANOLOL HCL                        SOLN         40MG/5ML    T2

   00054372763     PROPRANOLOL HCL                        SOLN         20MG/5ML    T2

   00186109005     TOPROL XL                              TB24         50MG        T2




   (24:28.08) Cardiovasculars » Calcium-Channel Blockers » CCBs - Dihydropyridines
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00378520977     AMLODIPINE BESYLATE                    TABS         5MG         T1

   00378520877     AMLODIPINE BESYLATE                    TABS         2.5MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 34 of 285
   00378521077     AMLODIPINE BESYLATE                    TABS         10MG          T1

   00093737301     AMLODIPINE BESYLATE/BENAZEPRIL         CAPS         10MG; 20MG    T1
                   HYDROCHLORIDE
   00093737201     AMLODIPINE BESYLATE/BENAZEPRIL         CAPS         5MG; 20MG     T1
                   HYDROCHLORIDE
   00093737001     AMLODIPINE BESYLATE/BENAZEPRIL         CAPS         2.5MG; 10MG   T1
                   HYDROCHLORIDE
   00093737101     AMLODIPINE BESYLATE/BENAZEPRIL         CAPS         5MG; 10MG     T1
                   HYDROCHLORIDE
   53489036801     FELODIPINE ER                          TB24         2.5MG         T1

   53489036901     FELODIPINE ER                          TB24         5MG           T1

   53489037001     FELODIPINE ER                          TB24         10MG          T1

   00093102201     NIFEDIAC CC                            TB24         60MG          T1

   00093102301     NIFEDIAC CC                            TB24         90MG          T1

   00093527201     NIFEDIAC CC                            TB24         30MG          T1

   00228249710     NIFEDIPINE                             CAPS         10MG          T1

   00378348201     NIFEDIPINE ER                          TB24         60MG          T1

   00378347501     NIFEDIPINE ER                          TB24         30MG          T1

   00378349501     NIFEDIPINE ER                          TB24         90MG          T1

   57664013564     NIMODIPINE                             CAPS         30MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00078049115     EXFORGE                                TABS         10MG; 320MG   T2            MN


   00078048815     EXFORGE                                TABS         5MG; 160MG    T2            MN


   00078048915     EXFORGE                                TABS         10MG; 160MG   T2            MN


   00078049015     EXFORGE                                TABS         5MG; 320MG    T2            MN


   00078037905     LOTREL                                 CAPS         10MG; 40MG    T2

   00078038405     LOTREL                                 CAPS         5MG; 40MG     T2

   00228253010     NIFEDIPINE                             CAPS         20MG          T2

   59630044010     SULAR                                  TB24         10MG          T2

   59630044110     SULAR                                  TB24         20MG          T2

   59630044210     SULAR                                  TB24         30MG          T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 35 of 285
   59630044310     SULAR                                  TB24         40MG          T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00069215030     CADUET                                 TABS         5MG; 10MG     T3            MN


   00069217030     CADUET                                 TABS         5MG; 20MG     T3            MN


   00069219030     CADUET                                 TABS         5MG; 40MG     T3            MN


   00069296030     CADUET                                 TABS         2.5MG; 10MG   T3            MN


   00069216030     CADUET                                 TABS         10MG; 10MG    T3            MN


   00069225030     CADUET                                 TABS         10MG; 40MG    T3            MN


   00069227030     CADUET                                 TABS         10MG; 80MG    T3            MN


   00069298030     CADUET                                 TABS         2.5MG; 40MG   T3            MN


   00069226030     CADUET                                 TABS         5MG; 80MG     T3            MN


   00069218030     CADUET                                 TABS         10MG; 20MG    T3            MN


   00069297030     CADUET                                 TABS         2.5MG; 20MG   T3            MN


   67286081203     CARDENE I.V.                           SOLN         2.5MG/ML      T3

   67286081304     CARDENE SR                             CP12         45MG          T3            MN


   67286081404     CARDENE SR                             CP12         30MG          T3            MN


   67286081504     CARDENE SR                             CP12         60MG          T3            MN


   65726023610     DYNACIRC CR                            TB24         10MG          T3            MN


   65726023510     DYNACIRC-CR                            TB24         5MG           T3            MN


   16252053901     ISRADIPINE                             CAPS         2.5MG         T3            MN


   16252054001     ISRADIPINE                             CAPS         5MG           T3            MN


   00186000131     LEXXEL                                 TBCR         5MG; 5MG      T3            MN


   00378143077     NICARDIPINE HCL                        CAPS         30MG          T3

   00093079401     NICARDIPINE HCL                        CAPS         30MG          T3            MN


   00093079301     NICARDIPINE HCL                        CAPS         20MG          T3            MN


   00378102077     NICARDIPINE HCL                        CAPS         20MG          T3

   00069152068     NORVASC                                TABS         2.5MG         T3

   00069154068     NORVASC                                TABS         10MG          T3




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 36 of 285
   00069153068     NORVASC                                TABS         5MG        T3




   (24:28.92) Cardiovasculars » Calcium-Channel Blockers » CCBs, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   62037059790     CARTIA XT                              CP24         120MG      T1

   62037059890     CARTIA XT                              CP24         180MG      T1

   62037059990     CARTIA XT                              CP24         240MG      T1

   62037060090     CARTIA XT                              CP24         300MG      T1

   00378052501     DILTIAZEM HCL                          TABS         120MG      T1

   00378013501     DILTIAZEM HCL                          TABS         90MG       T1

   00378004501     DILTIAZEM HCL                          TABS         60MG       T1

   00378002301     DILTIAZEM HCL                          TABS         30MG       T1

   00378606001     DILTIAZEM HCL ER                       CP12         60MG       T1

   00378528001     DILTIAZEM HCL ER                       CP24         180MG      T1

   00378612001     DILTIAZEM HCL ER                       CP12         120MG      T1

   58177006619     DILTIAZEM HCL ER                       CP24         420MG      T1

   00378522001     DILTIAZEM HCL ER                       CP24         120MG      T1

   00378534001     DILTIAZEM HCL ER                       CP24         240MG      T1

   00378609001     DILTIAZEM HCL ER                       CP12         90MG       T1

   58177006526     DILTIAZEM HCL ER                       CP24         360MG      T1

   62037069890     TAZTIA XT                              CP24         240MG      T1

   62037069630     TAZTIA XT                              CP24         120MG      T1

   62037069930     TAZTIA XT                              CP24         300MG      T1

   62037069790     TAZTIA XT                              CP24         180MG      T1

   00378051201     VERAPAMIL HCL                          TABS         80MG       T1

   00378077201     VERAPAMIL HCL                          TABS         120MG      T1

   00409114402     VERAPAMIL HCL                          SOLN         2.5MG/ML   T1

   00591040401     VERAPAMIL HCL                          TABS         40MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 37 of 285
   00378041105     VERAPAMIL HCL ER                       TBCR         240MG        T1

   00172428660     VERAPAMIL HCL ER                       TBCR         180MG        T1

   00378112001     VERAPAMIL HCL ER                       TBCR         120MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   64455079942     CARDIZEM CD                            CP24         360MG        T2            MN




   Tier: T3
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   60598012230     CARDIZEM LA                            TB24         240MG        T3            MN


   60598012430     CARDIZEM LA                            TB24         360MG        T3            MN


   60598012030     CARDIZEM LA                            TB24         120MG        T3            MN


   60598012330     CARDIZEM LA                            TB24         300MG        T3            MN


   60598012530     CARDIZEM LA                            TB24         420MG        T3            MN


   60598012130     CARDIZEM LA                            TB24         180MG        T3            MN


   00025201131     COVERA-HS                              TB24         180MG        T3            MN


   00025202131     COVERA-HS                              TB24         240MG        T3            MN


   00074328813     TARKA                                  TBCR         1MG; 240MG   T3            MN


   00074329013     TARKA                                  TBCR         4MG; 240MG   T3            MN


   00074328913     TARKA                                  TBCR         2MG; 240MG   T3            MN


   00074328713     TARKA                                  TBCR         2MG; 180MG   T3            MN


   00378632001     VERAPAMIL HCL ER                       CP24         120MG        T3

   00378644001     VERAPAMIL HCL ER                       CP24         240MG        T3

   00378638001     VERAPAMIL HCL ER                       CP24         180MG        T3

   00591288601     VERAPAMIL HCL SR                       CP24         360MG        T3

   00091408501     VERELAN PM                             CP24         100MG        T3            MN


   00091408701     VERELAN PM                             CP24         300MG        T3            MN


   00091408601     VERELAN PM                             CP24         200MG        T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 38 of 285
   (24:32.04) Cardiovasculars » Renin-Angiotensin-Aldosterone Inhib » ACE Inhibitors
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093512501     BENAZEPRIL HCL                         TABS         10MG          T1

   00093512401     BENAZEPRIL HCL                         TABS         5MG           T1

   00093512601     BENAZEPRIL HCL                         TABS         20MG          T1

   00093512701     BENAZEPRIL HCL                         TABS         40MG          T1

   00378474501     BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE     TABS         20MG; 12.5MG T1

   00378477501     BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE     TABS         20MG; 25MG    T1

   00378473501     BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE     TABS         10MG; 12.5MG T1

   00378472501     BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE     TABS         5MG; 6.25MG   T1

   00143117101     CAPTOPRIL                              TABS         12.5MG        T1

   00143117201     CAPTOPRIL                              TABS         25MG          T1

   00143117401     CAPTOPRIL                              TABS         100MG         T1

   00143117301     CAPTOPRIL                              TABS         50MG          T1

   00378008401     CAPTOPRIL /HYDROCHLOROTHIAZIDE         TABS         50MG; 15MG    T1

   00378008101     CAPTOPRIL /HYDROCHLOROTHIAZIDE         TABS         25MG; 15MG    T1

   00378008301     CAPTOPRIL /HYDROCHLOROTHIAZIDE         TABS         25MG; 25MG    T1

   00378008601     CAPTOPRIL /HYDROCHLOROTHIAZIDE         TABS         50MG; 25MG    T1

   00378105101     ENALAPRIL MALEATE                      TABS         2.5MG         T1

   00093002801     ENALAPRIL MALEATE                      TABS         10MG          T1

   64679092402     ENALAPRIL MALEATE                      TABS         5MG           T1

   64679092602     ENALAPRIL MALEATE                      TABS         20MG          T1

   00093104401     ENALAPRIL                              TABS         5MG; 12.5MG   T1
                   MALEATE/HYDROCHLOROTHIAZIDE
   00093105201     ENALAPRIL                              TABS         10MG; 25MG    T1
                   MALEATE/HYDROCHLOROTHIAZIDE
   00093722298     FOSINOPRIL SODIUM                      TABS         10MG          T1

   00093722398     FOSINOPRIL SODIUM                      TABS         20MG          T1

   00093722498     FOSINOPRIL SODIUM                      TABS         40MG          T1

   63304040301     FOSINOPRIL                             TABS         10MG; 12.5MG T1
                   SODIUM/HYDROCHLOROTHIAZIDE



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 39 of 285
   63304040401     FOSINOPRIL                             TABS         20MG; 12.5MG T1
                   SODIUM/HYDROCHLOROTHIAZIDE
   68180051201     LISINOPRIL                             TABS         2.5MG        T1

   68180051403     LISINOPRIL                             TABS         10MG         T1

   68180051503     LISINOPRIL                             TABS         20MG         T1

   68180051601     LISINOPRIL                             TABS         30MG         T1

   68180051303     LISINOPRIL                             TABS         5MG          T1

   68180051703     LISINOPRIL                             TABS         40MG         T1

   00591086001     LISINOPRIL /HYDROCHLOROTHIAZIDE        TABS         12.5MG; 10MG T1

   00591086201     LISINOPRIL /HYDROCHLOROTHIAZIDE        TABS         25MG; 20MG   T1

   00591086101     LISINOPRIL /HYDROCHLOROTHIAZIDE        TABS         12.5MG; 20MG T1

   59762502001     QUINAPRIL HCL                          TABS         10MG         T1

   59762501901     QUINAPRIL HCL                          TABS         5MG          T1

   59762502101     QUINAPRIL HCL                          TABS         20MG         T1

   59762502201     QUINAPRIL HCL                          TABS         40MG         T1

   00093732501     TRANDOLAPRIL                           TABS         1MG          T1

   00093732601     TRANDOLAPRIL                           TABS         2MG          T1

   00093732701     TRANDOLAPRIL                           TABS         4MG          T1


   Tier: T3
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00071053523     ACCUPRIL                               TABS         40MG         T3

   00071053223     ACCUPRIL                               TABS         20MG         T3

   00071052723     ACCUPRIL                               TABS         5MG          T3

   00071053023     ACCUPRIL                               TABS         10MG         T3

   00071022023     ACCURETIC                              TABS         12.5MG; 20MG T3

   00071022323     ACCURETIC                              TABS         25MG; 20MG   T3

   00071022223     ACCURETIC                              TABS         12.5MG; 10MG T3

   00032110201     ACEON                                  TABS         4MG          T3            MN


   00032110301     ACEON                                  TABS         8MG          T3            MN


   00032110101     ACEON                                  TABS         2MG          T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 40 of 285
   61570011001     ALTACE                                 CAPS         1.25MG       T3            MN


   61570012001     ALTACE                                 CAPS         10MG         T3            MN


   61570011101     ALTACE                                 CAPS         2.5MG        T3            MN


   61570011201     ALTACE                                 CAPS         5MG          T3            MN


   00093521301     MOEXIPRIL /HYDROCHLOROTHIAZIDE         TABS         12.5MG;      T3
                                                                       7.5MG
   00093521501     MOEXIPRIL /HYDROCHLOROTHIAZIDE         TABS         25MG; 15MG   T3

   62175072037     MOEXIPRIL /HYDROCHLOROTHIAZIDE         TABS         12.5MG; 15MG T3

   62175017737     MOEXIPRIL HCL                          TABS         15MG         T3

   62175017137     MOEXIPRIL HCL                          TABS         7.5MG        T3

   52152023930     QUINARETIC                             TABS         12.5MG; 20MG T3

   52152023830     QUINARETIC                             TABS         12.5MG; 10MG T3

   52152024030     QUINARETIC                             TABS         25MG; 20MG   T3

   00091371201     UNIRETIC                               TABS         12.5MG;      T3            MN
                                                                       7.5MG
   00091372001     UNIRETIC                               TABS         12.5MG; 15MG T3            MN


   00091372501     UNIRETIC                               TABS         25MG; 15MG   T3            MN


   00091371501     UNIVASC                                TABS         15MG         T3            MN


   00091370701     UNIVASC                                TABS         7.5MG        T3            MN




   (24:32.08) Cardiovasculars » Renin-Angiotensin-Aldosterone Inhib » ARBs
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00186000431     ATACAND                                TABS         4MG          T2

   00186000831     ATACAND                                TABS         8MG          T2

   00186001631     ATACAND                                TABS         16MG         T2

   00186003231     ATACAND                                TABS         32MG         T2

   00186016254     ATACAND HCT                            TABS         16MG; 12.5MG T2

   00186032254     ATACAND HCT                            TABS         32MG; 12.5MG T2

   00006095154     COZAAR                                 TABS         25MG         T2

   00006095254     COZAAR                                 TABS         50MG         T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 41 of 285
   00006096031     COZAAR                                 TABS         100MG         T2

   00006074731     HYZAAR                                 TABS         25MG; 100MG   T2

   00006071731     HYZAAR                                 TABS         12.5MG; 50MG T2

   00006074531     HYZAAR                                 TABS         12.5MG;       T2
                                                                       100MG
   00597003937     MICARDIS                               TABS         20MG          T2

   00597004037     MICARDIS                               TABS         40MG          T2

   00597004137     MICARDIS                               TABS         80MG          T2

   00597004237     MICARDIS HCT                           TABS         25MG; 80MG    T2

   00597004337     MICARDIS HCT                           TABS         12.5MG; 40MG T2

   00597004437     MICARDIS HCT                           TABS         12.5MG; 80MG T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00087278831     AVALIDE                                TABS         25MG; 300MG   T3            MN


   00087277531     AVALIDE                                TABS         12.5MG;       T3            MN
                                                                       150MG
   00087277631     AVALIDE                                TABS         12.5MG;       T3            MN
                                                                       300MG
   00087277232     AVAPRO                                 TABS         150MG         T3            MN


   00087277332     AVAPRO                                 TABS         300MG         T3            MN


   00087277132     AVAPRO                                 TABS         75MG          T3            MN


   65597010130     BENICAR                                TABS         5MG           T3            MN


   65597010330     BENICAR                                TABS         20MG          T3            MN


   65597010430     BENICAR                                TABS         40MG          T3            MN


   65597010630     BENICAR HCT                            TABS         12.5MG; 40MG T3             MN


   65597010530     BENICAR HCT                            TABS         12.5MG; 20MG T3             MN


   65597010730     BENICAR HCT                            TABS         25MG; 40MG    T3            MN


   00078035834     DIOVAN                                 TABS         80MG          T3            MN


   00078035934     DIOVAN                                 TABS         160MG         T3            MN


   00078036034     DIOVAN                                 TABS         320MG         T3            MN


   00078042315     DIOVAN                                 TABS         40MG          T3            MN


   00078047134     DIOVAN HCT                             TABS         12.5MG;       T3            MN
                                                                       320MG

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 42 of 285
   00078031434     DIOVAN HCT                             TABS         12.5MG; 80MG T3             MN


   00078038334     DIOVAN HCT                             TABS         25MG; 160MG   T3            MN


   00078031534     DIOVAN HCT                             TABS         12.5MG;       T3            MN
                                                                       160MG
   00078047234     DIOVAN HCT                             TABS         25MG; 320MG   T3            MN


   60598010101     TEVETEN                                TABS         600MG         T3            MN


   60598010001     TEVETEN                                TABS         400MG         T3            MN


   60598008001     TEVETEN HCT                            TABS         600MG;        T3            MN
                                                                       12.5MG
   60598008101     TEVETEN HCT                            TABS         600MG; 25MG   T3            MN




   (24:32.20) Cardiovasculars » Renin-Angiotensin-Aldosterone Inhib » Aldosterone Receptor Antagonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00228267311     SPIRONOLACTONE                         TABS         100MG         T1

   00228267211     SPIRONOLACTONE                         TABS         50MG          T1

   00378214601     SPIRONOLACTONE                         TABS         25MG          T1

   00378014101     SPIRONOLACTONE /HYDROCHLOROTHIAZID TABS             25MG; 25MG    T1
                   E


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00025102131     ALDACTAZIDE                            TABS         50MG; 50MG    T2

   00025171001     INSPRA                                 TABS         25MG          T2

   00025172003     INSPRA                                 TABS         50MG          T2




   (28:08.04.08) CNS Agents » Analgesics & Antipyretics » NSAIDs » COX-2 Inhib
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00025152031     CELEBREX                               CAPS         100MG         T2

   00025152531     CELEBREX                               CAPS         200MG         T2

   00025153002     CELEBREX                               CAPS         400MG         T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 43 of 285
   00025151501     CELEBREX                               CAPS         50MG        T2




   (28:08.04.24) CNS Agents » Analgesics & Antipyretics » NSAIDs » Salicylates
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00536308641     ASPIRIN EC                             TBEC         81MG        T1

   00527155201     BUTAL/ASA/CAFF                         CAPS         325MG; 50MG; T1
                                                                       40MG
   00143178501     BUTALBITAL /ASPIRIN /CAFFEINE          TABS         325MG; 50MG; T1
                                                                       40MG
   00182142095     CHILDRENS ASPIRIN                      CHEW         81MG        T1

   50111052801     CHOLINE MAGNESIUM TRISALICYLATE        TABS         500MG       T1

   60258009008     CHOLINE MAGNESIUM TRISALICYLATE        LIQD         500MG/5ML   T1

   50111052901     CHOLINE MAGNESIUM TRISALICYLATE        TABS         750MG       T1

   50111053001     CHOLINE MAGNESIUM TRISALICYLATE        TABS         1000MG      T1

   00225036035     MOBISYL                                CREA         10%         T1

   60258010601     MST 600                                TABS         600MG       T1

   00185071301     ORPHENADRINE COMPOUND                  TABS         385MG; 30MG; T1
                                                                       25MG
   00185071401     ORPHENADRINE COMPOUND DS               TABS         770MG; 60MG; T1
                                                                       50MG
   57664010508     SALSALATE                              TABS         750MG       T1

   57664010308     SALSALATE                              TABS         500MG       T1

   49884065701     ZORPRIN                                TBCR         800MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   41167005703     ASPERCREME/ALOE                        CREA         10%         T2

   66992016050     LEVACET                                TABS         250MG;      T2
                                                                       500MG;
                                                                       32.5MG;
                                                                       150MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 44 of 285
   (28:08.04.92) CNS Agents » Analgesics & Antipyretics » NSAIDs » NSAIDs, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00781501701     DICLOFENAC POTASSIUM                   TABS         50MG        T1

   00591033901     DICLOFENAC SODIUM                      TBEC         75MG        T1

   00591033801     DICLOFENAC SODIUM DR                   TBEC         50MG        T1

   00781178501     DICLOFENAC SODIUM EC                   TBEC         25MG        T1

   00093104101     DICLOFENAC SODIUM ER                   TB24         100MG       T1

   00093075506     DIFLUNISAL                             TABS         500MG       T1

   51672401601     ETODOLAC                               CAPS         200MG       T1

   00185013901     ETODOLAC                               TABS         500MG       T1

   00093839701     ETODOLAC                               CAPS         300MG       T1

   60505004101     ETODOLAC                               TABS         400MG       T1

   00093111801     ETODOLAC ER                            TB24         600MG       T1

   00093112201     ETODOLAC ER                            TB24         400MG       T1

   00093717201     ETODOLAC ER                            TB24         500MG       T1

   00378047101     FENOPROFEN CALCIUM                     TABS         600MG       T1

   00093071101     FLURBIPROFEN                           TABS         100MG       T1

   00378007601     FLURBIPROFEN                           TABS         50MG        T1

   00591346505     IBUPROFEN                              TABS         600MG       T1

   49884077705     IBUPROFEN                              TABS         400MG       T1

   00904791540     IBUPROFEN                              TABS         200MG       T1

   00472127016     IBUPROFEN                              SUSP         100MG/5ML   T1

   53746013705     IBUPROFEN                              TABS         800MG       T1

   00713017630     INDOMETHACIN                           SUPP         50MG        T1

   00378014701     INDOMETHACIN                           CAPS         50MG        T1

   00378014301     INDOMETHACIN                           CAPS         25MG        T1

   00185072001     INDOMETHACIN ER                        CPCR         75MG        T1

   00378407001     KETOPROFEN                             CAPS         50MG        T1

   00378575001     KETOPROFEN                             CAPS         75MG        T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 45 of 285
   00378820001     KETOPROFEN ER                          CP24         200MG       T1

   00093031401     KETOROLAC TROMETHAMINE                 TABS         10MG        T1   QL (20.00 per 30 days)


   10019002209     KETOROLAC TROMETHAMINE                 SOLN         30MG/ML     T1   QL (20.00 per 30 days)


   55390048102     KETOROLAC TROMETHAMINE                 SOLN         30MG/ML     T1   QL (10.00 per 30 days)


   55390048001     KETOROLAC TROMETHAMINE                 SOLN         15MG/ML     T1   QL (40.00 per 30 days)


   00409228761     KETOROLAC TROMETHAMINE                 SOLN         30MG/ML     T1   QL (10.00 per 30 days)


   10019002232     KETOROLAC TROMETHAMINE                 SOLN         30MG/ML     T1   QL (10.00 per 30 days)


   55390048101     KETOROLAC TROMETHAMINE                 SOLN         30MG/ML     T1   QL (20.00 per 30 days)


   60505072602     KETOROLAC TROMETHAMINE                 SOLN         30MG/ML     T1   QL (10.00 per 30 days)


   10019002109     KETOROLAC TROMETHAMINE                 SOLN         15MG/ML     T1   QL (40.00 per 30 days)


   00378215001     MECLOFENAMATE SODIUM                   CAPS         50MG        T1

   00378300001     MECLOFENAMATE SODIUM                   CAPS         100MG       T1

   00054022849     MELOXICAM                              SUSP         7.5MG/5ML   T1

   00093723401     MELOXICAM                              TABS         7.5MG       T1

   00378108901     MELOXICAM                              TABS         15MG        T1

   00093101501     NABUMETONE                             TABS         500MG       T1

   00093101601     NABUMETONE                             TABS         750MG       T1

   00093014905     NAPROXEN                               TABS         500MG       T1

   00054363063     NAPROXEN                               SUSP         125MG/5ML   T1

   00093014701     NAPROXEN                               TABS         250MG       T1

   00093014801     NAPROXEN                               TABS         375MG       T1

   00093100501     NAPROXEN DR                            TBEC         375MG       T1

   00093100601     NAPROXEN DR                            TBEC         500MG       T1

   00093053601     NAPROXEN SODIUM                        TABS         275MG       T1

   00093053705     NAPROXEN SODIUM                        TABS         550MG       T1

   62037082675     NAPROXEN SODIUM                        TB24         500MG       T1

   55111017001     OXAPROZIN                              TABS         600MG       T1

   00093075601     PIROXICAM                              CAPS         10MG        T1

   00093075701     PIROXICAM                              CAPS         20MG        T1

   00591566001     SULINDAC                               TABS         200MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 46 of 285
   00591566101     SULINDAC                               TABS         150MG         T1

   00093881501     TOLMETIN SODIUM                        CAPS         400MG         T1

   53489050601     TOLMETIN SODIUM                        TABS         200MG         T1

   00378031301     TOLMETIN SODIUM                        TABS         600MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00025141160     ARTHROTEC 50                           TABS         50MG;         T2
                                                                       200MCG
   00025142160     ARTHROTEC 75                           TABS         75MG;         T2
                                                                       200MCG
   00006337666     INDOCIN                                SUSP         25MG/5ML      T2

   50580019815     MOTRIN INFANTS                         SUSP         40MG/ML       T2

   00884660010     NALFON                                 CAPS         200MG         T2

   68453037510     NAPRELAN                               TB24         375MG         T2

   59630040010     PONSTEL                                CAPS         250MG         T2

   00300154630     PREVACID NAPRAPAC                      KIT          15MG; 500MG   T2




   (28:08.08) CNS Agents » Analgesics & Antipyretics » Opiate Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093005001     ACETAMINOPHEN/CODEINE                  TABS         300MG; 15MG   T1

   00093035001     ACETAMINOPHEN/CODEINE                  TABS         300MG; 60MG   T1

   00677099633     ACETAMINOPHEN/CODEINE                  SOLN         120MG/5ML;    T1
                                                                       12MG/5ML
   00093015010     ACETAMINOPHEN/CODEINE #3               TABS         300MG; 30MG   T1

   00603236121     ASPIRIN/CODEINE                        TABS         325MG; 30MG   T1

   00603236221     ASPIRIN/CODEINE                        TABS         325MG; 60MG   T1

   10122030110     BALACET 325                            TABS         325MG; 100MG T1

   00904514060     BUTAL/ASA/CAFF/COD                     CAPS         325MG; 50MG; T1
                                                                       40MG; 30MG
   00143300001     BUTALBITAL /APAP /CAFFEINE /CODEINE    CAPS         325MG; 50MG; T1
                                                                       40MG; 30MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 47 of 285
   00054415625     CODEINE SULFATE                        TABS         30MG          T1

   00054815524     CODEINE SULFATE                        TABS         15MG          T1

   00054415725     CODEINE SULFATE                        TABS         60MG          T1

   58177091401     ETH-OXYDOSE                            CONC         20MG/ML       T1

   58177091456     ETH-OXYDOSE                            CONC         20MG/ML       T1

   00378911998     FENTANYL                               PT72         12.5MCG/HR    T1   PA


   00378912198     FENTANYL                               PT72         25MCG/HR      T1   PA


   00378912298     FENTANYL                               PT72         50MCG/HR      T1   PA


   00378912398     FENTANYL                               PT72         75MCG/HR      T1   PA


   00378912498     FENTANYL                               PT72         100MCG/HR     T1   PA


   00555108001     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         200MCG        T1   QL (120.00 per 30 days)


   00555108201     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         600MCG        T1   QL (120.00 per 30 days)


   00555108501     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         1600MCG       T1   QL (120.00 per 30 days)


   00555108401     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         1200MCG       T1   QL (120.00 per 30 days)


   00555108101     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         400MCG        T1   QL (120.00 per 30 days)


   00555108301     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         800MCG        T1   QL (120.00 per 30 days)


   00406035705     HYDROCODONE /ACETAMINOPHEN             TABS         500MG; 5MG    T1

   00406036201     HYDROCODONE /ACETAMINOPHEN             TABS         660MG; 10MG   T1

   00406036501     HYDROCODONE /ACETAMINOPHEN             TABS         325MG; 5MG    T1

   00591038505     HYDROCODONE /ACETAMINOPHEN             TABS         500MG; 7.5MG T1

   00591038705     HYDROCODONE /ACETAMINOPHEN             TABS         750MG; 7.5MG T1

   00591038801     HYDROCODONE /ACETAMINOPHEN             TABS         500MG; 2.5MG T1

   00406035901     HYDROCODONE /ACETAMINOPHEN             TABS         650MG; 7.5MG T1

   00406036101     HYDROCODONE /ACETAMINOPHEN             TABS         650MG; 10MG   T1

   00406036601     HYDROCODONE /ACETAMINOPHEN             TABS         325MG; 7.5MG T1

   00603129558     HYDROCODONE /ACETAMINOPHEN             SOLN         500MG/15ML;   T1
                                                                       7.5MG/15ML
   00591322801     HYDROCODONE                            TABS         750MG; 10MG   T1
                   BITARTRATE/ACETAMINOPHEN
   00591054005     HYDROCODONE BITARTRATE/APAP            TABS         500MG; 10MG   T1

   00591085305     HYDROCODONE/APAP                       TABS         325MG; 10MG   T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                        Page 48 of 285
   00093516101     HYDROCODONE/IBUPROFEN                  TABS         7.5MG; 200MG T1

   00406324401     HYDROMORPHONE HCL                      TABS         4MG          T1

   00406324901     HYDROMORPHONE HCL                      TABS         8MG          T1

   00641234141     HYDROMORPHONE HCL                      SOLN         2MG/ML       T1

   00406324301     HYDROMORPHONE HCL                      TABS         2MG          T1

   00574722406     HYDROMORPHONE HCL                      SUPP         3MG          T1

   60977011401     INFUMORPH 200                          SOLN         10MG/ML      T1

   00054449425     LEVORPHANOL TARTRATE                   TABS         2MG          T1

   10019016001     MEPERIDINE HCL                         SOLN         50MG/ML      T1

   00054354563     MEPERIDINE HCL                         SOLN         50MG/5ML     T1

   00555038102     MEPERIDINE HCL                         TABS         50MG         T1

   10019015868     MEPERIDINE HCL                         SOLN         100MG/ML     T1

   10019016101     MEPERIDINE HCL                         SOLN         75MG/ML      T1

   10019016201     MEPERIDINE HCL                         SOLN         100MG/ML     T1

   00555038202     MEPERIDINE HCL                         TABS         100MG        T1

   10019015901     MEPERIDINE HCL                         SOLN         25MG/ML      T1

   00603442421     MEPROZINE                              CAPS         50MG; 25MG   T1

   00406575501     METHADONE HCL                          TABS         5MG          T1

   00054355663     METHADONE HCL                          SOLN         10MG/5ML     T1

   00054355563     METHADONE HCL                          SOLN         5MG/5ML      T1

   00406577101     METHADONE HCL                          TABS         10MG         T1

   00054355344     METHADONE HCL INTENSOL                 CONC         10MG/ML      T1

   00406054034     METHADOSE                              TBSO         40MG         T1

   00574711612     MORPHINE SULFATE                       SUPP         30MG         T1

   10019017644     MORPHINE SULFATE                       SOLN         5MG/ML       T1

   58177088601     MORPHINE SULFATE                       SOLN         20MG/ML      T1

   00054378663     MORPHINE SULFATE                       SOLN         20MG/5ML     T1

   00409176230     MORPHINE SULFATE                       SOLN         2MG/ML       T1

   00574711412     MORPHINE SULFATE                       SUPP         20MG         T1

   10019017744     MORPHINE SULFATE                       SOLN         8MG/ML       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com             Page 49 of 285
   10019017963     MORPHINE SULFATE                       SOLN         15MG/ML       T1

   58177088880     MORPHINE SULFATE                       SOLN         5MG/0.25ML    T1

   58177088981     MORPHINE SULFATE                       SOLN         10MG/0.5ML    T1

   00054378563     MORPHINE SULFATE                       SOLN         10MG/5ML      T1

   00409113403     MORPHINE SULFATE                       SOLN         50MG/ML       T1

   00409113502     MORPHINE SULFATE                       SOLN         25MG/ML       T1

   00409126130     MORPHINE SULFATE                       SOLN         10MG/ML       T1

   10019017844     MORPHINE SULFATE                       SOLN         10MG/ML       T1

   00409125830     MORPHINE SULFATE                       SOLN         4MG/ML        T1

   00409405812     MORPHINE SULFATE                       SOLN         1MG/ML        T1

   00574711012     MORPHINE SULFATE                       SUPP         5MG           T1

   00574711212     MORPHINE SULFATE                       SUPP         10MG          T1

   58177031304     MORPHINE SULFATE                       TABS         15MG          T1

   58177031404     MORPHINE SULFATE                       TABS         30MG          T1

   00591351201     MORPHINE SULFATE CR                    TB12         30MG          T1

   00591351501     MORPHINE SULFATE CR                    TB12         200MG         T1

   60951065270     MORPHINE SULFATE ER                    TB12         15MG          T1

   60951065570     MORPHINE SULFATE ER                    TB12         60MG          T1

   60951065870     MORPHINE SULFATE ER                    TB12         100MG         T1

   67204096001     NARVOX                                 TABS         500MG; 10MG   T1

   00591082501     OXYCODONE /ACETAMINOPHEN               TABS         650MG; 10MG   T1

   00406055201     OXYCODONE HCL                          TABS         5MG           T1

   52152021502     OXYCODONE HCL                          TABS         30MG          T1

   58177004104     OXYCODONE HCL                          CAPS         5MG           T1

   52152021402     OXYCODONE HCL                          TABS         15MG          T1

   00406855550     OXYCODONE HCL                          SOLN         5MG/5ML       T1

   00591093301     OXYCODONE-APAP                         TABS         325MG; 7.5MG T1

   00591093201     OXYCODONE-APAP                         TABS         325MG; 10MG   T1

   00555065802     OXYCODONE/ACETAMINOPHEN                CAPS         500MG; 5MG    T1

   00406051201     OXYCODONE/ACETAMINOPHEN                TABS         325MG; 5MG    T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 50 of 285
   00591082401     OXYCODONE/APAP                         TABS         500MG; 7.5MG T1

   00591082001     OXYCODONE/ASPIRIN                      TABS         325MG;        T1
                                                                       4.5MG;
                                                                       0.38MG
   00525001601     PANLOR DC                              CAPS         356.4MG;      T1
                                                                       30MG; 16MG
   66813081001     PERLOXX                                TABS         300MG; 10MG   T1

   00378013001     PROPOXYPHENE /ACETAMINOPHEN            TABS         650MG; 65MG   T1

   00603545921     PROPOXYPHENE HCL                       CAPS         65MG          T1

   00603546521     PROPOXYPHENE-N /ACETAMINOPHEN          TABS         325MG; 50MG   T1

   50111079001     PROPOXYPHENE-N /ACETAMINOPHEN          TABS         500MG; 100MG T1

   00603546728     PROPOXYPHENE-N /ACETAMINOPHEN          TABS         650MG; 100MG T1

   00054478425     ROXICET                                TABS         500MG; 5MG    T1

   00054368663     ROXICET                                SOLN         325MG/5ML;    T1
                                                                       5MG/5ML
   50111061603     TRAMADOL HCL                           TABS         50MG          T1            QL (240.00 per 30 days)


   57664053788     TRAMADOL                               TABS         325MG;        T1            QL (240.00 per 30 days)
                   HYDROCHLORIDE/ACETAMINOPHEN                         37.5MG
   66813092201     VOPAC                                  TABS         650MG; 30MG   T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   60793060501     AVINZA                                 CP24         30MG          T2

   60793060601     AVINZA                                 CP24         60MG          T2

   60793060801     AVINZA                                 CP24         120MG         T2

   60793060701     AVINZA                                 CP24         90MG          T2

   00187000301     CAPITAL/CODEINE                        SUSP         120MG/5ML;    T2
                                                                       12MG/5ML
   63304074801     CODEINE PHOSPHATE                      TBSO         30MG          T2

   00456520001     COMBUNOX                               TABS         400MG; 5MG    T2

   66479051210     DARVON-N                               TABS         100MG         T2

   00409118069     DEMEROL                                SOLN         100MG/ML      T2

   00409118130     DEMEROL                                SOLN         50MG/ML       T2

   00409117930     DEMEROL                                SOLN         75MG/ML       T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                           Page 51 of 285
   00409120120     DEMEROL                                SOLN         100MG/ML      T2

   00409117630     DEMEROL                                SOLN         25MG/ML       T2

   00409120301     DEMEROL                                SOLN         50MG/ML       T2

   00409117830     DEMEROL                                SOLN         50MG/ML       T2

   00409125301     DEMEROL                                SOLN         50MG/ML       T2

   00409125502     DEMEROL                                SOLN         50MG/ML       T2

   00074233411     DILAUDID                               SOLN         4MG/ML        T2

   00074233311     DILAUDID                               SOLN         2MG/ML        T2

   00074245202     DILAUDID-5                             LIQD         1MG/ML        T2

   00074245531     DILAUDID-HP                            SOLR         250MG         T2

   63459054228     FENTORA                                TABS         200MCG        T2   QL (112.00 per 28 days)


   63459054328     FENTORA                                TABS         300MCG        T2   QL (112.00 per 28 days)


   63459054828     FENTORA                                TABS         800MCG        T2   QL (112.00 per 28 days)


   63459054428     FENTORA                                TABS         400MCG        T2   QL (112.00 per 28 days)


   63459054128     FENTORA                                TABS         100MCG        T2   QL (112.00 per 28 days)


   63459054628     FENTORA                                TABS         600MCG        T2   QL (112.00 per 28 days)


   66479057416     HYCET                                  SOLN         325MG/15ML;   T2
                                                                       7.5MG/15ML
   60977011501     INFUMORPH 500                          SOLN         25MG/ML       T2

   63857032411     KADIAN                                 CP24         100MG         T2

   63857037711     KADIAN                                 CP24         200MG         T2

   63857041011     KADIAN                                 CP24         10MG          T2

   63857041211     KADIAN                                 CP24         80MG          T2

   63857032211     KADIAN                                 CP24         20MG          T2

   63857032311     KADIAN                                 CP24         50MG          T2

   63857032511     KADIAN                                 CP24         30MG          T2

   63857032611     KADIAN                                 CP24         60MG          T2

   23635099301     MAGNACET                               TABS         400MG; 7.5MG T2

   23635099201     MAGNACET                               TABS         400MG; 5MG    T2

   23635099401     MAGNACET                               TABS         400MG; 10MG   T2

   23635099101     MAGNACET                               TABS         400MG; 2.5MG T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                        Page 52 of 285
   10019017868     MORPHINE SULFATE                       SOLN         10MG/ML       T2

   63304070801     MORPHINE SULFATE                       TBSO         30MG          T2

   63304070601     MORPHINE SULFATE                       TBSO         10MG          T2

   63304070701     MORPHINE SULFATE                       TBSO         15MG          T2

   63481061270     OPANA                                  TABS         5MG           T2

   63481061370     OPANA                                  TABS         10MG          T2

   63481061770     OPANA ER                               TB12         20MG          T2

   63481067470     OPANA ER                               TB12         10MG          T2

   63481069370     OPANA ER                               TB12         40MG          T2

   63481090770     OPANA ER                               TB12         5MG           T2

   59011010710     OXYCONTIN                              TB12         80MG          T2

   59011010310     OXYCONTIN                              TB12         20MG          T2

   59011010010     OXYCONTIN                              TB12         10MG          T2

   59011010510     OXYCONTIN                              TB12         40MG          T2

   00525003201     PANLOR SS                              TABS         712.8MG;      T2
                                                                       60MG; 32MG
   63481062770     PERCOCET                               TABS         325MG; 2.5MG T2

   63481012170     PERCODAN                               TABS         325MG;        T2
                                                                       4.5MG;
                                                                       0.38MG
   11528041001     REPREXAIN                              TABS         5MG; 200MG    T2

   10551041910     SYNALGOS-DC                            CAPS         356.4MG;      T2
                                                                       30MG; 16MG
   68453091110     XODOL                                  TABS         300MG; 10MG   T2

   68453091210     XODOL                                  TABS         300MG; 5MG    T2

   68453091310     XODOL                                  TABS         300MG; 7.5MG T2

   63481066870     ZYDONE                                 TABS         400MG; 5MG    T2

   63481066970     ZYDONE                                 TABS         400MG; 7.5MG T2

   63481069870     ZYDONE                                 TABS         400MG; 10MG   T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details             Comment

   00062065730     ULTRAM ER                              TB24         300MG         T3            MN; QL (30.00 per 30 days)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                              Page 53 of 285
   00062065330     ULTRAM ER                              TB24         100MG         T3            MN; QL (30.00 per 30 days)


   00062065530     ULTRAM ER                              TB24         200MG         T3            MN; QL (30.00 per 30 days)




   (28:08.12) CNS Agents » Analgesics & Antipyretics » Opiate Partial Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details             Comment

   00378963943     BUTORPHANOL TARTRATE                   SOLN         10MG/ML       T1            QL (4.00 per 30 days)


   00409162301     BUTORPHANOL TARTRATE                   SOLN         1MG/ML        T1

   55390018401     BUTORPHANOL TARTRATE                   SOLN         2MG/ML        T1

   00409146301     NALBUPHINE HCL                         SOLN         10MG/ML       T1

   00409146401     NALBUPHINE HCL                         SOLN         10MG/ML       T1

   00409146501     NALBUPHINE HCL                         SOLN         20MG/ML       T1

   00409146701     NALBUPHINE HCL                         SOLN         20MG/ML       T1

   00591039601     PENTAZOCINE /ACETAMINOPHEN             TABS         650MG; 25MG   T1

   52152021102     PENTAZOCINE/NALOXONE HCL               TABS         0.5MG; 50MG   T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details             Comment

   12496075701     BUPRENEX                               SOLN         0.3MG/ML      T2

   12496130602     SUBOXONE                               SUBL         8MG; 2MG      T2

   12496128302     SUBOXONE                               SUBL         2MG; 0.5MG    T2

   12496127802     SUBUTEX                                SUBL         2MG           T2

   12496131002     SUBUTEX                                SUBL         8MG           T2




   (28:08.92) CNS Agents » Analgesics & Antipyretics » Analgesics & Antipyretics, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details             Comment

   20254020004     ACETAMINOPHEN                          TABS         325MG         T1

   00143111501     BUTALBITAL /ACETAMINOPHEN /CAFFEINE    TABS         500MG; 50MG; T1
                                                                       40MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                              Page 54 of 285
   00603254428     BUTALBITAL /APAP /CAFFEINE             TABS         325MG; 50MG; T1
                                                                       40MG
   00603254021     BUTALBITAL/ACETAMINOPHEN               TABS         325MG; 50MG   T1

   00603254621     BUTALBITAL/APAP/CAFFEINE               CAPS         325MG; 50MG; T1
                                                                       40MG
   59702065001     CEPHADYN                               TABS         650MG; 50MG   T1

   12539058001     DOLOREX                                CAPS         300MG; 20MG; T1
                                                                       200MG
   49963061501     DURAXIN                                CAPS         300MG; 20MG; T1
                                                                       200MG
   00485006601     ED-FLEX                                CAPS         300MG; 20MG; T1
                                                                       200MG
   12539085010     FRENADOL                               TABS         250MG; 600MG T1

   00182145310     GENEBS                                 TABS         500MG         T1

   00603083873     Q-PAP INFANTS                          SOLN         100MG/ML      T1

   59630017010     ZEBUTAL                                CAPS         500MG; 50MG; T1
                                                                       40MG


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   66813007316     DOLGIC LQ                              ELIX         325MG/15ML;   T2
                                                                       50MG/15ML;
                                                                       40MG/15ML
   68453007410     DOLGIC PLUS                            TABS         750MG; 50MG; T2
                                                                       40MG
   66869082610     DURABAC                                CAPS         325MG; 50MG; T2
                                                                       20MG; 250MG
   66869082710     DURABAC FORTE                          TABS         500MG; 50MG; T2
                                                                       500MG; 20MG
   00187084401     PHRENILIN FORTE                        CAPS         650MG; 50MG   T2




   (28:10) CNS Agents » Opiate Antagonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00409121201     NALOXONE HCL                           SOLN         0.4MG/ML      T1

   00409121501     NALOXONE HCL                           SOLN         0.4MG/ML      T1

   00548336600     NALOXONE HCL                           SOLN         0.4MG/ML      T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 55 of 285
   00555090201     NALTREXONE HCL                         TABS         50MG       T1




   (28:12.04) CNS Agents » Anticonvulsants » Barbiturates
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00603537121     PRIMIDONE                              TABS         50MG       T1

   00591532101     PRIMIDONE                              TABS         250MG      T1




   (28:12.08) CNS Agents » Anticonvulsants » Benzodiazepines
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093083401     CLONAZEPAM                             TABS         2MG        T1

   00093083201     CLONAZEPAM                             TABS         0.5MG      T1

   00093083301     CLONAZEPAM                             TABS         1MG        T1

   49884030602     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         0.125MG    T1

   49884030802     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         0.5MG      T1

   49884030702     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         0.25MG     T1

   49884031002     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         2MG        T1

   49884030902     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         1MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00187065820     DIASTAT ACUDIAL                        GEL          10MG       T2

   00187065920     DIASTAT ACUDIAL                        GEL          20MG       T2

   66490065020     DIASTAT PEDIATRIC                      GEL          2.5MG      T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 56 of 285
   (28:12.12) CNS Agents » Anticonvulsants » Hydantoins
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00472006708     PHENYTOIN                              SUSP         125MG/5ML   T1

   00409131701     PHENYTOIN SODIUM                       SOLN         50MG/ML     T1

   00378156010     PHENYTOIN SODIUM EXTENDED              CAPS         100MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00071036524     DILANTIN                               CAPS         30MG        T2

   00071000724     DILANTIN INFATABS                      CHEW         50MG        T2

   67386060101     PEGANONE                               TABS         250MG       T2

   62794075093     PHENYTEK                               CAPS         300MG       T2

   62794067001     PHENYTEK                               CAPS         200MG       T2




   (28:12.20) CNS Agents » Anticonvulsants » Succinimides
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00093966016     ETHOSUXIMIDE                           SOLN         250MG/5ML   T1

   50111090101     ETHOSUXIMIDE                           CAPS         250MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00071052524     CELONTIN                               CAPS         300MG       T2




   (28:12.92) CNS Agents » Anticonvulsants » Anticonvulsants, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   51672404709     CARBAMAZEPINE                          SUSP         100MG/5ML   T1

   00093010901     CARBAMAZEPINE                          TABS         200MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 57 of 285
   00093077801     CARBAMAZEPINE                          CHEW         100MG       T1

   00172444260     GABAPENTIN                             TABS         400MG       T1

   00172444380     GABAPENTIN                             TABS         600MG       T1

   00093103901     GABAPENTIN                             CAPS         300MG       T1

   00172444460     GABAPENTIN                             TABS         800MG       T1

   00172444470     GABAPENTIN                             TABS         800MG       T1

   00172444360     GABAPENTIN                             TABS         600MG       T1

   00093103801     GABAPENTIN                             CAPS         100MG       T1

   00093104001     GABAPENTIN                             CAPS         400MG       T1

   00182271801     GABARONE                               TABS         100MG       T1

   00182272001     GABARONE                               TABS         400MG       T1

   00093013201     LAMOTRIGINE CHEWABLE DISPERSIBLE       TBDP         25MG        T1

   00093068801     LAMOTRIGINE CHEWABLE DISPERSIBLE       TBDP         5MG         T1

   63323006410     MAGNESIUM SULFATE                      SOLN         50%         T1

   60432062116     VALPROIC ACID                          SYRP         250MG/5ML   T1

   00591401201     VALPROIC ACID                          CAPS         250MG       T1

   68462012801     ZONISAMIDE                             CAPS         25MG        T1

   68462012901     ZONISAMIDE                             CAPS         50MG        T1

   68462013001     ZONISAMIDE                             CAPS         100MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   54092017112     CARBATROL                              CP12         100MG       T2

   54092017312     CARBATROL                              CP12         300MG       T2

   54092017212     CARBATROL                              CP12         200MG       T2

   00074621413     DEPAKOTE                               TBEC         250MG       T2

   00074621213     DEPAKOTE                               TBEC         125MG       T2

   00074621513     DEPAKOTE                               TBEC         500MG       T2

   00074712613     DEPAKOTE ER                            TB24         500MG       T2

   00074382613     DEPAKOTE ER                            TB24         250MG       T2

   00074611413     DEPAKOTE SPRINKLES                     CPSP         125MG       T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 58 of 285
   00037043001     FELBATOL                               TABS         400MG       T2

   00037044267     FELBATOL                               SUSP         600MG/5ML   T2

   00037043101     FELBATOL                               TABS         600MG       T2

   63459040401     GABITRIL                               TABS         4MG         T2

   63459041601     GABITRIL                               TABS         16MG        T2

   63459040201     GABITRIL                               TABS         2MG         T2

   63459041201     GABITRIL                               TABS         12MG        T2

   50474059440     KEPPRA                                 TABS         250MG       T2

   50474059640     KEPPRA                                 TABS         750MG       T2

   50474059766     KEPPRA                                 TABS         1000MG      T2

   50474059540     KEPPRA                                 TABS         500MG       T2

   50474000148     KEPPRA                                 SOLN         100MG/ML    T2

   00173063302     LAMICTAL                               TABS         25MG        T2

   00173064255     LAMICTAL                               TABS         100MG       T2

   00173064360     LAMICTAL                               TABS         150MG       T2

   00173064460     LAMICTAL                               TABS         200MG       T2

   00173059402     LAMICTAL STARTER/NOT TAKING            KIT          0           T2
                   CARBAMAZEPINE
   00173059401     LAMICTAL STARTER/TAKING                KIT          0           T2
                   CARBAMAZEPINE/NOT TAKING VALPROATE
   00173063310     LAMICTAL STARTER/TAKING VALPROATE      KIT          25MG        T2

   00071201223     NEURONTIN                              SOLN         250MG/5ML   T2

   00083006230     TEGRETOL-XR                            TB12         200MG       T2

   00083006030     TEGRETOL-XR                            TB12         400MG       T2

   00083006130     TEGRETOL-XR                            TB12         100MG       T2

   00045064065     TOPAMAX                                TABS         50MG        T2

   00045063965     TOPAMAX                                TABS         25MG        T2

   00045064165     TOPAMAX                                TABS         100MG       T2

   00045064265     TOPAMAX                                TABS         200MG       T2

   00045064565     TOPAMAX SPRINKLE                       CPSP         25MG        T2

   00045064765     TOPAMAX SPRINKLE                       CPSP         15MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com            Page 59 of 285
   00078033705     TRILEPTAL                              TABS         300MG       T2

   00078035752     TRILEPTAL                              SUSP         300MG/5ML   T2

   00078045605     TRILEPTAL                              TABS         150MG       T2

   00078045705     TRILEPTAL                              TABS         600MG       T2


   Tier: T3
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00071101268     LYRICA                                 CAPS         25MG        T3            MN


   00071101468     LYRICA                                 CAPS         75MG        T3            MN


   00071101668     LYRICA                                 CAPS         150MG       T3            MN


   00071101368     LYRICA                                 CAPS         50MG        T3            MN


   00071101568     LYRICA                                 CAPS         100MG       T3            MN


   00071101768     LYRICA                                 CAPS         200MG       T3            MN


   00071101868     LYRICA                                 CAPS         300MG       T3            MN


   00071101968     LYRICA                                 CAPS         225MG       T3            MN




   (28:16.04.12) CNS Agents » Psychotherapeutics » Antidepressants » MAO Inhibitors
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   49884003201     TRANYLCYPROMINE SULFATE                TABS         10MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   30698003201     MARPLAN                                TABS         10MG        T2

   00071035060     NARDIL                                 TABS         15MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 60 of 285
   (28:16.04.16) CNS Agents » Psychotherapeutics » Antidepressants » Selective Serotonin- and Norepinephrine-
   reuptake Inhibitors
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093738101     VENLAFAXINE HCL                        TABS         50MG       T1

   00093738301     VENLAFAXINE HCL                        TABS         100MG      T1

   00093019901     VENLAFAXINE HCL                        TABS         25MG       T1

   00093738201     VENLAFAXINE HCL                        TABS         75MG       T1

   00093738001     VENLAFAXINE HCL                        TABS         37.5MG     T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00008083621     EFFEXOR XR                             CP24         150MG      T2

   00008083321     EFFEXOR XR                             CP24         75MG       T2

   00008083721     EFFEXOR XR                             CP24         37.5MG     T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00002323560     CYMBALTA                               CPEP         20MG       T3            MN


   00002323730     CYMBALTA                               CPEP         60MG       T3            MN


   00002324030     CYMBALTA                               CPEP         30MG       T3            MN




   (28:16.04.20) CNS Agents » Psychotherapeutics » Antidepressants » SSRIs
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   65862000701     CITALOPRAM HYDROBROMIDE                TABS         40MG       T1

   00054006258     CITALOPRAM HYDROBROMIDE                SOLN         10MG/5ML   T1

   65862000501     CITALOPRAM HYDROBROMIDE                TABS         10MG       T1

   65862000601     CITALOPRAM HYDROBROMIDE                TABS         20MG       T1

   00093718856     FLUOXETINE HCL                         TABS         10MG       T1

   00555087702     FLUOXETINE HCL                         CAPS         20MG       T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 61 of 285
   60505035201     FLUOXETINE HCL                         SOLN         20MG/5ML     T1

   49884073510     FLUOXETINE HCL                         TABS         20MG         T1

   00093104201     FLUOXETINE HCL                         CAPS         10MG         T1

   00093719856     FLUOXETINE HCL                         CAPS         40MG         T1

   00093005601     FLUVOXAMINE MALEATE                    TABS         50MG         T1

   00172439260     FLUVOXAMINE MALEATE                    TABS         100MG        T1

   00172438960     FLUVOXAMINE MALEATE                    TABS         25MG         T1

   60505008401     PAROXETINE HCL                         TABS         30MG         T1

   60505037401     PAROXETINE HCL                         SUSP         10MG/5ML     T1

   60505008302     PAROXETINE HCL                         TABS         20MG         T1

   60505010101     PAROXETINE HCL                         TABS         40MG         T1

   60505009701     PAROXETINE HCL                         TABS         10MG         T1

   59762496001     SERTRALINE HCL                         TABS         25MG         T1

   00093717756     SERTRALINE HCL                         TABS         100MG        T1

   59762494001     SERTRALINE HCL                         CONC         20MG/ML      T1

   00093717656     SERTRALINE HCL                         TABS         50MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   68968202001     PEXEVA                                 TABS         20MG         T2

   68968201001     PEXEVA                                 TABS         10MG         T2

   68968203001     PEXEVA                                 TABS         30MG         T2

   68968204001     PEXEVA                                 TABS         40MG         T2

   00002323130     SYMBYAX                                CAPS         25MG; 6MG    T2

   00002323230     SYMBYAX                                CAPS         25MG; 12MG   T2

   00002323330     SYMBYAX                                CAPS         50MG; 6MG    T2

   00002323430     SYMBYAX                                CAPS         50MG; 12MG   T2

   00002323030     SYMBYAX                                CAPS         25MG; 3MG    T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 62 of 285
   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   00456200501     LEXAPRO                                TABS         5MG        T3            MN


   00456201001     LEXAPRO                                TABS         10MG       T3            MN


   00456202001     LEXAPRO                                TABS         20MG       T3            MN


   00456210108     LEXAPRO                                SOLN         5MG/5ML    T3            MN


   00029320613     PAXIL CR                               TB24         12.5MG     T3            MN


   00029320813     PAXIL CR                               TB24         37.5MG     T3            MN


   00029320713     PAXIL CR                               TB24         25MG       T3            MN


   00002300475     PROZAC WEEKLY                          CPDR         90MG       T3            MN; QL (4.00 per 28 days)


   00430043614     SARAFEM                                CAPS         20MG       T3            MN




   (28:16.04.24) CNS Agents » Psychotherapeutics » Antidepressants » Serotonin Modulators
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   00093102406     NEFAZODONE HCL                         TABS         100MG      T1

   00093102506     NEFAZODONE HCL                         TABS         200MG      T1

   00093711306     NEFAZODONE HCL                         TABS         150MG      T1

   00093102606     NEFAZODONE HCL                         TABS         250MG      T1

   00093717801     NEFAZODONE HCL                         TABS         50MG       T1

   50111043301     TRAZODONE HCL                          TABS         50MG       T1

   50111043401     TRAZODONE HCL                          TABS         100MG      T1

   50111044101     TRAZODONE HCL                          TABS         150MG      T1

   00555073302     TRAZODONE HCL                          TABS         300MG      T1




   (28:16.04.28) CNS Agents » Psychotherapeutics » Antidepressants » NRIs & TCAs
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   00378267501     AMITRIPTYLINE HCL                      TABS         75MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                          Page 63 of 285
   00378261001     AMITRIPTYLINE HCL                      TABS         10MG          T1

   00378265010     AMITRIPTYLINE HCL                      TABS         50MG          T1

   00378268501     AMITRIPTYLINE HCL                      TABS         100MG         T1

   00378262510     AMITRIPTYLINE HCL                      TABS         25MG          T1

   00378269501     AMITRIPTYLINE HCL                      TABS         150MG         T1

   00591571501     AMOXAPINE                              TABS         100MG         T1

   00591571301     AMOXAPINE                              TABS         25MG          T1

   00591571401     AMOXAPINE                              TABS         50MG          T1

   00378021101     CHLORDIAZEPOXIDE /AMITRIPTYLINE        TABS         12.5MG; 5MG   T1

   00378027701     CHLORDIAZEPOXIDE /AMITRIPTYLINE        TABS         25MG; 10MG    T1

   51672401206     CLOMIPRAMINE HCL                       CAPS         50MG          T1

   51672401306     CLOMIPRAMINE HCL                       CAPS         75MG          T1

   00378302501     CLOMIPRAMINE HCL                       CAPS         25MG          T1

   00781197201     DESIPRAMINE HCL                        TABS         25MG          T1

   00781197301     DESIPRAMINE HCL                        TABS         50MG          T1

   00781197101     DESIPRAMINE HCL                        TABS         10MG          T1

   00781197501     DESIPRAMINE HCL                        TABS         100MG         T1

   00781197650     DESIPRAMINE HCL                        TABS         150MG         T1

   00781197401     DESIPRAMINE HCL                        TABS         75MG          T1

   00378312501     DOXEPIN HCL                            CAPS         25MG          T1

   00378537501     DOXEPIN HCL                            CAPS         75MG          T1

   00378425001     DOXEPIN HCL                            CAPS         50MG          T1

   00378104901     DOXEPIN HCL                            CAPS         10MG          T1

   49884022201     DOXEPIN HCL                            CAPS         150MG         T1

   60432065104     DOXEPIN HCL                            CONC         10MG/ML       T1

   00378641001     DOXEPIN HCL                            CAPS         100MG         T1

   00781176401     IMIPRAMINE HCL                         TABS         25MG          T1

   00781176201     IMIPRAMINE HCL                         TABS         10MG          T1

   00781176601     IMIPRAMINE HCL                         TABS         50MG          T1

   00406993103     IMIPRAMINE PAMOATE                     CAPS         75MG          T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 64 of 285
   00406993403     IMIPRAMINE PAMOATE                     CAPS         150MG       T1

   00378009201     MAPROTILINE HCL                        TABS         75MG        T1

   00378006001     MAPROTILINE HCL                        TABS         25MG        T1

   00378008701     MAPROTILINE HCL                        TABS         50MG        T1

   00591578901     NORTRIPTYLINE HCL                      CAPS         75MG        T1

   63304020201     NORTRIPTYLINE HCL                      SOLN         10MG/5ML    T1

   00591578601     NORTRIPTYLINE HCL                      CAPS         10MG        T1

   00591578701     NORTRIPTYLINE HCL                      CAPS         25MG        T1

   00591578801     NORTRIPTYLINE HCL                      CAPS         50MG        T1

   00378044201     PERPHENAZINE /AMITRIPTYLINE            TABS         25MG; 2MG   T1

   00378004201     PERPHENAZINE /AMITRIPTYLINE            TABS         10MG; 4MG   T1

   00378007301     PERPHENAZINE /AMITRIPTYLINE            TABS         50MG; 4MG   T1

   00378033001     PERPHENAZINE /AMITRIPTYLINE            TABS         10MG; 2MG   T1

   00378057401     PERPHENAZINE /AMITRIPTYLINE            TABS         25MG; 4MG   T1

   52152029308     TRIMIPRAMINE MALEATE                   CAPS         25MG        T1

   52152029408     TRIMIPRAMINE MALEATE                   CAPS         50MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00591571630     AMOXAPINE                              TABS         150MG       T2

   51285053802     SURMONTIL                              CAPS         25MG        T2

   51285053902     SURMONTIL                              CAPS         50MG        T2

   51285055402     SURMONTIL                              CAPS         100MG       T2

   00406992403     TOFRANIL-PM                            CAPS         100MG       T2

   00406992503     TOFRANIL-PM                            CAPS         125MG       T2

   51285059502     VIVACTIL                               TABS         5MG         T2

   51285059402     VIVACTIL                               TABS         10MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 65 of 285
   (28:16.04.92) CNS Agents » Psychotherapeutics » Antidepressants » Antidepressants, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093550201     BUDEPRION SR                           TB12         150MG      T1

   00093028001     BUPROPION HCL                          TABS         75MG       T1

   00093029001     BUPROPION HCL                          TABS         100MG      T1

   00115544513     BUPROPION HCL SR                       TB12         200MG      T1

   00591086760     BUPROPION HCL SR                       TB12         150MG      T1

   00185041060     BUPROPION HCL SR                       TB12         100MG      T1

   00093720756     MIRTAZAPINE                            TABS         30MG       T1

   00378354593     MIRTAZAPINE                            TABS         45MG       T1

   66993071230     MIRTAZAPINE                            TBDP         45MG       T1

   00093720656     MIRTAZAPINE                            TABS         15MG       T1

   00555024171     MIRTAZAPINE                            TBDP         15MG       T1

   00555024271     MIRTAZAPINE                            TBDP         30MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   57664051083     MIRTAZAPINE                            TABS         7.5MG      T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093535156     BUDEPRION XL                           TB24         300MG      T3

   00173073001     WELLBUTRIN XL                          TB24         150MG      T3            MN




   (28:16.08.04) CNS Agents » Psychotherapeutics » Antipsychotics » Atypical Antipsychotics
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093436001     CLOZAPINE                              TABS         100MG      T1

   00378082501     CLOZAPINE                              TABS         25MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 66 of 285
   00093440401     CLOZAPINE                              TABS         50MG       T1

   00093440505     CLOZAPINE                              TABS         200MG      T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   59148000713     ABILIFY                                TABS         5MG        T2

   59148000813     ABILIFY                                TABS         10MG       T2

   59148000913     ABILIFY                                TABS         15MG       T2

   59148001113     ABILIFY                                TABS         30MG       T2

   59148000613     ABILIFY                                TABS         2MG        T2

   59148001013     ABILIFY                                TABS         20MG       T2

   59148001315     ABILIFY                                SOLN         1MG/ML     T2

   59148064023     ABILIFY DISCMELT                       TBDP         10MG       T2

   59148064123     ABILIFY DISCMELT                       TBDP         15MG       T2

   68322000104     FAZACLO                                TBDP         25MG       T2

   68322000204     FAZACLO                                TBDP         100MG      T2

   00049398060     GEODON                                 CAPS         60MG       T2

   00049392083     GEODON                                 SOLR         20MG       T2

   00049397060     GEODON                                 CAPS         40MG       T2

   00049396060     GEODON                                 CAPS         20MG       T2

   00049399060     GEODON                                 CAPS         80MG       T2

   50458055001     INVEGA                                 TB24         3MG        T2

   50458055201     INVEGA                                 TB24         9MG        T2

   50458055101     INVEGA                                 TB24         6MG        T2

   50458030104     RISPERDAL                              TABS         0.25MG     T2

   50458032006     RISPERDAL                              TABS         2MG        T2

   50458033006     RISPERDAL                              TABS         3MG        T2

   50458030206     RISPERDAL                              TABS         0.5MG      T2

   50458030503     RISPERDAL                              SOLN         1MG/ML     T2

   50458030006     RISPERDAL                              TABS         1MG        T2

   50458035006     RISPERDAL                              TABS         4MG        T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 67 of 285
   50458030811     RISPERDAL CONSTA                       SUSR         50MG     T2

   50458030611     RISPERDAL CONSTA                       SUSR         25MG     T2

   50458030711     RISPERDAL CONSTA                       SUSR         37.5MG   T2

   50458030911     RISPERDAL CONSTA                       SUSR         12.5MG   T2

   50458032528     RISPERDAL M-TAB                        TBDP         2MG      T2

   50458033528     RISPERDAL M-TAB                        TBDP         3MG      T2

   50458035528     RISPERDAL M-TAB                        TBDP         4MG      T2

   50458039530     RISPERDAL M-TAB                        TBDP         0.5MG    T2

   50458031528     RISPERDAL M-TAB                        TBDP         1MG      T2

   00310027210     SEROQUEL                               TABS         200MG    T2

   00310027510     SEROQUEL                               TABS         25MG     T2

   00310027810     SEROQUEL                               TABS         50MG     T2

   00310027910     SEROQUEL                               TABS         400MG    T2

   00310027110     SEROQUEL                               TABS         100MG    T2

   00310027460     SEROQUEL                               TABS         300MG    T2

   00310028260     SEROQUEL XR                            TB24         200MG    T2

   00310028360     SEROQUEL XR                            TB24         300MG    T2

   00310028460     SEROQUEL XR                            TB24         400MG    T2

   00002411630     ZYPREXA                                TABS         7.5MG    T2

   00002441530     ZYPREXA                                TABS         15MG     T2

   00002411230     ZYPREXA                                TABS         2.5MG    T2

   00002411530     ZYPREXA                                TABS         5MG      T2

   00002759701     ZYPREXA                                SOLR         10MG     T2

   00002411730     ZYPREXA                                TABS         10MG     T2

   00002442030     ZYPREXA                                TABS         20MG     T2

   00002445385     ZYPREXA ZYDIS                          TBDP         5MG      T2

   00002445485     ZYPREXA ZYDIS                          TBDP         10MG     T2

   00002445585     ZYPREXA ZYDIS                          TBDP         15MG     T2

   00002445685     ZYPREXA ZYDIS                          TBDP         20MG     T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com         Page 68 of 285
   (28:16.08.08) CNS Agents » Psychotherapeutics » Antipsychotics » Butyrophenones
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00378025701     HALOPERIDOL                            TABS         1MG        T1

   00378032701     HALOPERIDOL                            TABS         5MG        T1

   00378035101     HALOPERIDOL                            TABS         0.5MG      T1

   00781139801     HALOPERIDOL                            TABS         20MG       T1

   00378021401     HALOPERIDOL                            TABS         2MG        T1

   00093960412     HALOPERIDOL                            CONC         2MG/ML     T1

   00781139701     HALOPERIDOL                            TABS         10MG       T1

   00703701301     HALOPERIDOL DECANOATE                  SOLN         50MG/ML    T1

   00703702301     HALOPERIDOL DECANOATE                  SOLN         100MG/ML   T1

   00703704103     HALOPERIDOL LACTATE                    SOLN         5MG/ML     T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00045025501     HALDOL                                 SOLN         5MG/ML     T2

   00045025414     HALDOL DECANOATE-100                   SOLN         100MG/ML   T2

   00045025301     HALDOL DECANOATE-50                    SOLN         50MG/ML    T2

   60505072703     HALOPERIDOL LACTATE                    SOLN         5MG/ML     T2




   (28:16.08.24) CNS Agents » Psychotherapeutics » Antipsychotics » Phenothiazines
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00781171501     CHLORPROMAZINE HCL                     TABS         10MG       T1

   00781171801     CHLORPROMAZINE HCL                     TABS         100MG      T1

   00781171601     CHLORPROMAZINE HCL                     TABS         25MG       T1

   00641139835     CHLORPROMAZINE HCL                     SOLN         25MG/ML    T1

   00781171701     CHLORPROMAZINE HCL                     TABS         50MG       T1

   00832030400     CHLORPROMAZINE HCL                     TABS         200MG      T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 69 of 285
   00574722612     COMPRO                                 SUPP         25MG       T1

   60505066402     FLUPHENAZINE DECANOATE                 SOLN         25MG/ML    T1

   00378600401     FLUPHENAZINE HCL                       TABS         1MG        T1

   00378600901     FLUPHENAZINE HCL                       TABS         2.5MG      T1

   00378607401     FLUPHENAZINE HCL                       TABS         5MG        T1

   63323028110     FLUPHENAZINE HCL                       SOLN         2.5MG/ML   T1

   00378609701     FLUPHENAZINE HCL                       TABS         10MG       T1

   00603509021     PERPHENAZINE                           TABS         2MG        T1

   00603509121     PERPHENAZINE                           TABS         4MG        T1

   00603509321     PERPHENAZINE                           TABS         16MG       T1

   00603509221     PERPHENAZINE                           TABS         8MG        T1

   00641049125     PROCHLORPERAZINE EDISYLATE             SOLN         5MG/ML     T1

   00781502001     PROCHLORPERAZINE MALEATE               TABS         5MG        T1

   00093965201     PROCHLORPERAZINE MALEATE               TABS         10MG       T1

   00378061201     THIORIDAZINE HCL                       TABS         10MG       T1

   00378061601     THIORIDAZINE HCL                       TABS         50MG       T1

   00378061401     THIORIDAZINE HCL                       TABS         25MG       T1

   00378061801     THIORIDAZINE HCL                       TABS         100MG      T1

   00378240201     TRIFLUOPERAZINE HCL                    TABS         2MG        T1

   00378240501     TRIFLUOPERAZINE HCL                    TABS         5MG        T1

   00378240101     TRIFLUOPERAZINE HCL                    TABS         1MG        T1

   00781103601     TRIFLUOPERAZINE HCL                    TABS         10MG       T1




   (28:16.08.32) CNS Agents » Psychotherapeutics » Antipsychotics » Thioxanthenes
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00378100101     THIOTHIXENE                            CAPS         1MG        T1

   00378200201     THIOTHIXENE                            CAPS         2MG        T1

   00378501001     THIOTHIXENE                            CAPS         10MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 70 of 285
   00378300501     THIOTHIXENE                            CAPS         5MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00049577066     NAVANE                                 CAPS         20MG         T2




   (28:16.08.92) CNS Agents » Psychotherapeutics » Antipsychotics » Antipsychotics, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00591036901     LOXAPINE SUCCINATE                     CAPS         5MG          T1

   00591037201     LOXAPINE SUCCINATE                     CAPS         50MG         T1

   00591037001     LOXAPINE SUCCINATE                     CAPS         10MG         T1

   00591037101     LOXAPINE SUCCINATE                     CAPS         25MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   63481007270     MOBAN                                  TABS         5MG          T2

   63481007370     MOBAN                                  TABS         10MG         T2

   63481007470     MOBAN                                  TABS         25MG         T2

   63481007670     MOBAN                                  TABS         50MG         T2

   57844018701     ORAP                                   TABS         2MG          T2

   57844015101     ORAP                                   TABS         1MG          T2




   (28:20.04) CNS Agents » Anorexic, Respiratory & Cerebral Stimulants » Amphetamines
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00555077502     AMPHETAMINE SALT COMBO                 TABS         1.875MG;     T1
                                                                       1.875MG;
                                                                       1.875MG;
                                                                       1.875MG
   00555097202     AMPHETAMINE SALT COMBO                 TABS         2.5MG; 2.5MG; T1
                                                                       2.5MG; 2.5MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 71 of 285
   00555097402     AMPHETAMINE SALT COMBO                 TABS         7.5MG; 7.5MG; T1
                                                                       7.5MG; 7.5MG
   00555077702     AMPHETAMINE SALT COMBO                 TABS         3.75MG;      T1
                                                                       3.75MG;
                                                                       3.75MG;
                                                                       3.75MG
   00555077602     AMPHETAMINE SALT COMBO                 TABS         3.125MG;     T1
                                                                       3.125MG;
                                                                       3.125MG;
                                                                       3.125MG
   00555097102     AMPHETAMINE SALT COMBO                 TABS         1.25MG;      T1
                                                                       1.25MG;
                                                                       1.25MG;
                                                                       1.25MG
   00555097302     AMPHETAMINE SALT COMBO                 TABS         5MG; 5MG;    T1
                                                                       5MG; 5MG
   00555095302     DEXTROAMPHETAMINE SULFATE              TABS         10MG         T1

   00555095202     DEXTROAMPHETAMINE SULFATE              TABS         5MG          T1

   00555095502     DEXTROAMPHETAMINE SULFATECR            CP24         10MG         T1

   00555095602     DEXTROAMPHETAMINE SULFATECR            CP24         15MG         T1

   00555095402     DEXTROAMPHETAMINE SULFATECR            CP24         5MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   54092039101     ADDERALL XR                            CP24         7.5MG; 7.5MG; T2
                                                                       7.5MG; 7.5MG
   54092038901     ADDERALL XR                            CP24         6.25MG;      T2
                                                                       6.25MG;
                                                                       6.25MG;
                                                                       6.25MG
   54092038101     ADDERALL XR                            CP24         1.25MG;      T2
                                                                       1.25MG;
                                                                       1.25MG;
                                                                       1.25MG
   54092038301     ADDERALL XR                            CP24         2.5MG; 2.5MG; T2
                                                                       2.5MG; 2.5MG
   54092038501     ADDERALL XR                            CP24         3.75MG;      T2
                                                                       3.75MG;
                                                                       3.75MG;
                                                                       3.75MG
   54092038701     ADDERALL XR                            CP24         5MG; 5MG;    T2
                                                                       5MG; 5MG
   67386010201     DESOXYN                                TABS         5MG          T2

   59417010510     VYVANSE                                CAPS         50MG         T2            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 72 of 285
   59417010310     VYVANSE                                CAPS         30MG       T2            MN


   59417010710     VYVANSE                                CAPS         70MG       T2            MN




   (28:20.92) CNS Agents » Anorexic, Respiratory & Cerebral Stimulants » Anorexic, Respiratory & Cerebral Stimulants,
   Misc
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00187049802     BONTRIL SR                             CP24         105MG      T1

   00574015210     CAFFEINE CITRATE                       SOLN         20MG/ML    T1

   00591078201     DIETHYLPROPION HCL ER                  TB24         75MG       T1

   00406112201     METHYLIN                               TABS         10MG       T1

   00406112101     METHYLIN                               TABS         5MG        T1

   00406112401     METHYLIN                               TABS         20MG       T1

   00406142301     METHYLIN ER                            TBCR         10MG       T1

   00406145101     METHYLIN ER                            TBCR         20MG       T1

   00185500001     PHENTERMINE HCL                        CAPS         30MG       T1

   52152015902     PHENTERMINE HCL                        TABS         37.5MG     T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   17314585002     CONCERTA                               TBCR         18MG       T2

   17314585102     CONCERTA                               TBCR         36MG       T2

   17314585202     CONCERTA                               TBCR         54MG       T2

   17314585302     CONCERTA                               TBCR         27MG       T2

   00074245812     MERIDIA                                CAPS         15MG       T2

   00074245712     MERIDIA                                CAPS         10MG       T2

   53014058207     METADATE CD                            CPCR         40MG       T2

   53014058107     METADATE CD                            CPCR         30MG       T2

   53014058307     METADATE CD                            CPCR         50MG       T2

   53014057907     METADATE CD                            CPCR         10MG       T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 73 of 285
   53014058007     METADATE CD                            CPCR         20MG       T2

   53014058407     METADATE CD                            CPCR         60MG       T2

   68188013701     METHYLIN                               CHEW         10MG       T2

   68188088150     METHYLIN                               SOLN         5MG/5ML    T2

   68188013201     METHYLIN                               CHEW         2.5MG      T2

   68188013501     METHYLIN                               CHEW         5MG        T2

   68188088250     METHYLIN                               SOLN         10MG/5ML   T2

   63459020101     PROVIGIL                               TABS         200MG      T2            PA


   63459010101     PROVIGIL                               TABS         100MG      T2            PA


   00078037205     RITALIN LA                             CP24         40MG       T2

   00078037105     RITALIN LA                             CP24         30MG       T2

   00078037005     RITALIN LA                             CP24         20MG       T2

   00078042405     RITALIN LA                             CP24         10MG       T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   54092055230     DAYTRANA                               PTCH         10MG/9HR   T3            MN


   54092055430     DAYTRANA                               PTCH         20MG/9HR   T3            MN


   54092055530     DAYTRANA                               PTCH         30MG/9HR   T3            MN


   54092055330     DAYTRANA                               PTCH         15MG/9HR   T3            MN


   00093527701     DEXMETHYLPHENIDATE HCL                 TABS         10MG       T3

   00078038005     FOCALIN                                TABS         2.5MG      T3            MN


   00078038105     FOCALIN                                TABS         5MG        T3            MN


   00078043105     FOCALIN XR                             CP24         10MG       T3            MN


   00078049305     FOCALIN XR                             CP24         15MG       T3            MN


   00078043005     FOCALIN XR                             CP24         5MG        T3            MN


   00078043205     FOCALIN XR                             CP24         20MG       T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 74 of 285
   (28:24.04) CNS Agents » Anxiolytics, Sedatives, & Hypnotics » Barbiturates
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00143144510     PHENOBARBITAL                          TABS         15MG       T1

   00143145510     PHENOBARBITAL                          TABS         60MG       T1

   00603516632     PHENOBARBITAL                          TABS         32.4MG     T1

   00603516721     PHENOBARBITAL                          TABS         64.8MG     T1

   64125090301     PHENOBARBITAL                          TABS         100MG      T1

   00603150858     PHENOBARBITAL                          ELIX         20MG/5ML   T1

   00603516532     PHENOBARBITAL                          TABS         16.2MG     T1

   00143145010     PHENOBARBITAL                          TABS         30MG       T1

   00603516821     PHENOBARBITAL                          TABS         97.2MG     T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00037011016     BUTISOL SODIUM                         ELIX         30MG/5ML   T2

   00037011460     BUTISOL SODIUM                         TABS         50MG       T2

   00037011360     BUTISOL SODIUM                         TABS         30MG       T2

   67386080202     MEBARAL                                TABS         50MG       T2

   67386080102     MEBARAL                                TABS         32MG       T2

   67386080302     MEBARAL                                TABS         100MG      T2

   63304067901     SECONAL                                CAPS         100MG      T2




   (28:24.08) CNS Agents » Anxiolytics, Sedatives, & Hypnotics » Benzodiazepines
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00378400305     ALPRAZOLAM                             TABS         0.5MG      T1

   00228202796     ALPRAZOLAM                             TABS         0.25MG     T1

   00228203150     ALPRAZOLAM                             TABS         1MG        T1

   59762372201     ALPRAZOLAM                             TABS         2MG        T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 75 of 285
   59762005701     ALPRAZOLAM XR                          TB24         0.5MG    T1

   59762005901     ALPRAZOLAM XR                          TB24         1MG      T1

   59762006601     ALPRAZOLAM XR                          TB24         2MG      T1

   59762006801     ALPRAZOLAM XR                          TB24         3MG      T1

   49884096001     CHLORDIAZEPOXIDE HCL                   CAPS         25MG     T1

   00555003302     CHLORDIAZEPOXIDE HCL                   CAPS         10MG     T1

   00555015802     CHLORDIAZEPOXIDE HCL                   CAPS         5MG      T1

   00378007001     CLORAZEPATE DIPOTASSIUM                TABS         15MG     T1

   00378003001     CLORAZEPATE DIPOTASSIUM                TABS         3.75MG   T1

   00378004001     CLORAZEPATE DIPOTASSIUM                TABS         7.5MG    T1

   00378027105     DIAZEPAM                               TABS         2MG      T1

   00378047705     DIAZEPAM                               TABS         10MG     T1

   00409127332     DIAZEPAM                               SOLN         5MG/ML   T1

   00409321302     DIAZEPAM                               SOLN         5MG/ML   T1

   00378034505     DIAZEPAM                               TABS         5MG      T1

   00093012901     ESTAZOLAM                              TABS         1MG      T1

   00093013001     ESTAZOLAM                              TABS         2MG      T1

   00378441501     FLURAZEPAM HCL                         CAPS         15MG     T1

   00378443001     FLURAZEPAM HCL                         CAPS         30MG     T1

   00409198530     LORAZEPAM                              SOLN         2MG/ML   T1

   63304077305     LORAZEPAM                              TABS         1MG      T1

   10019010201     LORAZEPAM                              SOLN         2MG/ML   T1

   63304077205     LORAZEPAM                              TABS         0.5MG    T1

   63304077405     LORAZEPAM                              TABS         2MG      T1

   55390013705     MIDAZOLAM HCL                          SOLN         1MG/ML   T1

   63304020518     MIDAZOLAM HCL                          SYRP         2MG/ML   T1

   00228206710     OXAZEPAM                               CAPS         10MG     T1

   00228207310     OXAZEPAM                               CAPS         30MG     T1

   00228206910     OXAZEPAM                               CAPS         15MG     T1

   00378505001     TEMAZEPAM                              CAPS         30MG     T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com         Page 76 of 285
   00378401001     TEMAZEPAM                              CAPS         15MG        T1

   59762371804     TRIAZOLAM                              TABS         0.25MG      T1

   59762371704     TRIAZOLAM                              TABS         0.125MG     T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00054306844     ALPRAZOLAM INTENSOL                    CONC         1MG/ML      T2

   00054318863     DIAZEPAM                               SOLN         1MG/ML      T2

   00054318544     DIAZEPAM INTENSOL                      CONC         5MG/ML      T2

   63004773401     DORAL                                  TABS         15MG        T2

   00054353244     LORAZEPAM INTENSOL                     CONC         2MG/ML      T2

   00091332201     NIRAVAM                                TBDP         0.5MG       T2

   00091332301     NIRAVAM                                TBDP         1MG         T2

   00091332401     NIRAVAM                                TBDP         2MG         T2

   00091332101     NIRAVAM                                TBDP         0.25MG      T2

   00406991403     RESTORIL                               CAPS         22.5MG      T2

   00406991501     RESTORIL                               CAPS         7.5MG       T2

   67386040401     TRANXENE-SD                            TB24         11.25MG     T2

   67386040501     TRANXENE-SD                            TB24         22.5MG      T2




   (28:24.92) CNS Agents » Anxiolytics, Sedatives, & Hypnotics » Anxiolytics, Sedatives, & Hypnotics - Misc
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00378117591     BUSPIRONE HCL                          TABS         30MG        T1

   00172566560     BUSPIRONE HCL                          TABS         15MG        T1

   00378115001     BUSPIRONE HCL                          TABS         10MG        T1

   00591065701     BUSPIRONE HCL                          TABS         5MG         T1

   49884072501     BUSPIRONE HCL                          TABS         7.5MG       T1

   00603108858     CHLORAL HYDRATE                        SYRP         500MG/5ML   T1

   50111030801     HYDROXYZINE HCL                        TABS         25MG        T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 77 of 285
   50111030901     HYDROXYZINE HCL                        TABS         50MG        T1

   63323005101     HYDROXYZINE HCL                        SOLN         50MG/ML     T1

   00603131058     HYDROXYZINE HCL                        SYRP         10MG/5ML    T1

   50111030701     HYDROXYZINE HCL                        TABS         10MG        T1

   00555032402     HYDROXYZINE PAMOATE                    CAPS         100MG       T1

   00185061301     HYDROXYZINE PAMOATE                    CAPS         25MG        T1

   00185061501     HYDROXYZINE PAMOATE                    CAPS         50MG        T1

   00591523901     MEPROBAMATE                            TABS         200MG       T1

   00591523801     MEPROBAMATE                            TABS         400MG       T1

   51991008051     SOMNOTE                                CAPS         500MG       T1

   00093007301     ZOLPIDEM TARTRATE                      TABS         5MG         T1

   00093007401     ZOLPIDEM TARTRATE                      TABS         10MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details      Comment

   00024542131     AMBIEN                                 TABS         10MG        T2            PA; MN


   00024540131     AMBIEN                                 TABS         5MG         T2            PA; MN


   00713053325     CHLORAL HYDRATE                        SUPP         500MG       T2

   10551009110     EQUAGESIC                              TABS         325MG; 200MG T2

   63402019110     LUNESTA                                TABS         2MG         T2            PA; ST(#2:SED1)


   63402019310     LUNESTA                                TABS         3MG         T2            PA; ST(#2:SED1)


   63402019010     LUNESTA                                TABS         1MG         T2            PA; ST(#2:SED1)




   Tier: T3
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details      Comment

   00024550131     AMBIEN CR                              TBCR         6.25MG      T3            MN; ST(#2:SED1)


   00024552131     AMBIEN CR                              TBCR         12.5MG      T3            MN; ST(#2:SED1)


   64764080530     ROZEREM                                TABS         8MG         T3            PA; MN; ST(#2:SED1)


   60793014501     SONATA                                 CAPS         5MG         T3            PA; MN; ST(#2:SED1)


   60793014601     SONATA                                 CAPS         10MG        T3            PA; MN; ST(#2:SED1)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 78 of 285
   (28:28) CNS Agents » Antimanics
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details         Comment

   00054252725     LITHIUM CARBONATE                      CAPS         300MG       T1

   00054452725     LITHIUM CARBONATE                      TABS         300MG       T1

   00054252625     LITHIUM CARBONATE                      CAPS         150MG       T1

   00054002125     LITHIUM CARBONATE ER                   TBCR         300MG       T1

   00143127701     LITHIUM CARBONATE ER                   TBCR         450MG       T1

   60432061616     LITHIUM CITRATE                        SYRP         8MEQ/5ML    T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details         Comment

   00054253125     LITHIUM CARBONATE                      CAPS         600MG       T2




   (28:32.28) CNS Agents » Antimigraine » Selective Serotonin Agonists
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details         Comment

   00173056100     AMERGE                                 TABS         1MG         T2            QL (9.00 per 30 days)


   00173056200     AMERGE                                 TABS         2.5MG       T2            QL (9.00 per 30 days)


   00062208006     AXERT                                  TABS         6.25MG      T2            QL (12.00 per 30 days)


   00062208512     AXERT                                  TABS         12.5MG      T2            QL (12.00 per 30 days)


   63481002509     FROVA                                  TABS         2.5MG       T2            QL (9.00 per 30 days)


   00173073500     IMITREX                                TABS         25MG        T2            QL (18.00 per 30 days)


   00173073701     IMITREX                                TABS         100MG       T2            QL (9.00 per 30 days)


   00173073601     IMITREX                                TABS         50MG        T2            QL (18.00 per 30 days)


   00173052300     IMITREX                                SOLN         20MG/ACT    T2            QL (6.00 per 30 days)


   00173052400     IMITREX                                SOLN         5MG/ACT     T2            QL (6.00 per 30 days)


   00173044902     IMITREX                                SOLN         6MG/0.5ML   T2            QL (8.00 per 30 days)


   00173073902     IMITREX STATDOSE REFILL                KIT          4MG/0.5ML   T2            QL (8.00 per 30 days)


   00173047800     IMITREX STATDOSE REFILL                KIT          6MG/0.5ML   T2            QL (8.00 per 30 days)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 79 of 285
   00173047900     IMITREX STATDOSE SYSTEM                KIT          6MG/0.5ML     T2            QL (8.00 per 30 days)


   00173073900     IMITREX STATDOSE SYSTEM                KIT          4MG/0.5ML     T2            QL (8.00 per 30 days)


   00006026712     MAXALT                                 TABS         10MG          T2            QL (12.00 per 30 days)


   00006026612     MAXALT                                 TABS         5MG           T2            QL (12.00 per 30 days)


   00006380012     MAXALT-MLT                             TBDP         5MG           T2            QL (12.00 per 30 days)


   00006380112     MAXALT-MLT                             TBDP         10MG          T2            QL (12.00 per 30 days)


   00049234045     RELPAX                                 TABS         40MG          T2            QL (12.00 per 30 days)


   00049233045     RELPAX                                 TABS         20MG          T2            QL (12.00 per 30 days)


   00310021020     ZOMIG                                  TABS         2.5MG         T2            QL (12.00 per 30 days)


   00310021125     ZOMIG                                  TABS         5MG           T2            QL (12.00 per 30 days)


   00310020860     ZOMIG                                  SOLN         5MG           T2            QL (12.00 per 30 days)


   00310021321     ZOMIG ZMT                              TBDP         5MG           T2            QL (12.00 per 30 days)


   00310020920     ZOMIG ZMT                              TBDP         2.5MG         T2            QL (12.00 per 30 days)




   (28:32.92) CNS Agents » Antimigraine » Antimigraine, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details         Comment

   00574085010     DIHYDROERGOTAMINE MESYLATE             SOLN         1MG/ML        T1            QL (30.00 per 30 days)


   64125010101     EPIDRIN                                CAPS         325MG;        T1
                                                                       100MG; 65MG
   00143212001     ERGOTAMINE TARTRATE/CAFFEINE           TABS         100MG; 1MG    T1

   00713016612     MIGERGOT                               SUPP         100MG; 2MG    T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details         Comment

   55390001310     DIHYDROERGOTAMINE MESYLATE             SOLN         1MG/ML        T2            QL (30.00 per 30 days)


   10802120200     ERGOMAR                                SUBL         2MG           T2

   00187024503     MIGRANAL                               SOLN         4MG/ML        T2            QL (16.00 per 30 days)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                          Page 80 of 285
   (28:36.04) CNS Agents » Antiparkinsonian Agents » Adamantanes
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   60432009316     AMANTADINE HCL                         SYRP         50MG/5ML   T1

   00781204801     AMANTADINE HCL                         CAPS         100MG      T1

   00832011100     AMANTADINE HCL                         TABS         100MG      T1




   (28:36.08) CNS Agents » Antiparkinsonian Agents » Anticholinergic Agents
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   49884016501     BENZTROPINE MESYLATE                   TABS         1MG        T1

   49884016401     BENZTROPINE MESYLATE                   TABS         0.5MG      T1

   49884016601     BENZTROPINE MESYLATE                   TABS         2MG        T1

   00591533501     TRIHEXYPHENIDYL HCL                    TABS         2MG        T1

   00603624121     TRIHEXYPHENIDYL HCL                    TABS         5MG        T1

   61748005416     TRIHEXYPHENIDYL HCL                    ELIX         0.4MG/ML   T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   67386061152     COGENTIN                               SOLN         1MG/ML     T2

   61570005901     KEMADRIN                               TABS         5MG        T2




   (28:36.12) CNS Agents » Antiparkinsonian Agents » Catechol-O-Methyltransferase (COMT) Inhibitors
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00078032705     COMTAN                                 TABS         200MG      T2

   00187093901     TASMAR                                 TABS         200MG      T2

   00187093801     TASMAR                                 TABS         100MG      T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 81 of 285
   (28:36.16) CNS Agents » Antiparkinsonian Agents » Dopamine Precursors
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093029301     CARBIDOPA/LEVODOPA                     TABS         25MG; 100MG   T1

   00093029401     CARBIDOPA/LEVODOPA                     TABS         25MG; 250MG   T1

   00093029201     CARBIDOPA/LEVODOPA                     TABS         10MG; 100MG   T1

   00378008801     CARBIDOPA/LEVODOPA ER                  TBCR         25MG; 100MG   T1

   00378009401     CARBIDOPA/LEVODOPA ER                  TBCR         50MG; 200MG   T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00056051168     LODOSYN                                TABS         25MG          T2

   00091334101     PARCOPA                                TBDP         10MG; 100MG   T2

   00091334201     PARCOPA                                TBDP         25MG; 100MG   T2

   00091334301     PARCOPA                                TBDP         25MG; 250MG   T2

   00078040805     STALEVO 100                            TABS         25MG; 200MG; T2
                                                                       100MG
   00078040905     STALEVO 150                            TABS         37.5MG;      T2
                                                                       200MG; 150MG
   00078040705     STALEVO 50                             TABS         12.5MG;       T2
                                                                       200MG; 50MG




   (28:36.20.04) CNS Agents » Antiparkinsonian Agents » Dopamine Receptor Agonists » Ergot-derivative Dopamine
   Receptor Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00378709693     BROMOCRIPTINE MESYLATE                 CAPS         5MG           T1

   00781532531     BROMOCRIPTINE MESYLATE                 TABS         2.5MG         T1

   49884067314     CABERGOLINE                            TABS         0.5MG         T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 82 of 285
   (28:36.20.08) CNS Agents » Antiparkinsonian Agents » Dopamine Receptor Agonists » Nonergot-derivative Dopamine
   Receptor Agonists
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   16887021101     APOKYN                                 SOLN         10MG/ML    T2

   00597018390     MIRAPEX                                TABS         0.125MG    T2

   00597018490     MIRAPEX                                TABS         0.25MG     T2

   00597019190     MIRAPEX                                TABS         1.5MG      T2

   00597018590     MIRAPEX                                TABS         0.5MG      T2

   00597019090     MIRAPEX                                TABS         1MG        T2

   00091648801     NEUPRO                                 PT24         6MG/24HR   T2

   00091648601     NEUPRO                                 PT24         2MG/24HR   T2

   00091648701     NEUPRO                                 PT24         4MG/24HR   T2

   00007489020     REQUIP                                 TABS         0.25MG     T2

   00007489420     REQUIP                                 TABS         5MG        T2

   00007489620     REQUIP                                 TABS         4MG        T2

   00007489220     REQUIP                                 TABS         1MG        T2

   00007489320     REQUIP                                 TABS         2MG        T2

   00007489520     REQUIP                                 TABS         3MG        T2

   00007489120     REQUIP                                 TABS         0.5MG      T2




   (28:36.32) CNS Agents » Antiparkinsonian Agents » Monoamine Oxidase B Inhibitors
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   60505005501     SELEGILINE HCL                         CAPS         5MG        T1

   60505343803     SELEGILINE HCL                         TABS         5MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   68546014256     AZILECT                                TABS         0.5MG      T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 83 of 285
   68546022956     AZILECT                                TABS         1MG         T2

   00187045302     ZELAPAR                                TBDP         1.25MG      T2


   Tier: T3
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   39506003330     EMSAM                                  PT24         6MG/24HR    T3            MN


   39506004430     EMSAM                                  PT24         9MG/24HR    T3            MN


   39506005530     EMSAM                                  PT24         12MG/24HR   T3            MN




   (28:92) CNS Agents » CNS, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00456333001     CAMPRAL                                TBEC         333MG       T2

   00456333060     CAMPRAL                                TBEC         333MG       T2

   00456320212     NAMENDA                                SOLN         10MG/5ML    T2

   00456321060     NAMENDA                                TABS         10MG        T2

   00456320560     NAMENDA                                TABS         5MG         T2

   00456320014     NAMENDA TITRATION PAK                  TABS         0           T2

   00075770060     RILUTEK                                TABS         50MG        T2

   00002322730     STRATTERA                              CAPS         10MG        T2

   00002322830     STRATTERA                              CAPS         25MG        T2

   00002323830     STRATTERA                              CAPS         18MG        T2

   00002323930     STRATTERA                              CAPS         60MG        T2

   00002325030     STRATTERA                              CAPS         80MG        T2

   00002322930     STRATTERA                              CAPS         40MG        T2

   00002325130     STRATTERA                              CAPS         100MG       T2

   68727010001     XYREM                                  SOLN         500MG/ML    T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 84 of 285
   (32:00) Contraceptives (foams, devices)
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   00062318012     GYNOL II                               GEL          2%         T2




   (34:00) Dental Agents
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   00126007061     PREVIDENT 5000 SENSITIVE               PSTE         5%; 1.1%   T2




   (36:00) Diagnostics
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   64281010006     PROVOCHOLINE                           SOLR         20MG/ML    T2




   (36:04) Diagnostics » Adrenocortical Insufficiency
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   00548590000     CORTROSYN                              SOLR         0.25MG     T2




   (36:26) Diagnostics » Diabetes Mellitus
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details          Comment

   50924088401     ACCU-CHEK COMPACT TEST DRUM            STRP         0          T2            QL (204.00 per 30 days)


   00193362721     ASCENSIA AUTODISC BLOOD GLUCOSE TEST STRP           0          T2            QL (204.00 per 30 days)
                   STRIPS
   53885024510     ONETOUCH ULTRA TEST STRIPS             STRP         0          T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 85 of 285
   (36:84) Diagnostics » Tuberculosis
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   64029452501     APLISOL                                SOLN         5UNIT/0.1ML   T2




   (36:88) Diagnostics » Urine & Feces Contents
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   00193288250     KETO-DIASTIX                           STRP         0             T2            QL (204.00 per 30 days)


   00193216121     MULTISTIX 10 SG STRIPS                 STRP         0             T2            QL (204.00 per 30 days)




   (36:88.12) Diagnostics » Urine & Feces Contents » Ketones
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   00193288050     KETOSTIX                               STRP         0             T2            QL (204.00 per 30 days)




   (36:88.40) Diagnostics » Urine & Feces Contents » Sugar
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   00193280250     DIASTIX                                STRP         0             T2            QL (204.00 per 30 days)




   (38:00) Disinfectants (not for topical use)
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details          Comment

   10481105005     FORMADON                               SOLN         10%; 0        T1

   68032019403     FORMALAZ                               SOLN         10%; 0        T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                           Page 86 of 285
   (4:04.04) Antihistamines » 1st Generation » 1st Gen Ethanolamines
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   60258005401     ALPAIN                                 TABS         500MG; 60MG   T1

   68308012204     BEN-TANN                               SUSP         25MG/5ML      T1

   00093030912     CLEMASTINE FUMARATE                    SYRP         0.67MG/5ML    T1

   00781135901     CLEMASTINE FUMARATE                    TABS         2.68MG        T1

   68308012604     D-TANN                                 SUSP         25MG/5ML;     T1
                                                                       7.5MG/5ML
   00548139000     DIPHENHYDRAMINE HCL                    SOLN         50MG/ML       T1

   00182049210     DIPHENHYDRAMINE HCL                    CAPS         25MG          T1

   00555005902     DIPHENHYDRAMINE HCL                    CAPS         50MG          T1

   00641037625     DIPHENHYDRAMINE HCL                    SOLN         50MG/ML       T1

   00536377206     DIPHENHYDRAMINE HCL                    TABS         50MG          T1

   10892011265     DYTUSS                                 SYRP         12.5MG/5ML    T1

   00525675216     PALGIC                                 LIQD         4MG/5ML       T1

   00603082358     Q-DRYL                                 LIQD         12.5MG/5ML    T1

   15370000710     RHINOFLEX                              TABS         500MG; 50MG   T1

   60258010501     TETRA-MAG                              TABS         600MG; 25MG   T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   68025000410     ACUFLEX                                TABS         635MG; 55MG   T2

   54859010150     DOLOGESIC                              TABS         500MG; 30MG   T2

   54859051206     DOLOGESIC                              LIQD         500MG/15ML;   T2
                                                                       30MG/15ML
   63717057106     DYTAN                                  CHEW         25MG          T2

   63717057706     DYTAN-D                                CHEW         25MG; 10MG    T2

   00277018701     LAGESIC                                TBCR         600MG; 66MG   T2

   00525674801     PALGIC                                 TABS         4MG           T2

   11584047601     RELAGESIC                              TABS         650MG; 50MG   T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 87 of 285
   (4:04.08) Antihistamines » 1st Generation » 1st Gen Ethylenediamines
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   66993052502     K-TAN                                  TABS         25MG; 60MG    T1

   51991026616     V-TANN B.I.D                           SUSP         12.5MG/5ML;   T1
                                                                       30MG/5ML


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   66813016116     PYRLEX                                 SUSP         12MG/5ML      T2

   66813016316     PYRLEX PD                              SUSP         9MG/5ML;      T2
                                                                       12MG/5ML




   (4:04.12) Antihistamines » 1st Generation » 1st Gen Phenothiazines
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00409231231     PROMETHAZINE HCL                       SOLN         25MG/ML       T1

   00603543721     PROMETHAZINE HCL                       TABS         12.5MG        T1

   00641149535     PROMETHAZINE HCL                       SOLN         25MG/ML       T1

   00641149635     PROMETHAZINE HCL                       SOLN         50MG/ML       T1

   00703219104     PROMETHAZINE HCL                       SOLN         25MG/ML       T1

   00781183201     PROMETHAZINE HCL                       TABS         50MG          T1

   50383080116     PROMETHAZINE HCL                       SYRP         6.25MG/5ML    T1

   00703220104     PROMETHAZINE HCL                       SOLN         50MG/ML       T1

   00781183001     PROMETHAZINE HCL                       TABS         25MG          T1

   00603158758     PROMETHAZINE VC PLAIN                  SYRP         5MG/5ML;      T1
                                                                       6.25MG/5ML
   00713013212     PROMETHEGAN                            SUPP         50MG          T1

   00713053612     PROMETHEGAN                            SUPP         12.5MG        T1

   00713052612     PROMETHEGAN                            SUPP         25MG          T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 88 of 285
   (4:04.20) Antihistamines » 1st Generation » 1st Gen Propylamines
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   60258042416     ALENAZE-D                              LIQD         2MG/5ML;      T1
                                                                       7.5MG/5ML
   60258043416     ANDEHIST NR                            SYRP         4MG/5ML;      T1
                                                                       45MG/5ML
   68308092204     B-VEX                                  SUSP         12MG/5ML      T1

   68308092604     B-VEX D                                SUSP         12MG/5ML;     T1
                                                                       20MG/5ML
   60258044901     BELLAHIST-D LA                         TB12         0.04MG; 8MG; T1
                                                                       0.19MG;
                                                                       20MG; 0.01MG
   58177001904     BROMFENEX                              CPCR         12MG; 120MG   T1

   58177002004     BROMFENEX PD                           CPCR         6MG; 60MG     T1

   60258043330     BROMHIST PEDIATRIC                     LIQD         1MG/ML;       T1
                                                                       15MG/ML
   60258042730     BROMHIST-NR                            LIQD         1MG/ML;       T1
                                                                       12.5MG/ML
   68013000760     BROMPHENIRAMINE TANNATE                CHEW         12MG          T1

   60258041416     CERON                                  SYRP         4MG/5ML;      T1
                                                                       12.5MG/5ML
   60258041630     CERON                                  LIQD         1MG/ML;       T1
                                                                       3.5MG/ML
   60258022116     CHLOR-MES D                            SYRP         2MG/5ML;     T1
                                                                       0.625MG/5ML;
                                                                       10MG/5ML
   60258028301     CHLOREX-A                              TBCR         4MG; 20MG;    T1
                                                                       40MG
   64376043116     CHLORPHENIRAMINE /PHENYLTOLOXAMINE     LIQD         2.5MG/5ML;    T1
                   /PHENYLEPHRINE                                      5MG/5ML;
                                                                       7.5MG/5ML
   64376071416     CHLORPHENIRAMINE /PSEUDOEPHEDRINE      SYRP         2MG/5ML;      T1
                                                                       30MG/5ML
   49483004101     CHLORPHENIRAMINE MALEATE ER            CPCR         8MG           T1

   49483004301     CHLORPHENIRAMINE MALEATE ER            CPCR         12MG          T1

   00185130401     CHLORPHENIRAMINE/PSEUDOEPHEDRINE CR CPCR            8MG; 120MG    T1

   68032018210     CHLORPHENIRAMINE/PSEUDOEPHEDRINE LA TB12            12MG; 120MG   T1

   10914095501     CPM                                    CP24         12MG          T1

   60258025001     CPM 8/PE 20/MSC 1.25                   TB12         8MG; 1.25MG; T1
                                                                       20MG

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 89 of 285
   60258028201     CPM 8/PSE 90/MSC 2.5                   TB12         8MG; 2.5MG;   T1
                                                                       90MG
   60258022016     DEHISTINE                              SYRP         2MG/5ML;      T1
                                                                       1.25MG/5ML;
                                                                       10MG/5ML
   60432053916     DEXCHLORPHENIRAMINE MALEATE            SYRP         2MG/5ML       T1

   52152001402     DEXCHLORPHENIRAMINE MALEATE CR         TBCR         4MG           T1

   51991018916     DUOTAN PD                              SUSP         2.5MG/5ML;    T1
                                                                       75MG/5ML
   66869043010     DURATAN PE                             SUSP         2MG/5ML;      T1
                                                                       1.5MG/5ML;
                                                                       10MG/5ML
   51991021701     DYNAHIST ER                            CP12         4MG; 60MG     T1

   00485007602     ED CHLORPED D                          SUSP         2MG/ML;       T1
                                                                       6MG/ML
   14629010201     EXTENDRYL JR                           TB12         4MG; 1.25MG; T1
                                                                       10MG
   00256011101     EXTENDRYL SR                           CP12         8MG; 2.5MG;   T1
                                                                       20MG
   58177022704     HISTA-VENT DA                          TB12         8MG; 2.5MG;   T1
                                                                       20MG
   58177042604     HISTA-VENT PSE                         TB12         8MG; 2.5MG;   T1
                                                                       120MG
   51991017001     HISTADE SR                             CP12         12MG; 120MG   T1

   68047012101     LOHIST-12                              TB12         6MG           T1

   68047012201     LOHIST-12D                             TB12         6MG; 45MG     T1

   68047012016     LOHIST-D                               LIQD         2MG/5ML;      T1
                                                                       30MG/5ML
   68047016001     NOHIST                                 TBCR         8MG; 20MG     T1

   68047016101     NOHIST-EXT                             TB12         8MG; 2.5MG    T1

   68308041016     P-TANN                                 SUSP         8MG/5ML       T1

   64376053001     PCM                                    CHEW         2MG; 1.25MG; T1
                                                                       10MG
   60258028001     PCM LA                                 TB12         8MG; 1.25MG; T1
                                                                       60MG
   50383084216     PHENYL CHLOR-TAN                       SUSP         4.5MG/5ML;    T1
                                                                       5MG/5ML
   10914060001     PHENYLEPHRINE                          CP12         12MG; 15MG    T1
                   HYDROCHLORIDE/BROMPHENIRAMINE
                   MALEATE
   10892012710     PROTID                                 TBCR         500MG; 8MG;   T1
                                                                       40MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 90 of 285
   10914095001     PSEUDOEPHEDRINE                        CP24         12MG; 100MG   T1
                   HCL/CHLORPHENIRAMINE MALEATE
   66993053402     R-TANNA                                TABS         9MG; 25MG     T1

   60258023201     RALIX                                  TB12         8MG; 2.5MG;   T1
                                                                       40MG
   64543008501     RESCON-JR                              TBCR         4MG; 20MG     T1

   58869040601     TOURO ALLERGY                          TB12         6MG; 45MG     T1

   50383081904     TRI-HIST PEDIATRIC                     SUSP         2MG/5ML;      T1
                                                                       5MG/5ML;
                                                                       12.5MG/5ML
   66992013016     VAZOL                                  LIQD         2MG/5ML       T1

   67204032016     ZYMINE                                 LIQD         1.25MG/5ML    T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   23589000403     ACCUHIST                               SOLN         0.8MG/ML;     T2
                                                                       9MG/ML
   38739011003     AEROKID                                SYRP         4MG/5ML;      T2
                                                                       1.25MG/5ML;
                                                                       10MG/5ML
   59196003301     AH-CHEW II                             CHEW         2MG; 1.25MG; T2
                                                                       15MG
   59196011501     AH-CHEW ULTRA                          CHEW         2MG; 1.5MG;   T2
                                                                       10MG
   63162051516     ALACOL                                 SYRP         2MG/5ML;      T2
                                                                       5MG/5ML
   63162051760     ALACOL                                 LIQD         0.4MG/ML;     T2
                                                                       1MG/ML
   66869040710     ALLERDUR                               SUSP         3MG/5ML;      T2
                                                                       50MG/5ML
   66869016210     ALLERTAN                               SUSP         8MG/5ML;      T2
                                                                       15MG/5ML;
                                                                       12.5MG/5ML
   10122070316     ALLERX                                 SUSP         3MG/5ML;      T2
                                                                       7.5MG/5ML
   10122070420     ALLERX DF                              MISC         0; 0          T2

   10122070520     ALLERX PE                              MISC         0; 0; 0       T2

   68453020110     BROMFED-PD                             CP12         6MG; 7.5MG    T2

   00277016001     DALLERGY                               TABS         4MG; 1.25MG; T2
                                                                       10MG
   00277018201     DALLERGY                               TB12         12MG; 2.5MG; T2
                                                                       20MG


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   16477012030     DALLERGY                               LIQD         1MG/ML;       T2
                                                                       2MG/ML
   16477081901     DALLERGY                               SYRP         2MG/5ML;      T2
                                                                       0.75MG/5ML;
                                                                       8MG/5ML
   00277018301     DALLERGY JR                            CP12         4MG; 20MG     T2

   00277018641     DALLERGY-JR                            SUSP         4MG/5ML;      T2
                                                                       20MG/5ML
   10122020210     DECONSAL CT                            CHEW         10MG; 16MG    T2

   11528010016     DICEL                                  SUSP         5MG/5ML;      T2
                                                                       75MG/5ML
   66869042610     DURAHIST D                             TB12         3.5MG; 1MG;   T2
                                                                       45MG
   00485005516     ED A-HIST                              LIQD         4MG/5ML;      T2
                                                                       10MG/5ML
   00485007402     ED CHLORPED                            SUSP         2MG/ML        T2

   00485007201     ED-CHLOR-TAN                           TABS         8MG           T2

   14629011416     EXTENDRYL                              SOLN         1MG/5ML;      T2
                                                                       1.25MG/5ML;
                                                                       10MG/5ML
   23589000110     HISTEX SR                              CP12         10MG; 120MG   T2

   23589000310     HISTEX SR                              TB12         10MG; 120MG   T2

   64661002016     J-TAN                                  SUSP         4MG/5ML       T2

   64661002216     J-TAN D                                SUSP         4MG/5ML;      T2
                                                                       5MG/5ML
   64661003230     J-TAN D PD                             LIQD         1MG/ML;       T2
                                                                       7.5MG/ML
   64661003130     J-TAN PD                               LIQD         1MG/ML        T2

   00095600416     LODRANE                                LIQD         4MG/5ML;      T2
                                                                       60MG/5ML
   00095120006     LODRANE 24                             CP24         12MG          T2

   00095129006     LODRANE 24D                            CP24         12MG; 90MG    T2

   00095900816     LODRANE D                              SUSP         8MG/5ML;      T2
                                                                       90MG/5ML
   00095000816     LODRANE XR                             SUSP         8MG/5ML       T2

   59196003201     OMNIHIST II LA                         TB12         8MG; 2.5MG;   T2
                                                                       25MG
   66869020110     PEDIATAN D                             SUSP         8MG/5ML;      T2
                                                                       10MG/5ML
   59702014104     PEDIOX-S                               SUSP         4MG/5ML       T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 92 of 285
   64543009590     RESCON                                 TB12         12MG; 2MG;    T2
                                                                       40MG
   60575017719     RESPA-A.R.                             TB12         0.24MG; 8MG; T2
                                                                       90MG
   00037071203     RYNATAN PEDIATRIC                      CHEW         4.5MG; 5MG    T2

   59702081901     SUDAL 12 TANNATE                       CHEW         4MG; 30MG     T2

   66992023004     VAZOBID                                SUSP         6MG/5ML;      T2
                                                                       10MG/5ML
   66992013616     VAZOL-D                                LIQD         4MG/5ML;      T2
                                                                       7.5MG/5ML
   68013001420     VISRX DOSE PACK                        TBCR         0; 0; 0       T2

   14629047401     ZINX ALLERGY                           KIT          8MG; 0;       T2
                                                                       120MG
   67204034016     ZYMINE DXR                             SUSP         45MG/5ML;     T2
                                                                       2.5MG/5ML
   67204032516     ZYMINE XR                              SUSP         2.5MG/5ML     T2

   67204024516     ZYMINE-D                               LIQD         45MG/5ML;     T2
                                                                       1.25MG/5ML




   (4:04.92) Antihistamines » 1st Generation » 1st Gen, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00472075516     CYPROHEPTADINE HCL                     SYRP         2MG/5ML       T1

   50111031401     CYPROHEPTADINE HCL                     TABS         4MG           T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   52747042070     NOREL SR                               TB12         325MG; 8MG;   T2
                                                                       40MG; 50MG




   (4:08) Antihistamines » 2nd Generation
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00573262148     ALAVERT                                TBDP         10MG          T1

   51672207308     CHILDREN'S LORATADINE                  SYRP         5MG/5ML       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 93 of 285
   00093725201     FEXOFENADINE HCL                       TABS         60MG          T1

   00093725301     FEXOFENADINE HCL                       TABS         180MG         T1

   00093725101     FEXOFENADINE HCL                       TABS         30MG          T1

   00781507701     LORATADINE                             TABS         10MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00088109720     ALLEGRA                                SUSP         30MG/5ML      T2

   00088109047     ALLEGRA-D 12 HOUR                      TB12         60MG; 120MG   T2

   00088109547     ALLEGRA-D 24 HOUR                      TB24         180MG; 240MG T2

   53014040410     SEMPREX-D                              CAPS         8MG; 60MG     T2

   00024580090     XYZAL                                  TABS         5MG           T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00085126401     CLARINEX                               TABS         5MG           T3            MN


   00085133401     CLARINEX                               SYRP         0.5MG/ML      T3            MN


   00085138401     CLARINEX REDITABS                      TBDP         5MG           T3            MN


   00085140801     CLARINEX REDITABS                      TBDP         2.5MG         T3            MN


   00085132201     CLARINEX-D 12 HOUR                     TB12         2.5MG; 120MG T3             MN


   00085131701     CLARINEX-D 24 HOUR                     TB24         5MG; 240MG    T3            MN




   (40:04) Electrolyte & Fluid Maint » Acidifiers
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00486113501     K-PHOS MF                              TABS         155MG; 350MG T2

   00486113401     K-PHOS NO 2                            TABS         305MG; 700MG T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 94 of 285
   (40:08) Electrolyte & Fluid Maint » Alkalinizers
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   60258000501     CYTRA K CRYSTALS                       PACK         1002MG;      T1
                                                                       3300MG
   60258000116     CYTRA-2                                SOLN         334MG/5ML;   T1
                                                                       500MG/5ML
   60258000216     CYTRA-3                                SYRP         334MG/5ML;   T1
                                                                       550MG/5ML;
                                                                       500MG/5ML
   64980013701     POTASSIUM CITRATE EXTENDED-RELEASE     TBCR         540MG        T1

   64980013801     POTASSIUM CITRATE EXTENDED-RELEASE     TBCR         1080MG       T1

   00802396216     SHOHL'S SOLUTION MODIFIED              SOLN         334MG/5ML;   T1
                                                                       500MG/5ML


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   46287001401     ORACIT                                 SOLN         640MG/5ML;   T2
                                                                       490MG/5ML
   17314932201     POLYCITRA                              SYRP         334MG/5ML;   T2
                                                                       550MG/5ML;
                                                                       500MG/5ML




   (40:10) Electrolyte & Fluid Maint » Ammonia Detoxicants
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00472136016     ENULOSE                                SOLN         10GM/15ML    T1

   60505036001     LACTULOSE                              SOLN         10GM/15ML    T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   62592049603     BUPHENYL                               TABS         500MG        T2

   66220072930     KRISTALOSE                             PACK         20GM         T2

   66220071930     KRISTALOSE                             PACK         10GM         T2

   00178050001     LITHOSTAT                              TABS         250MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 95 of 285
   (40:12) Electrolyte & Fluid Maint » Replacement Preparations
   Tier: T1
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00603350816     EFFERVESCENT POT CHLORIDE              TBEF         0.55GM;        T1
                                                                       0.91GM;
                                                                       0.5GM; 1.5GM
   00245003530     KLOR-CON                               PACK         20MEQ          T1

   00245004115     KLOR-CON 10                            TBCR         10MEQ          T1

   00245004015     KLOR-CON 8                             TBCR         8MEQ           T1

   00245005711     KLOR-CON M10                           TBCR         10MEQ          T1

   00245015011     KLOR-CON M15                           TBCR         15MEQ          T1

   00245005811     KLOR-CON M20                           TBCR         20MEQ          T1

   00245003930     KLOR-CON/EF                            TBEF         25MEQ          T1

   17474300205     MONOJECT PREFILL SODIUM CHLORIDE       SOLN         0.9%           T1

   00182443926     OYST-CAL-D 500                         TABS         500MG;         T1
                                                                       200UNIT
   60258000601     PHOS-NAK POWDER CONCENTRATE            PACK         250MG;       T1
                                                                       278MG; 164MG
   64980010401     PHOSPHA 250 NEUTRAL                    TABS         155MG;       T1
                                                                       852MG; 130MG
   00603153658     POTASSIUM CHLORIDE                     LIQD         20%            T1

   00603153458     POTASSIUM CHLORIDE                     LIQD         10%            T1

   58177000108     POTASSIUM CHLORIDE ER                  CPCR         10MEQ          T1

   00409488810     SODIUM CHLORIDE 0.9%                   SOLN         0.9%           T1

   00245008011     ZINC SULFATE                           CAPS         220MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00642006630     CALCIFOL                               WAFR         1MG; 1342MG; T2
                                                                       200UNIT;
                                                                       25MCG;
                                                                       1.6MG; 50MG;
                                                                       10MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 96 of 285
   00642006860     CALCIFOLIC-D                           WAFR         250MCG;      T2
                                                                       1342MG;
                                                                       300UNIT;
                                                                       125MCG; 1MG;
                                                                       50MG; 10MG
   57844021552     GALZIN                                 CAPS         25MG          T2

   57844020852     GALZIN                                 CAPS         50MG          T2

   00482015706     GLUTOFAC-MX                            TABS         100MG;       T2
                                                                       300MCG;
                                                                       150MCG;
                                                                       425MG;
                                                                       130MG;
                                                                       200MCG; 5MG;
                                                                       10MCG; 10MG;
                                                                       0.8MG; 15MG;
                                                                       415MG; 5MG;
                                                                       5MCG; 25MG;
                                                                       80MG;
                                                                       150MCG;
                                                                       100MCG;
                                                                       75MCG;
                                                                       10MCG;
                                                                       10MCG; 35MG
   00486111101     K-PHOS                                 TABS         500MG         T2

   00245003730     KLOR-CON 25                            PACK         25MEQ         T2

   09198013303     MAGINEX                                TBEC         615MG         T2

   59528041605     MAGNEBIND 400                          TABS         200MG; 1MG;   T2
                                                                       400MG
   64011001004     MICRO-K                                CPCR         8MEQ          T2

   59630041360     OSTIVA                                 TABS         500MG;        T2
                                                                       200UNIT;
                                                                       0.25MG;
                                                                       0.565MG;
                                                                       50MG; 1.2MG
   49230064021     PHOSLO                                 CAPS         667MG         T2




   (40:18.18) Electrolyte & Fluid Maint » Ion-removing Agents » K-removal
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00054016563     SODIUM POLYSTYRENE SULFONATE           SUSP         15GM/60ML     T1

   46287001216     SODIUM POLYSTYRENE SULFONATE           POWD         0             T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 97 of 285
   46287000604     SPS                                    SUSP         30GM/120ML               T1




   (40:18.19) Electrolyte & Fluid Maint » Ion-removing Agents » PO4-removal
   Tier: T2
   NDC             Product Name                           Form         Strength                 Pref   Cost   Coverage Details   Comment

   54092025290     FOSRENOL                               CHEW         500MG                    T2

   54092025490     FOSRENOL                               CHEW         1000MG                   T2

   54092025390     FOSRENOL                               CHEW         750MG                    T2

   58468002001     RENAGEL                                TABS         400MG                    T2

   58468002101     RENAGEL                                TABS         800MG                    T2




   (40:20) Electrolyte & Fluid Maint » Caloric Agents
   Tier: T1
   NDC             Product Name                           Form         Strength                 Pref   Cost   Coverage Details   Comment

   41679093266     BOOST PLUS                             LIQD         0;   0;   0;   0;   0;   T1
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                               Page 98 of 285
   43900037120     PEPTINEX 1.0                           LIQD         40MG/237ML; T1
                                                                       0;
                                                                       80MCG/237ML;
                                                                       237MG/237ML;
                                                                       2.6MG/237ML;
                                                                       190MG/237ML;
                                                                       95UNIT/237ML
                                                                       ;
                                                                       54.5MG/237ML
                                                                       ;
                                                                       23.7MCG/237M
                                                                       L;
                                                                       0.31MG/237ML
                                                                       ;
                                                                       1.9MCG/237ML
                                                                       ;
                                                                       2.8MG/237ML;
                                                                       142MCG/237M
                                                                       L;
                                                                       23.7MG/237ML
                                                                       ; 64MG/237ML;
                                                                       0.4MG/237ML;
                                                                       5.5MG/237ML;
                                                                       237MG/237ML;
                                                                       12.6MCG/237M
                                                                       L;
                                                                       360MG/237ML;
                                                                       23.7MCG/237M
                                                                       L;
                                                                       0.95MG/237ML
                                                                       ;
                                                                       0.45MG/237ML
                                                                       ;
                                                                       250MG/237ML;
                                                                       15.4MCG/237M
                                                                       L;
                                                                       14.5MCG/237M
                                                                       L; 0;
                                                                       47.4MG/237ML
                                                                       ;
                                                                       0.4MG/237ML;
                                                                       20UNIT/237ML
                                                                       ;
                                                                       790UNIT/237M
                                                                       L;
                                                                       3.1MG/237ML




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com            Page 99 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   17204042750     A/G PRO                                TABS         100MG; 1MG; T2
                                                                       75MG;
                                                                       0.15MG;
                                                                       10MG; 300MG;
                                                                       20MG; 2MG;
                                                                       20MG;
                                                                       3.25GM; 2MG;
                                                                       2MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 100 of 285
   49735012666     EO28 SPLASH                            LIQD         7.4MG/237ML; T2
                                                                       4.7MCG/237ML
                                                                       ;
                                                                       147MG/237ML;
                                                                       0.57MG/237ML
                                                                       ; 83MG/237ML;
                                                                       43.4MG/237ML
                                                                       ;
                                                                       7.1MCG/237ML
                                                                       ;
                                                                       240MCG/237M
                                                                       L;
                                                                       0.17MCG/237M
                                                                       L;
                                                                       73.5UNIT/237
                                                                       ML;
                                                                       1.8MG/237ML;
                                                                       14.2MCG/237M
                                                                       L;
                                                                       4.3MG/237ML;
                                                                       21.3MG/237ML
                                                                       ;
                                                                       0.24MG/237ML
                                                                       ;
                                                                       2.1MG/237ML;
                                                                       147MG/237ML;
                                                                       220MG/237ML;
                                                                       14.2MCG/237M
                                                                       L;
                                                                       0.19MG/237ML
                                                                       ;
                                                                       0.15MG/237ML
                                                                       ;
                                                                       3.7MCG/237ML
                                                                       ;
                                                                       47.4MG/237ML
                                                                       ;
                                                                       8.3MCG/237ML
                                                                       ;
                                                                       0.13MG/237ML
                                                                       ;
                                                                       277UNIT/237M
                                                                       L;
                                                                       1.9UNIT/237M
                                                                       L;
                                                                       3.6MCG/237ML
                                                                       ; 1.8MG/237ML




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com             Page 101 of 285
   70074050653     PEDIASURE WITH FIBER                   LIQD         24MG/240ML; T2
                                                                       76MCG/240ML;
                                                                       230MG/240ML;
                                                                       240MG/240ML;
                                                                       71MG/240ML;
                                                                       7.1MCG/240ML
                                                                       ;
                                                                       0.24MG/240ML
                                                                       ;
                                                                       1.4MCG/240ML
                                                                       ;
                                                                       88MCG/240ML;
                                                                       19MG/240ML;
                                                                       23MCG/240ML;
                                                                       3.3MG/240ML;
                                                                       47MG/240ML;
                                                                       0.59MG/240ML
                                                                       ;
                                                                       8.5MCG/240ML
                                                                       ; 4MG/240ML;
                                                                       2.4MG/240ML;
                                                                       190MG/240ML;
                                                                       310MG/240ML;
                                                                       0.62MG/240ML
                                                                       ;
                                                                       0.5MG/240ML;
                                                                       5.4MCG/240ML
                                                                       ; 90MG/240ML;
                                                                       0.64MG/240ML
                                                                       ;
                                                                       610UNIT/240M
                                                                       L;
                                                                       120UNIT/240M
                                                                       L;
                                                                       5.4UNIT/240M
                                                                       L;
                                                                       9MCG/240ML;
                                                                       2.8MG/240ML
   00847035501     PHENYLADE PHEBLOC                      TABS         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0




   (40:28.08) Electrolyte & Fluid Maint » Diuretics » Diuretics - Loop
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00185012901     BUMETANIDE                             TABS         1MG              T1

   00185013001     BUMETANIDE                             TABS         2MG              T1

   00185012801     BUMETANIDE                             TABS         0.5MG            T1

   00378020810     FUROSEMIDE                             TABS         20MG             T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 102 of 285
   00378021610     FUROSEMIDE                             TABS         40MG         T1

   00378023201     FUROSEMIDE                             TABS         80MG         T1

   60432061360     FUROSEMIDE                             SOLN         10MG/ML      T1

   00093712801     TORSEMIDE                              TABS         10MG         T1

   00093713001     TORSEMIDE                              TABS         100MG        T1

   00093712901     TORSEMIDE                              TABS         20MG         T1

   49884065101     TORSEMIDE                              TABS         5MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   25010020515     EDECRIN                                TABS         25MG         T2

   00054329863     FUROSEMIDE                             SOLN         8MG/ML       T2




   (40:28.16) Electrolyte & Fluid Maint » Diuretics » Diuretics - K sparing
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00555048302     AMILORIDE /HYDROCHLOROTHIAZIDE         TABS         5MG; 50MG    T1

   49884011701     AMILORIDE HCL                          TABS         5MG          T1

   00378135505     TRIAMTERENE /HYDROCHLOROTHIAZIDE       TABS         50MG; 75MG   T1

   00781271501     TRIAMTERENE /HYDROCHLOROTHIAZIDE       CAPS         25MG; 50MG   T1

   50111053402     TRIAMTERENE /HYDROCHLOROTHIAZIDE       TABS         25MG; 37.5MG T1

   00781207410     TRIAMTERENE /HYDROCHLOROTHIAZIDE       CAPS         25MG; 37.5MG T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   65197000201     DYRENIUM                               CAPS         50MG         T2

   65197000301     DYRENIUM                               CAPS         100MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 103 of 285
   (40:28.20) Electrolyte & Fluid Maint » Diuretics » Diuretics - Thiazides
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00378016201     CHLOROTHIAZIDE                         TABS         500MG       T1

   00378015001     CHLOROTHIAZIDE                         TABS         250MG       T1

   00172208980     HYDROCHLOROTHIAZIDE                    TABS         50MG        T1

   00228282011     HYDROCHLOROTHIAZIDE                    TABS         12.5MG      T1

   00378081001     HYDROCHLOROTHIAZIDE                    CAPS         12.5MG      T1

   00172208380     HYDROCHLOROTHIAZIDE                    TABS         25MG        T1

   00378016001     METHYCLOTHIAZIDE                       TABS         5MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   65649031112     DIURIL                                 SUSP         250MG/5ML   T2




   (40:28.24) Electrolyte & Fluid Maint » Diuretics » Diuretics - Thiazide-like
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00378021301     CHLORTHALIDONE                         TABS         50MG        T1

   00378022201     CHLORTHALIDONE                         TABS         25MG        T1

   50111036401     CHLORTHALIDONE                         TABS         100MG       T1

   00378008001     INDAPAMIDE                             TABS         2.5MG       T1

   00378006901     INDAPAMIDE                             TABS         1.25MG      T1

   00185005501     METOLAZONE                             TABS         5MG         T1

   00185560001     METOLAZONE                             TABS         10MG        T1

   00185505001     METOLAZONE                             TABS         2.5MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   61570002401     THALITONE                              TABS         15MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 104 of 285
   (40:36) Electrolyte & Fluid Maint » Irrigating Solns
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00338065604     ACETIC ACID 0.25%                      SOLN         0.25%        T1

   00338011404     LACTATED RINGER'S IRRIGATION           SOLN         3MEQ/L;      T1
                                                                       109MEQ/L;
                                                                       28MEQ/L;
                                                                       4MEQ/L;
                                                                       130MEQ/L
   00338004804     SODIUM CHLORIDE 0.9%                   SOLN         0.9%         T1

   00338000404     STERILE WATER IRRIGATION PLASTIC       SOLN         0            T1
                   BOTTLE


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00327001105     RENACIDIN                              SOLN         6.602GM/100M T2
                                                                       L;
                                                                       0.198GM/100M
                                                                       L;
                                                                       3.177GM/100M
                                                                       L




   (40:40) Electrolyte & Fluid Maint » Uricosurics
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00378015601     PROBENECID                             TABS         500MG        T1

   00591532501     PROBENECID/COLCHICINE                  TABS         0.5MG; 500MG T1




   (44:00) Enzymes
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   49326034650     ANANA FORTE                            TABS         133333UNIT   T2

   50242010040     PULMOZYME                              SOLN         1MG/ML       T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 105 of 285
   67871001104     SUCRAID                                SOLN         8500UNIT/ML   T2




   (48:08) Respiratory Agents » Antitussives
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   49326028904     ALBATUSSIN NN                          LIQD         0; 10MG/5ML; T1
                                                                       5MG/5ML;
                                                                       75MG/5ML;
                                                                       8.85MG/5ML; 0
   60258044416     ANDEHIST DM NR                         SYRP         4MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       45MG/5ML
   60258024101     ANEXTUSS                               TB12         60MG; 600MG; T1
                                                                       40MG
   00258367801     BENZONATATE                            CAPS         200MG         T1

   50111085101     BENZONATATE                            CAPS         100MG         T1

   10914091016     BROM TANN/DM TANN/PSE TANN             SUSP         8MG/5ML;      T1
                                                                       60MG/5ML;
                                                                       90MG/5ML
   60258041016     BROMATAN PLUS                          SUSP         3.5MG/5ML;    T1
                                                                       30MG/5ML;
                                                                       45MG/5ML
   50383059316     BROMETANE DX                           SYRP         2MG/5ML;      T1
                                                                       10MG/5ML;
                                                                       30MG/5ML
   60258042830     BROMHIST PDX                           LIQD         1MG/ML;       T1
                                                                       3MG/ML;
                                                                       12.5MG/ML
   60258044730     BROMHIST-DM                            LIQD         1MG/ML;       T1
                                                                       4MG/ML;
                                                                       15MG/ML
   60258044616     BROMHIST-DM PEDIATRIC                  SYRP         2MG/5ML;      T1
                                                                       5MG/5ML;
                                                                       50MG/5ML;
                                                                       30MG/5ML
   60258042916     BROMHIST-PDX                           SYRP         2MG/5ML;      T1
                                                                       5MG/5ML;
                                                                       50MG/5ML;
                                                                       5MG/5ML
   66993022057     BROMPLEX DM                            SYRP         4MG/5ML;      T1
                                                                       30MG/5ML;
                                                                       60MG/5ML
   66993022255     BROMPLEX HD                            SOLN         2MG/5ML;      T1
                                                                       1.7MG/5ML;
                                                                       30MG/5ML

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   60258068616     CANGES-HC                              LIQD         2MG/5ML;      T1
                                                                       2.5MG/5ML;
                                                                       7.5MG/5ML
   51991008316     CARBETAPLEX                            SYRP         20MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       15MG/5ML
   50383057516     CARBOFED DM                            SYRP         4MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       45MG/5ML
   60258041516     CERON-DM                               SYRP         4MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       12.5MG/5ML
   60258041730     CERON-DM                               LIQD         1MG/ML;       T1
                                                                       3MG/ML;
                                                                       3.5MG/ML
   00603107558     CHERATUSSIN AC                         SYRP         10MG/5ML;     T1
                                                                       100MG/5ML
   00603107858     CHERATUSSIN DAC                        SOLN         10MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       30MG/5ML
   60258024616     CHLORDEX GP                            SYRP         2MG/5ML;      T1
                                                                       7.5MG/5ML;
                                                                       100MG/5ML;
                                                                       10MG/5ML
   60258077116     CODAL-DM                               SYRP         10MG/5ML;     T1
                                                                       5MG/5ML;
                                                                       8.33MG/5ML
   10914081016     CODEINE PHOSPHATE 10MG/GUAI 300MG      LIQD         10MG/5ML;     T1
                                                                       300MG/5ML
   58177022304     CODEINE/GUAIFENESIN                    TABS         10MG; 300MG   T1

   51991022216     COLDCOUGH                              SYRP         2MG/5ML;      T1
                                                                       7.5MG/5ML;
                                                                       15MG/5ML
   51991022404     COLDCOUGH PD                           SYRP         2MG/5ML;      T1
                                                                       3MG/5ML;
                                                                       7.5MG/5ML
   60258068216     CORDRON-HC                             LIQD         2.5MG/5ML;    T1
                                                                       1.67MG/5ML;
                                                                       20MG/5ML
   68308013004     D-TANN CT                              SUSP         30MG/5ML;     T1
                                                                       25MG/5ML;
                                                                       7.5MG/5ML
   68308013804     D-TANN DM                              SUSP         75MG/5ML;     T1
                                                                       25MG/5ML;
                                                                       7.5MG/5ML
   60258024316     DACEX-DM                               SYRP         25MG/5ML;     T1
                                                                       175MG/5ML;
                                                                       12.5MG/5ML



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   60258023916     DE-CHLOR DM                            SYRP         2MG/5ML;     T1
                                                                       15MG/5ML;
                                                                       10MG/5ML
   00277018541     DONATUSSIN                             SYRP         2MG/5ML;     T1
                                                                       15MG/5ML;
                                                                       100MG/5ML;
                                                                       10MG/5ML
   51991021116     DYNATUSS EX                            SYRP         30MG/5ML;    T1
                                                                       200MG/5ML;
                                                                       10MG/5ML
   68047013016     ENDACOF-DM                             SYRP         4MG/5ML;     T1
                                                                       30MG/5ML;
                                                                       60MG/5ML
   60258026216     GANI-TUSS DM NR                        LIQD         10MG/5ML;    T1
                                                                       100MG/5ML
   60258026301     GFN 1200/DM 60                         TB12         60MG; 1200MG T1

   58552011016     GILTUSS HC                             LIQD         300MG/5ML;   T1
                                                                       5MG/5ML;
                                                                       10MG/5ML
   51991008716     GUIADEX DM                             LIQD         15MG/5ML;    T1
                                                                       300MG/5ML
   58177092607     HYDRO-TUSSIN DHC                       SYRP         2MG/5ML;     T1
                                                                       7.5MG/5ML;
                                                                       15MG/5ML
   58177090607     HYDRO-TUSSIN DM                        ELIX         20MG/5ML;    T1
                                                                       200MG/5ML
   58177092707     HYDRO-TUSSIN EXP                       SYRP         7.5MG/5ML;   T1
                                                                       100MG/5ML;
                                                                       15MG/5ML
   58177089007     HYDRO-TUSSIN HD                        SOLN         100MG/5ML;   T1
                                                                       2.5MG/5ML;
                                                                       30MG/5ML
   60432045516     HYDROCODONE /HOMATROPINE               SYRP         1.5MG/5ML;   T1
                                                                       5MG/5ML
   52152014002     HYDROCODONE BITARTRATE/HOMATROPINE TABS             1.5MG; 5MG   T1
                   METHYLBROMIDE
   00603132958     IOPHEN C-NR                            LIQD         10MG/5ML;    T1
                                                                       100MG/5ML
   68308092404     L-ALL 12                               SUSP         30MG/5ML;    T1
                                                                       30MG/5ML
   58173003704     LARTUS                                 LIQD         2MG/5ML;     T1
                                                                       15MG/5ML;
                                                                       150MG/5ML;
                                                                       5MG/5ML
   51674000207     NALEX EXPECTORANT                      SOLN         200MG/5ML;   T1
                                                                       5MG/5ML;
                                                                       60MG/5ML




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   24839022204     NOVASUS                                SUSP         4MG/5ML;      T1
                                                                       5MG/5ML
   68308067716     P-HIST                                 SYRP         1.25MG/5ML;   T1
                                                                       5MG/5ML;
                                                                       5MG/5ML;
                                                                       5MG/5ML
   64376053716     PHENCARB GG                            SYRP         20MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       10MG/5ML
   00603152058     PHENYLHISTINE DH MODIFIED              LIQD         2MG/5ML;      T1
                                                                       10MG/5ML;
                                                                       30MG/5ML
   00603158858     PROMETHAZINE VC/CODEINE                SYRP         10MG/5ML;     T1
                                                                       5MG/5ML;
                                                                       6.25MG/5ML
   00603158658     PROMETHAZINE-DM                        SYRP         15MG/5ML;     T1
                                                                       6.25MG/5ML
   00472162716     PROMETHAZINE/CODEINE                   SYRP         10MG/5ML;     T1
                                                                       6.25MG/5ML
   64376073340     PSEUDO COUGH                           LIQD         15MG/5ML;     T1
                                                                       175MG/5ML;
                                                                       32MG/5ML
   60258031404     PULMARI                                SUSP         4MG/5ML;      T1
                                                                       30MG/5ML;
                                                                       7.5MG/5ML
   50383080916     QUAD-TUSS TANNATE PEDIATRIC            SUSP         30MG/5ML;     T1
                                                                       4MG/5ML;
                                                                       5MG/5ML;
                                                                       5MG/5ML
   60258042316     RELACON-DM NR                          LIQD         15MG/5ML;     T1
                                                                       200MG/5ML;
                                                                       32MG/5ML
   59243000616     RU-TUSS DM                             SYRP         15MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       45MG/5ML
   60258042616     SIMUC-DM                               SOLN         25MG/5ML;     T1
                                                                       225MG/5ML
   60258024516     SU-TUSS DM                             ELIX         20MG/5ML;     T1
                                                                       200MG/5ML
   50383086316     TANNATE 12 S                           SUSP         30MG/5ML;     T1
                                                                       4MG/5ML
   50383086604     TANNATE DMP-DEX                        SUSP         2.5MG/5ML;    T1
                                                                       25MG/5ML;
                                                                       75MG/5ML
   50383085616     TANNATE-V-DM                           SUSP         25MG/5ML;     T1
                                                                       12.5MG/5ML;
                                                                       30MG/5ML




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   58177092507     TRI-VENT DM                            SYRP         15MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       40MG/5ML
   58177092307     TRI-VENT DPC                           SYRP         2MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       6MG/5ML
   51991013116     TRITAL DM                              LIQD         4MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       10MG/5ML
   60258043116     TUSDEC-DM                              LIQD         2MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       7.5MG/5ML
   00406886701     TUSSIZONE-12 RF                        TABS         60MG; 5MG     T1

   62559574200     VIRATAN-DM                             CHEW         25MG; 25MG;   T1
                                                                       30MG
   63717055106     XIRATUSS                               TABS         60MG; 5MG;    T1
                                                                       10MG
   68047021001     Y-COF DM                               TB12         6MG; 30MG;    T1
                                                                       20MG
   13811000216     Z-DEX                                  SYRP         20MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       10MG/5ML
   13811000130     Z-DEX                                  LIQD         3MG/ML;       T1
                                                                       35MG/ML;
                                                                       2.5MG/ML


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   23589000503     ACCUHIST PDX                           SOLN         0.8MG/ML;     T2
                                                                       3MG/ML;
                                                                       9MG/ML
   63162050716     ALACOL DM                              SYRP         2MG/5ML;      T2
                                                                       10MG/5ML;
                                                                       5MG/5ML
   63162051660     ALACOL DM                              LIQD         0.4MG/ML;     T2
                                                                       2MG/ML;
                                                                       1MG/ML
   59702080016     ATUSS DS                               SUSP         4MG/5ML;      T2
                                                                       30MG/5ML;
                                                                       30MG/5ML
   63162051316     BALTUSSIN                              SYRP         5MG/5ML;      T2
                                                                       3MG/5ML;
                                                                       20MG/5ML
   66992012016     BETAVENT                               LIQD         20MG/5ML;     T2
                                                                       100MG/5ML
   11026268106     BRONCOTRON-D                           SUSP         40MG/10ML;    T2
                                                                       400MG/10ML;
                                                                       10MG/10ML

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   49963081304     BRONTUSS SF                            SYRP         15MG/5ML;     T2
                                                                       350MG/5ML;
                                                                       10MG/5ML
   58552011716     CARBAPHEN 12                           SUSP         60MG/5ML;     T2
                                                                       8MG/5ML;
                                                                       20MG/5ML
   58552011802     CARBAPHEN 12 PED                       SUSP         15MG/ML;      T2
                                                                       2MG/ML;
                                                                       2.5MG/ML
   64543018090     CERTUSS                                TB12         60MG; 1200MG T2

   68453013804     CODIMAL PH                             SYRP         10MG/5ML;     T2
                                                                       5MG/5ML;
                                                                       8.33MG/5ML
   10122020310     DECONSAL DM                            CHEW         15MG; 10MG;   T2
                                                                       16MG
   58238021604     DELTUSS DMX                            LIQD         1MG/5ML;      T2
                                                                       20MG/5ML;
                                                                       30MG/5ML
   11584104506     DESPEC DM                              SYRP         15MG/5ML;     T2
                                                                       100MG/5ML;
                                                                       5MG/5ML
   11584104801     DESPEC DROPS                           LIQD         4MG/ML;       T2
                                                                       20MG/ML;
                                                                       10MG/ML
   11528010516     DICEL DM                               SUSP         5MG/5ML;      T2
                                                                       25MG/5ML;
                                                                       75MG/5ML
   16477013001     DONATUSSIN DM                          SUSP         2MG/5ML;      T2
                                                                       30MG/5ML;
                                                                       20MG/5ML
   16477081130     DONATUSSIN DM                          LIQD         1MG/ML;       T2
                                                                       3MG/ML;
                                                                       1.5MG/ML
   66869072330     DURAFLU                                TABS         500MG; 20MG; T2
                                                                       200MG; 60MG
   68453068516     DURATUSS AC 12                         SUSP         15MG/5ML;     T2
                                                                       12.5MG/5ML;
                                                                       15MG/5ML
   68453055010     DURATUSS CS                            TB12         60MG; 900MG   T2

   68453068016     DURATUSS DM 12                         SUSP         15MG/5ML;     T2
                                                                       225MG/5ML
   66813003816     DYNEX 12                               SUSP         22.5MG/5ML;   T2
                                                                       9MG/5ML
   63717059004     DYTAN-AT                               SUSP         30MG/5ML;     T2
                                                                       25MG/5ML
   63717058504     DYTAN-CD                               SUSP         30MG/5ML;     T2
                                                                       25MG/5ML;
                                                                       15MG/5ML

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   63717058106     DYTAN-CS                               TABS         30MG; 25MG;   T2
                                                                       10MG
   14629020201     EXTENDRYL DM                           TB12         8MG; 30MG;    T2
                                                                       2.5MG
   58552010808     GILTUSS                                LIQD         15MG/5ML;     T2
                                                                       300MG/5ML;
                                                                       10MG/5ML
   58552011602     GILTUSS PED-C                          LIQD         3MG/ML;       T2
                                                                       50MG/ML;
                                                                       2.5MG/ML
   58552010702     GILTUSS PEDIATRIC                      LIQD         5MG/ML;       T2
                                                                       50MG/ML;
                                                                       2.5MG/ML
   58552030301     GILTUSS TR                             TB12         30MG; 600MG; T2
                                                                       20MG
   14629030116     LEVALL                                 SOLN         15MG/5ML;     T2
                                                                       100MG/5ML;
                                                                       5MG/5ML
   14629030404     LEVALL-12                              SUSP         30MG/5ML;     T2
                                                                       25MG/5ML
   12830081016     M-END DM                               SYRP         2MG/5ML;      T2
                                                                       15MG/5ML;
                                                                       15MG/5ML
   63717071416     NARIZ-HC                               LIQD         200MG/5ML;    T2
                                                                       2.5MG/5ML;
                                                                       7.5MG/5ML
   63717029130     NASOHIST DM                            LIQD         1MG/ML;       T2
                                                                       3MG/ML;
                                                                       2MG/ML
   16477062030     NEO DM                                 LIQD         0.75MG/ML;    T2
                                                                       2.75MG/ML;
                                                                       1.75MG/ML
   16477056001     NEO DM                                 SUSP         10MG/5ML;     T2
                                                                       30MG/5ML;
                                                                       25MG/5ML
   16477062501     NEO HC                                 SYRP         3MG/5ML;      T2
                                                                       5MG/5ML;
                                                                       7.5MG/5ML
   12539088816     NEOTUSS-D                              LIQD         4MG/10ML;     T2
                                                                       60MG/10ML;
                                                                       400MG/10ML;
                                                                       60MG/10ML
   51724022004     NORTUSS-EX                             LIQD         20MG/5ML;     T2
                                                                       200MG/5ML
   24839022816     NOTUSS-FORTE                           SYRP         4MG/5ML;      T2
                                                                       5MG/5ML;
                                                                       40MG/5ML




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   16881040016     NOVAHISTINE DH                         LIQD         2MG/5ML;      T2
                                                                       7.25MG/5ML;
                                                                       5MG/5ML
   61570001860     NUCOFED                                CAPS         20MG; 60MG    T2

   67204021016     ORATUSS                                LIQD         20MG/5ML;     T2
                                                                       75MG/5ML
   11026267504     PANATUSS DXP                           LIQD         1MG/5ML;      T2
                                                                       15MG/5ML;
                                                                       100MG/5ML;
                                                                       5MG/5ML
   11026266202     PANATUSS DXP PEDIATRIC                 LIQD         0.5MG/ML;     T2
                                                                       5MG/ML;
                                                                       50MG/ML;
                                                                       2MG/ML
   00525988804     PANCOF PD                              SYRP         2MG/5ML;      T2
                                                                       3MG/5ML;
                                                                       7.5MG/5ML
   58552030601     PHENABID DM                            TB12         8MG; 30MG;    T2
                                                                       20MG
   66869080110     PROHIST DM                             LIQD         1MG/ML;       T2
                                                                       5MG/ML;
                                                                       12MG/ML
   51674001907     PROLEX DM                              LIQD         15MG/5ML;     T2
                                                                       300MG/5ML
   66813016216     PYRLEX CB                              SUSP         22.5MG/5ML;   T2
                                                                       12MG/5ML
   60575007819     RESPA DM                               TB12         28MG; 600MG   T2

   00037071792     RYNATUSS                               TABS         60MG; 5MG;    T2
                                                                       10MG; 10MG
   15014077704     SERADEX                                LIQD         6MG/5ML;      T2
                                                                       30MG/5ML;
                                                                       10MG/5ML
   63717028004     SOLOTUSS                               SUSP         30MG/5ML      T2

   51507001316     SORBUTUSS                              LIQD         10MG/5ML;     T2
                                                                       100MG/5ML;
                                                                       85MG/5ML
   66869010710     TANDUR DM                              SUSP         3MG/5ML;      T2
                                                                       27.5MG/5ML;
                                                                       50MG/5ML
   60575045719     TRIKOF-D                               TB12         28MG; 600MG; T2
                                                                       58MG
   58238021104     TRISPEC DMX                            LIQD         15MG/5ML;     T2
                                                                       25MG/5ML
   58238021201     TRISPEC DMX PEDIATRIC                  LIQD         15MG/5ML;     T2
                                                                       25MG/5ML




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   58238021304     TRISPEC PSE                            LIQD         15MG/5ML;     T2
                                                                       25MG/5ML;
                                                                       30MG/5ML
   58238021401     TRISPEC PSE PEDIATRIC                  LIQD         15MG/5ML;     T2
                                                                       25MG/5ML;
                                                                       30MG/5ML
   00642070016     TRITUSS                                SYRP         25MG/5ML;     T2
                                                                       175MG/5ML;
                                                                       12.5MG/5ML
   54859050206     TUSNEL                                 LIQD         15MG/5ML;     T2
                                                                       200MG/5ML;
                                                                       30MG/5ML
   54859055704     TUSNEL PED-C                           SYRP         5MG/5ML;      T2
                                                                       50MG/5ML;
                                                                       15MG/5ML
   54859054404     TUSNEL PEDIATRIC                       LIQD         5MG/5ML;      T2
                                                                       50MG/5ML;
                                                                       15MG/5ML
   54859060302     TUSNEL-DM PEDIATRIC                    LIQD         5MG/ML;       T2
                                                                       25MG/ML;
                                                                       5MG/ML
   53879010304     TUSSAFED EX                            LIQD         30MG/5ML;     T2
                                                                       200MG/5ML;
                                                                       10MG/5ML
   00642047016     TUSSALL                                SYRP         2MG/5ML;      T2
                                                                       20MG/5ML;
                                                                       10MG/5ML
   00037069210     TUSSI-12D                              TABS         60MG; 10MG;   T2
                                                                       40MG
   68453071416     TUSSI-ORGANIDIN DM NR                  LIQD         10MG/5ML;     T2
                                                                       300MG/5ML
   52083023304     TUSSI-PRES                             LIQD         15MG/5ML;     T2
                                                                       200MG/5ML;
                                                                       5MG/5ML
   52083023204     TUSSI-PRES PEDIATRIC                   LIQD         5MG/5ML;      T2
                                                                       75MG/5ML;
                                                                       2.5MG/5ML
   51674033004     TUSSINAL 12                            SUSP         2MG/5ML;      T2
                                                                       6MG/5ML;
                                                                       10MG/5ML
   53014054867     TUSSIONEX PENNKINETIC EXTENDED         LQCR         8MG/5ML;      T2
                   RELEASE                                             10MG/5ML
   00642061616     TUSSO-XR                               SUSP         40MG/10ML;    T2
                                                                       200MG/10ML;
                                                                       20MG/10ML
   66992022004     VAZOTAN                                SUSP         6MG/5ML;      T2
                                                                       25MG/5ML;
                                                                       10MG/5ML




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 114 of 285
   63717024001     XPECT-AT                               TB12         60MG; 600MG    T2

   63717070501     XPECT-HC                               TB12         600MG; 5MG     T2

   14629047201     ZINX COLD                              KIT          30MG/5ML; 0;   T2
                                                                       25MG/5ML
   14629047301     ZINX COUGH                             KIT          15MG/5ML;     T2
                                                                       100MG/5ML; 0;
                                                                       5MG/5ML
   68025002416     ZOTEX-12                               SUSP         25MG/5ML;      T2
                                                                       15.5MG/5ML;
                                                                       15.5MG/5ML




   (48:10.24) Respiratory Agents » Anti-inflammatories » Leukotriene Modifiers
   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details          Comment

   00310040160     ACCOLATE                               TABS         10MG           T2

   00310040260     ACCOLATE                               TABS         20MG           T2

   00006011731     SINGULAIR                              TABS         10MG           T2

   00006384130     SINGULAIR                              PACK         4MG            T2

   00006027531     SINGULAIR                              CHEW         5MG            T2

   00006071131     SINGULAIR                              CHEW         4MG            T2

   68734071010     ZYFLO CR                               TB12         600MG          T2            MN




   (48:10.32) Respiratory Agents » Anti-inflammatories » Mast-cell Stabilizers
   Tier: T1
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details          Comment

   00172640649     CROMOLYN SODIUM                        NEBU         20MG/2ML       T1            QL (180.00 per 30 days)




   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details          Comment

   60793001114     INTAL INHALER                          AERS         800MCG/ACT     T2            QL (2.00 per 30 days)


   60793012001     TILADE                                 AERS         1.75MG/ACT     T2            QL (3.00 per 30 days)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                            Page 115 of 285
   (48:12.08) Respiratory Agents » Bronchodilators » Anticholinergics
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   24208039915     IPRATROPIUM BROMIDE                    SOLN         0.06%         T1            QL (3.00 per 30 days)


   24208039830     IPRATROPIUM BROMIDE                    SOLN         0.03%         T1            QL (2.00 per 30 days)




   (48:16) Respiratory Agents » Expectorants
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   65162053086     A-TAN 12X                              SUSP         100MG/5ML;    T1
                                                                       5MG/5ML;
                                                                       30MG/5ML
   51991023316     CRANTEX                                SYRP         100MG/5ML;    T1
                                                                       7.5MG/5ML
   11584103206     DESPEC                                 LIQD         100MG/5ML;    T1
                                                                       5MG/5ML
   60258027701     G/P                                    TB12         1200MG; 75MG T1

   60258025616     GANDIDIN NR                            LIQD         100MG/5ML     T1

   60258028401     GFN 1200/PHENYLEPHRINE 40              TB12         1200MG; 40MG T1

   60258027901     GFN 550/PSE 60                         TB12         550MG; 60MG   T1

   60258026601     GFN/PSE                                TB12         1200MG;       T1
                                                                       120MG
   00395277516     IODINE STRONG                          SOLN         5%; 10%       T1

   64543013001     LIQUIBID                               TABS         400MG         T1

   63824000810     MUCINEX                                TB12         600MG         T1

   64376070730     P CHLOR GG                             SOLN         1MG/ML;       T1
                                                                       20MG/ML;
                                                                       2MG/ML
   58177007819     PHENAVENT                              CP12         400MG; 15MG   T1

   58177009519     PHENAVENT LA                           CP12         400MG; 30MG   T1

   58177007904     PHENAVENT PED                          CP12         200MG; 7.5MG T1

   64376071616     PSEUDOEPHEDRINE /GUAIFENESIN           SYRP         200MG/5ML;    T1
                                                                       40MG/5ML
   58177004504     PSEUDOVENT                             CPCR         250MG; 120MG T1

   58177009604     PSEUDOVENT 400                         CP12         400MG; 120MG T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 116 of 285
   00603163558     QUINTEX                                SYRP         100MG/5ML;    T1
                                                                       7.5MG/5ML
   54859060202     TUSNEL PEDIATRIC                       LIQD         50MG/ML;      T1
                                                                       5MG/ML
   52083023616     TUSSI PRES-B                           LIQD         2MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       200MG/5ML


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00024028016     BRONCHOLATE                            SYRP         6.25MG/5ML;   T2
                                                                       100MG/5ML
   51724021401     DECON-G                                LIQD         1MG/ML;       T2
                                                                       40MG/ML;
                                                                       2MG/ML
   16477010630     DONATUSSIN                             LIQD         20MG/ML;      T2
                                                                       1.5MG/ML
   68453075010     DURATUSS A                             TBCR         650MG;        T2
                                                                       600MG; 20MG
   68453077010     DURATUSS PE                            TB12         1050MG; 30MG T2

   58552030401     GILPHEX TR                             TB12         600MG; 25MG   T2

   64661001116     J-MAX                                  SYRP         200MG/5ML;    T2
                                                                       5MG/5ML
   64543015090     LIQUIBID-D                             TB12         650MG; 40MG   T2

   64543024090     LIQUIBID-D 1200                        TB12         1200MG; 40MG T2

   64543024690     LIQUIBID-PD                            TB12         315MG; 20MG   T2

   63717026216     NARIZ                                  LIQD         200MG/5ML;    T2
                                                                       7.5MG/5ML
   60575008719     RESPA-1ST                              TB12         600MG; 58MG   T2

   60575078719     RESPA-PE                               TB12         600MG; 18MG   T2

   00037170803     RYNA-12X                               TABS         200MG; 25MG; T2
                                                                       60MG
   00037630103     SINA-12X                               TABS         200MG; 25MG   T2

   00037630204     SINA-12X                               SUSP         100MG/5ML;    T2
                                                                       5MG/5ML
   67204004216     SITREX PD                              LIQD         75MG/5ML;     T2
                                                                       7.5MG/5ML
   58238021504     TRISPEC SFX                            LIQD         1MG/5ML;      T2
                                                                       15MG/5ML;
                                                                       25MG/5ML
   54859080160     TUSNEL                                 CAPS         2MG; 15MG;    T2
                                                                       200MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 117 of 285
   51724043204     YODEFAN                                LIQD         600MG/15ML   T2

   51724030004     YODEFAN-NF                             LIQD         300MG/5ML    T2

   68025000510     ZOTEX -GP                              TABS         550MG; 8.5MG T2




   (48:24) Respiratory Agents » Mucolytics
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   00054302702     ACETYLCYSTEINE                         SOLN         10%          T1

   00054302802     ACETYLCYSTEINE                         SOLN         20%          T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   83490010760     HYPER-SAL                              NEBU         7%           T2

   49502064015     SODIUM CHLORIDE DEY-PAK                NEBU         3%           T2

   49502064115     SODIUM CHLORIDE DEY-PAK                NEBU         10%          T2




   (52:02) EENT » Antiallergics
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   61314023710     CROMOLYN SODIUM                        SOLN         4%           T1

   17478071710     KETOTIFEN FUMARATE                     SOLN         0.025%       T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   68669071110     ALAMAST                                SOLN         0.1%         T2

   00023884205     ALOCRIL                                SOLN         2%           T2

   00065034510     ALOMIDE                                SOLN         0.1%         T2

   00037024130     ASTELIN                                SOLN         137MCG/SPRA T2             QL (2.00 per 30 days)
                                                                       Y
   00023920105     ELESTAT                                SOLN         0.05%        T2

   00065032505     EMADINE                                SOLN         0.05%        T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 118 of 285
   00037702560     OPTIVAR                                SOLN         0.05%        T2

   00065027225     PATADAY                                SOLN         0.2%         T2

   00065027105     PATANOL                                SOLN         0.1%         T2




   (52:04.04) EENT » Anti-infectives » Antibacterials
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00168002638     BACITRACIN                             OINT         500UNIT/GM   T1

   24208055555     BACITRACIN/POLYMYXIN B                 OINT         500UNIT/GM; T1
                                                                       10000UNIT/GM
   61314065605     CIPROFLOXACIN HCL                      SOLN         0.3%         T1

   00168007038     ERYTHROMYCIN                           OINT         5MG/GM       T1

   17478028435     GENTAK                                 OINT         0.3%         T1

   24208058060     GENTAMICIN SULFATE                     SOLN         0.3%         T1

   24208078055     NEOMYCIN /BACITRACIN /POLYMYXIN        OINT         400UNIT/GM; T1
                                                                       5MG/GM;
                                                                       10000UNIT/GM
   24208079062     NEOMYCIN /POLYMYXIN /GRAMICIDIN        SOLN         0.025MG/ML; T1
                                                                       2.5MG/ML;
                                                                       10000UNIT/ML
   61314001205     OFLOXACIN                              SOLN         0.3%         T1

   61314062810     POLYMYXIN B SULFATE/TRIMETHOPRIM       SOLN         10000UNIT/ML T1
                   SULFATE                                             ; 0.1%
   24208067004     SODIUM SULFACETAMIDE                   SOLN         10%          T1

   24208029005     TOBRAMYCIN SULFATE                     SOLN         0.3%         T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   31357004025     AZASITE                                SOLN         1%           T2

   00065065435     CILOXAN                                OINT         0.3%         T2

   10952003513     CRESYLATE                              SOLN         25%          T2

   63395010105     FLOXIN OTIC                            SOLN         0.3%         T2

   63395010111     FLOXIN OTIC SINGLES                    SOLN         0.3%         T2

   68669013505     QUIXIN                                 SOLN         0.5%         T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 119 of 285
   00065064435     TOBREX                                 OINT         0.3%         T2

   00065401303     VIGAMOX                                SOLN         0.5%         T2

   00023921805     ZYMAR                                  SOLN         0.3%         T2




   (52:04.16) EENT » Anti-infectives » Antifungals
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00065064515     NATACYN                                SUSP         5%           T2




   (52:04.20) EENT » Anti-infectives » Antivirals
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   61314004475     TRIFLURIDINE                           SOLN         1%           T1




   (52:04.92) EENT » Anti-infectives » Anti-infectives, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   12870000101     ARZOL SILVER NITRATE APP LICATORS      MISC         25%; 75%     T1

   00116200116     CHLORHEXIDINE GLUCONATE                SOLN         0.12%        T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   49326090115     OTOSPORIN                              SOLN         0; 0; 0; 0   T2




   (52:08.08) EENT » Anti-inflammatories » Corticosteroids
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00472088282     ACETASOL HC                            SOLN         2%; 1%       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 120 of 285
   00168002938     BAC /POLY /NEOMY /HC                   OINT         400UNIT/GM; T1
                                                                       1%; 0.5%;
                                                                       10000UNIT/GM
   24208072002     DEXAMETHASONE SODIUM PHOSPHATE         SOLN         0.1%         T1

   24208034425     FLUNISOLIDE                            SOLN         0.025%       T1            QL (3.00 per 30 days)


   60758088005     FLUOROMETHOLONE                        SUSP         0.1%         T1

   00054327099     FLUTICASONE PROPIONATE                 SUSP         50MCG/ACT    T1            QL (1.00 per 30 days)


   50383071915     HYDRO EAR DROPS                        SOLN         1MG/ML;      T1
                                                                       10MG/ML;
                                                                       10MG/ML
   61314063006     NEOMYCIN /POLYMYXIN /DEXAMETHASONE     SUSP         0.1%;        T1
                                                                       5MG/ML;
                                                                       10000UNIT/ML
   61314063136     NEOMYCIN /POLYMYXIN /DEXAMETHASONE     OINT         0.1%; 0.35%; T1
                                                                       10000UNIT/GM
   61314064511     NEOMYCIN /POLYMYXIN /HYDROCORTISONE SUSP            1%;          T1
                                                                       3.5MG/ML;
                                                                       10000UNIT/ML
   61314064610     NEOMYCIN /POLYMYXIN /HYDROCORTISONE SOLN            1%;          T1
                                                                       3.5MG/ML;
                                                                       10000UNIT/ML
   61314064175     NEOMYCIN /POLYMYXIN /HYDROCORTISONE SUSP            1%;          T1
                                                                       3.5MG/ML;
                                                                       10000UNIT/ML
   61314063705     PREDNISOLONE ACETATE                   SUSP         1%           T1

   24208071502     PREDNISOLONE SODIUM PHOSPHATE          SOLN         1%           T1

   61314029705     SULFACETAMIDE SODIUM/PREDNISOLONE      SOLN         0.23%; 10%   T1
                   SODIUM PHOSPHATE
   00603749539     ZOLENE HC                              SOLN         1MG/ML;      T1
                                                                       10MG/ML;
                                                                       10MG/ML
   00603749639     ZOTANE HC                              SOLN         1MG/ML;      T1
                                                                       10MG/ML;
                                                                       10MG/ML


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   24208035305     ALREX                                  SUSP         0.2%         T2

   11980002205     BLEPHAMIDE                             SUSP         0.2%; 10%    T2

   00023031304     BLEPHAMIDE S.O.P.                      OINT         0.2%; 10%    T2

   00065853110     CIPRO HC                               SUSP         0.2%; 1%     T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 121 of 285
   00065853302     CIPRODEX                               SUSP         0.3%; 0.1%   T2

   61570009010     CORTISPORIN-TC                         SUSP         3MG/ML;      T2
                                                                       10MG/ML;
                                                                       3.3MG/ML;
                                                                       0.5MG/ML
   28105016020     DERMOTIC                               OIL          0.01%        T2

   00065009605     FLAREX                                 SUSP         0.1%         T2

   11980022805     FML FORTE                              SUSP         0.25%        T2

   00023031604     FML S.O.P.                             OINT         0.1%         T2

   24208029905     LOTEMAX                                SUSP         0.5%         T2

   00998061505     MAXIDEX                                SUSP         0.1%         T2

   59310003725     NASAREL                                SOLN         29MCG/ACT    T2

   00085128801     NASONEX                                SUSP         50MCG/ACT    T2            QL (2.00 per 30 days)


   61570003875     PEDIOTIC                               SUSP         1%;          T2
                                                                       3.5MG/ML;
                                                                       10000UNIT/ML
   00023002805     POLY-PRED                              SUSP         0.35%;       T2
                                                                       10000UNIT/ML
                                                                       ; 0.5%
   11980017405     PRED MILD                              SUSP         0.12%        T2

   00023010605     PRED-G                                 SUSP         0.3%; 1%     T2

   00023006604     PRED-G S.O.P.                          OINT         0.3%; 0.6%   T2

   00065064835     TOBRADEX                               OINT         0.1%; 0.3%   T2

   00065064705     TOBRADEX                               SUSP         0.1%; 0.3%   T2

   00065062707     VEXOL                                  SUSP         1%           T2

   24208035805     ZYLET                                  SUSP         0.5%; 0.3%   T2


   Tier: T3
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details            Comment

   00173038879     BECONASE AQ                            SUSP         42MCG/SPRAY T3             MN; QL (2.00 per 30 days)


   00075150616     NASACORT AQ                            AERS         55MCG/ACT    T3            MN; QL (2.00 per 30 days)


   00186107008     RHINOCORT AQUA                         SUSP         32MCG/ACT    T3            MN; QL (2.00 per 30 days)


   00173075300     VERAMYST                               SUSP         27.5MCG/SPRA T3            MN; QL (1.00 per 30 days)
                                                                       Y




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                            Page 122 of 285
   (52:08.20) EENT » Anti-inflammatories » NSAIDs
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   24208031425     FLURBIPROFEN SODIUM                    SOLN         0.03%        T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00023218105     ACULAR                                 SOLN         0.5%         T2

   00023927705     ACULAR LS                              SOLN         0.4%         T2

   00023905504     ACULAR PF                              SOLN         0.5%         T2

   00065000203     NEVANAC                                SUSP         0.1%         T2

   58768010005     VOLTAREN                               SOLN         0.1%         T2

   67425000450     XIBROM                                 SOLN         0.09%        T2




   (52:08.92) EENT » Anti-inflammatories » Anti-inflammatories, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00023916332     RESTASIS                               EMUL         0.05%        T2




   (52:16) EENT » Local Anesthetics
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00603702073     A/B OTIC                               SOLN         5.4%; 1.4%   T1

   00603724073     EAR-GESIC                              SOLN         5%; 5%;      T1
                                                                       0.25%
   50383077504     LIDOCAINE VISCOUS                      SOLN         2%           T1

   00603723873     OTICAINE OTIC                          SOLN         20%          T1

   61314001601     PROPARACAINE HCL                       SOLN         0.5%         T1

   24208092064     TETRACAINE HCL                         SOLN         0.5%         T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 123 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   16881030015     AURALGAN                               SOLN         0.01%; 5.4%;   T2
                                                                       1.4%; 0.01%
   63717040010     PRAMOTIC                               LIQD         0.1%; 1%       T2

   24338071115     ZINOTIC                                LIQD         1MG/ML;        T2
                                                                       5MG/ML;
                                                                       1MG/ML




   (52:24) EENT » Mydriatics
   Tier: T1
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00168006538     ATROPINE SULFATE                       OINT         1%             T1

   24208075060     ATROPINE SULFATE                       SOLN         1%             T1

   24208073506     CYCLOPENTOLATE HCL                     SOLN         1%             T1

   60758008710     DIPIVEFRIN HCL                         SOLN         0.1%           T1

   00998031505     ISOPTO HOMATROPINE                     SOLN         5%             T1

   00998031105     ISOPTO HOMATROPINE                     SOLN         2%             T1

   24208059064     TROPICAMIDE                            SOLN         0.5%           T1

   61314035501     TROPICAMIDE                            SOLN         1%             T1


   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00065039705     CYCLOGYL                               SOLN         2%             T2

   00065039515     CYCLOGYL                               SOLN         0.5%           T2

   00065035902     CYCLOMYDRIL                            SOLN         0.2%; 1%       T2

   00998033105     ISOPTO HYOSCINE                        SOLN         0.25%          T2

   24208027805     MUROCOLL-2                             SOLN         10%; 0.3%      T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 124 of 285
   (52:32) EENT » Vasoconstrictors
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   17478021612     AK-CON                                 SOLN         0.1%       T1

   17478020510     AK-DILATE                              SOLN         10%        T1

   61314034202     PHENYLEPHRINE HCL                      SOLN         2.5%       T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00482476015     TYZINE                                 SOLN         0.1%       T2

   00482476030     TYZINE                                 SOLN         0.1%       T2

   00482477015     TYZINE PEDIATRIC NASAL DROPS           SOLN         0.05%      T2




   (52:40.04) EENT » Antiglaucoma Agents » alpha-Adrenergic Agonists
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   61314014305     BRIMONIDINE TARTRATE                   SOLN         0.2%       T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00023917705     ALPHAGAN P                             SOLN         0.15%      T2

   00023932105     ALPHAGAN P                             SOLN         0.1%       T2




   (52:40.08) EENT » Antiglaucoma Agents » beta-Adrenergic Blocking Agents
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   61314024501     BETAXOLOL HCL                          SOLN         0.5%       T1

   61314023810     CARTEOLOL HCL                          SOLN         1%         T1

   24208054510     LEVOBUNOLOL HCL                        SOLN         0.25%      T1

   24208050510     LEVOBUNOLOL HCL                        SOLN         0.5%       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 125 of 285
   61314044710     METIPRANOLOL                           SOLN         0.3%       T1

   61314022605     TIMOLOL MALEATE                        SOLN         0.25%      T1

   61314022705     TIMOLOL MALEATE                        SOLN         0.5%       T1

   61314022405     TIMOLOL MALEATE OPHTHALMIC GEL         SOLG         0.25%      T1
                   FORMING
   61314022505     TIMOLOL MALEATE OPHTHALMIC GEL         SOLG         0.5%       T1
                   FORMING


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00065024610     BETOPTIC-S                             SUSP         0.25%      T2

   00006969060     TIMOPTIC OCUDOSE                       SOLN         0.5%       T2

   00006968960     TIMOPTIC OCUDOSE                       SOLN         0.25%      T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   68669052505     BETIMOL                                SOLN         0.5%       T3            MN


   68669052205     BETIMOL                                SOLN         0.25%      T3            MN


   67425000350     ISTALOL                                SOLN         0.5%       T3            MN




   (52:40.12) EENT » Antiglaucoma Agents » Carbonic Anhydrase Inhibitors
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00006362836     COSOPT                                 SOLN         2%; 0.5%   T2

   00006351936     TRUSOPT                                SOLN         2%         T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00065027510     AZOPT                                  SUSP         1%         T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 126 of 285
   (52:40.20) EENT » Antiglaucoma Agents » Miotics
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   24208081115     PILOCARPINE HCL                        SOLN         3%         T1

   24208080615     PILOCARPINE HCL                        SOLN         0.5%       T1

   61314020415     PILOCARPINE HCL                        SOLN         2%         T1

   61314020615     PILOCARPINE HCL                        SOLN         4%         T1

   24208082115     PILOCARPINE HCL                        SOLN         6%         T1

   61314020315     PILOCARPINE HCL                        SOLN         1%         T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00998022515     ISOPTO CARBACHOL                       SOLN         3%         T2

   00998022315     ISOPTO CARBACHOL                       SOLN         1.5%       T2

   00046106505     PHOSPHOLINE IODIDE                     SOLR         0.125%     T2

   00065021535     PILOPINE HS                            GEL          4%         T2




   (52:40.28) EENT » Antiglaucoma Agents » Prostaglandin Analogs
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00023918703     LUMIGAN                                SOLN         0.03%      T2

   00013830304     XALATAN                                SOLN         0.005%     T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00065026625     TRAVATAN                               SOLN         0.004%     T3            MN


   00065026025     TRAVATAN Z                             SOLN         0.004%     T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 127 of 285
   (52:92) EENT » EENT, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   60432074115     ACETIC ACID                            SOLN         2%               T1

   24208061577     ACETIC ACID/ALUMINUM ACETATE           SOLN         2%; 0            T1

   24208027715     MURO 128                               SOLN         5%               T1

   10592000101     PONARIS                                SOLN         0; 0; 0; 0; 0; 0 T1


   Tier: T2
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   08546000140     AQUORAL                                AERS         0; 0             T2

   00225052547     AYR SALINE NASAL                       GEL          0                T2

   08489800001     CAPHOSOL                               SOLN         0.052%;          T2
                                                                       0.569%;
                                                                       0.032%;
                                                                       0.009%
   62942010102     DEBACTEROL                             SOLN         50%; 30%         T2

   15821010115     FRESHKOTE                              SOLN         0; 2.7%; 2%      T2

   00016031055     HEALON                                 SOLN         10MG/ML          T2

   00065066010     IOPIDINE                               SOLN         1%               T2

   00065066505     IOPIDINE                               SOLN         0.5%             T2

   00023031204     LACRI-LUBE S.O.P.                      OINT         0.5%; 2%;        T2
                                                                       42.5%; 55%
   25010080568     LACRISERT                              INST         5MG              T2

   08514011002     NUMOISYN                               LIQD         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0
   08514021001     NUMOISYN                               LOZG         0; 0; 0; 0; 0; T2
                                                                       0; 0; 0; 0.3GM
   49326050915     OTILAM                                 LIQD         5%; 0.5%; 0;     T2
                                                                       10%




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 128 of 285
   (56:04) GI Drugs » Antacids & Adsorbents
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00536341410     CALCIUM CARBONATE                      TABS         650MG            T1

   60258017101     MAGNESIUM OXIDE                        TABS         400MG            T1

   00677013110     SODIUM BICARBONATE                     TABS         650MG            T1




   (56:08) GI Drugs » Antidiarrheals
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00713041821     ANTI-DIARRHEAL                         TABS         2MG              T1

   00054319446     DIPHENOXYLATE/ATROPINE                 LIQD         0.025MG/5ML; T1
                                                                       2.5MG/5ML
   00378041501     DIPHENOXYLATE/ATROPINE                 TABS         0.025MG;         T1
                                                                       2.5MG
   00378210001     LOPERAMIDE HCL                         CAPS         2MG              T1

   00472080216     PAREGORIC                              TINC         2MG/5ML          T1


   Tier: T2
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00482400030     FLORA-Q                                CAPS         0; 0; 0; 0       T2

   00187050002     MOTOFEN                                TABS         0.025MG; 1MG T2

   63304020301     OPIUM TINCTURE                         TINC         10%              T2

   54482093001     VSL#3 DS                               PACK         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0




   (56:10) GI Drugs » Antiflatulents
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   65162044310     SIMETHICONE                            CHEW         80MG             T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 129 of 285
   (56:12) GI Drugs » Cathartics & Laxatives
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00603248221     BISACODYL EC                           TBEC         5MG           T1

   57896042401     DOCUSATE CALCIUM                       CAPS         240MG         T1

   00536375601     DOCUSATE SODIUM                        CAPS         100MG         T1

   62175044601     PEG 3350/ELECTROLYTES                  SOLR         240GM;        T1
                                                                       2.98GM;
                                                                       6.72GM;
                                                                       5.84GM;
                                                                       22.72GM
   00904545209     SENNA                                  SYRP         8.8MG/5ML     T1

   00182111301     SENNA S                                TABS         50MG; 8.6MG   T1

   00091044723     TRILYTE                                SOLR         420GM;        T1
                                                                       1.48GM;
                                                                       5.72GM;
                                                                       11.2GM


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   64764024060     AMITIZA                                CAPS         24MCG         T2

   52268070001     GOLYTELY                               SOLR         227.1GM;      T2
                                                                       2.82GM;
                                                                       6.36GM;
                                                                       5.53GM;
                                                                       21.5GM
   52268010001     GOLYTELY                               SOLR         236GM;        T2
                                                                       2.97GM;
                                                                       6.74GM;
                                                                       5.86GM;
                                                                       22.74GM
   52268052001     HALFLYTELY BOWEL PREP/FLAVOR PACKS     KIT          5MG; 210GM;   T2
                                                                       0.74GM;
                                                                       2.86GM;
                                                                       5.6GM
   65649020175     MOVIPREP                               SOLR         4.7GM;        T2
                                                                       100GM;
                                                                       1.015GM;
                                                                       5.9GM;
                                                                       2.691GM;
                                                                       7.5GM
   65649070141     OSMOPREP                               TABS         0.398GM;      T2
                                                                       1.102GM



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 130 of 285
   65649060141     VISICOL                                TABS         0.398GM;     T2
                                                                       1.102GM




   (56:14) GI Drugs » Cholelitholytics
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00093938001     URSODIOL                               CAPS         300MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   58914078510     URSO 250                               TABS         250MG        T2

   58914079010     URSO FORTE                             TABS         500MG        T2




   (56:16) GI Drugs » Digestants
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   11026261401     GASTRINEX                              CAPS         30MG; 2MG;   T1
                                                                       0.0625MG;
                                                                       1200UNIT;
                                                                       15MG; 6MG
   00091352501     KU-ZYME HP                             CAPS         30000UNIT;   T1
                                                                       8000UNIT;
                                                                       30000UNIT
   60258081001     LAPASE                                 CAPS         15000UNIT;   T1
                                                                       1200UNIT;
                                                                       15000UNIT
   58177002904     PANGESTYME CN 10                       CPEP         33200UNIT;   T1
                                                                       10000UNIT;
                                                                       37500UNIT
   58177003004     PANGESTYME CN 20                       CPEP         66400UNIT;   T1
                                                                       20000UNIT;
                                                                       75000UNIT
   58177003104     PANGESTYME EC                          CPEP         20000UNIT;   T1
                                                                       4500UNIT;
                                                                       25000UNIT
   58177004804     PANGESTYME UL 12                       CPEP         39000UNIT;   T1
                                                                       12000UNIT;
                                                                       39000UNIT




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 131 of 285
   58177004904     PANGESTYME UL 18                       CPEP         58500UNIT;   T1
                                                                       18000UNIT;
                                                                       58500UNIT
   58177005004     PANGESTYME UL 20                       CPEP         65000UNIT;   T1
                                                                       20000UNIT;
                                                                       65000UNIT
   51991065401     PANOKASE-16                            TABS         60000UNIT;   T1
                                                                       16000UNIT;
                                                                       60000UNIT
   58177041604     PLARETASE 8000                         TABS         30000UNIT;   T1
                                                                       8000UNIT;
                                                                       30000UNIT
   58914011110     VIOKASE 8                              TABS         30000UNIT;   T1
                                                                       8000UNIT;
                                                                       30000UNIT


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00032120501     CREON 5                                CPEP         16600UNIT;   T2
                                                                       5000UNIT;
                                                                       18750UNIT
   00032121001     CREON 10                               CPEP         33200UNIT;   T2
                                                                       10000UNIT;
                                                                       37500UNIT
   00032122001     CREON 20                               CPEP         66400UNIT;   T2
                                                                       20000UNIT;
                                                                       75000UNIT
   00091417501     KUTRASE                                CAPS         30000UNIT;   T2
                                                                       2400UNIT;
                                                                       30000UNIT
   00045034260     PANCREASE MT 10                        CPEP         30000UNIT;   T2
                                                                       10000UNIT;
                                                                       30000UNIT
   00045034360     PANCREASE MT 16                        CPEP         48000UNIT;   T2
                                                                       16000UNIT;
                                                                       48000UNIT
   00045034660     PANCREASE MT 20                        CPEP         56000UNIT;   T2
                                                                       20000UNIT;
                                                                       44000UNIT
   00045034160     PANCREASE MT 4                         CPEP         12000UNIT;   T2
                                                                       4000UNIT;
                                                                       12000UNIT
   59767000301     PANCRECARB MS-16                       CPEP         52000UNIT;   T2
                                                                       16000UNIT;
                                                                       52000UNIT
   59767000201     PANCRECARB MS-4                        CPEP         25000UNIT;   T2
                                                                       4000UNIT;
                                                                       25000UNIT



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 132 of 285
   59767000101     PANCRECARB MS-8                        CPEP         40000UNIT;   T2
                                                                       8000UNIT;
                                                                       45000UNIT
   58914004510     ULTRASE                                CPEP         20000UNIT;   T2
                                                                       4500UNIT;
                                                                       25000UNIT
   58914000210     ULTRASE MT 12                          CPEP         39000UNIT;   T2
                                                                       12000UNIT;
                                                                       39000UNIT
   58914001810     ULTRASE MT 18                          CPEP         58500UNIT;   T2
                                                                       18000UNIT;
                                                                       58500UNIT
   58914000410     ULTRASE MT 20                          CPEP         65000UNIT;   T2
                                                                       20000UNIT;
                                                                       65000UNIT
   58914011610     VIOKASE 16                             TABS         60000UNIT;   T2
                                                                       16000UNIT;
                                                                       60000UNIT




   (56:22.08) GI Drugs » Antiemetics » Antihistamines
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   63323036601     DIMENHYDRINATE                         SOLN         50MG/ML      T1

   49884003510     MECLIZINE HCL                          TABS         25MG         T1

   49884003401     MECLIZINE HCL                          TABS         12.5MG       T1

   52152018502     TRIMETHOBENZAMIDE HCL                  CAPS         300MG        T1

   00409195232     TRIMETHOBENZAMIDE HCL                  SOLN         100MG/ML     T1

   49326031090     VERTIN-32                              TABS         32MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00049214066     ANTIVERT                               TABS         50MG         T2

   61570054325     TIGAN                                  SOLN         100MG/ML     T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 133 of 285
   (56:22.20) GI Drugs » Antiemetics » 5-HT3 Receptor Antagonists
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   55111015330     ONDANSETRON HCL                        TABS         4MG        T1            QL (15.00 per 30 days)


   00703722102     ONDANSETRON HCL                        SOLN         2MG/ML     T1

   00781305780     ONDANSETRON HCL                        SOLN         2MG/ML     T1

   55111015611     ONDANSETRON HCL                        TABS         24MG       T1

   50111081942     ONDANSETRON HCL                        SOLN         4MG/5ML    T1

   55111015430     ONDANSETRON HCL                        TABS         8MG        T1            QL (15.00 per 30 days)


   50111094643     ONDANSETRON ODT                        TBDP         8MG        T1            QL (15.00 per 30 days)


   50111094543     ONDANSETRON ODT                        TBDP         4MG        T1            QL (15.00 per 30 days)




   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   00004024133     KYTRIL                                 TABS         1MG        T2            QL (8.00 per 30 days)


   00004023709     KYTRIL                                 SOLN         2MG/10ML   T2


   Tier: T3
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   00088120305     ANZEMET                                TABS         100MG      T3            MN; QL (5.00 per 30 days)


   00088120205     ANZEMET                                TABS         50MG       T3            MN; QL (5.00 per 30 days)




   (56:22.92) GI Drugs » Antiemetics » Antiemetics, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details            Comment

   00187024701     CESAMET                                CAPS         1MG        T2

   00006046410     EMEND                                  CAPS         40MG       T2

   00006046206     EMEND                                  CAPS         125MG      T2            QL (2.00 per 30 days)


   00006046106     EMEND                                  CAPS         80MG       T2            QL (4.00 per 30 days)


   00006386203     EMEND                                  MISC         0          T2            QL (2.00 per 30 days)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                          Page 134 of 285
   00051002121     MARINOL                                CAPS         2.5MG       T2

   00051002321     MARINOL                                CAPS         10MG        T2

   00051002221     MARINOL                                CAPS         5MG         T2

   60267030100     SCOPACE                                TABS         0.4MG       T2

   00067434504     TRANSDERM-SCOP                         PT72         1.5MG       T2




   (56:24) GI Drugs » Lipotropics
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   49326043990     LIPOCHOL PLUS                          TABS         334MG;       T1
                                                                       500MCG;
                                                                       334MG; 100MG




   (56:28.12) GI Drugs » Antiulcer & Antacids » Histamine H2-Antagonists
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00172771160     CIMETIDINE                             TABS         800MG       T1

   00172711760     CIMETIDINE                             TABS         300MG       T1

   00378005301     CIMETIDINE                             TABS         200MG       T1

   00172717160     CIMETIDINE                             TABS         400MG       T1

   50383005008     CIMETIDINE HCL                         SOLN         300MG/5ML   T1

   00172572960     FAMOTIDINE                             TABS         40MG        T1

   00172572860     FAMOTIDINE                             TABS         20MG        T1

   00093106656     NIZATIDINE                             CAPS         300MG       T1

   00378515091     NIZATIDINE                             CAPS         150MG       T1

   00172435846     RANITIDINE HCL                         TABS         300MG       T1

   00472038316     RANITIDINE HCL                         SYRP         15MG/ML     T1

   00172435749     RANITIDINE HCL                         TABS         150MG       T1

   00781285560     RANITIDINE HCL                         CAPS         150MG       T1

   00781286531     RANITIDINE HCL                         CAPS         300MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 135 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   52268014762     AXID                                   SOLN         15MG/ML    T2

   65649021124     PEPCID                                 SUSR         40MG/5ML   T2

   00173073400     ZANTAC                                 TBEF         25MG       T2




   (56:28.28) GI Drugs » Antiulcer & Antacids » Prostaglandins
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00172443149     MISOPROSTOL                            TABS         200MCG     T1

   00172443049     MISOPROSTOL                            TABS         100MCG     T1




   (56:28.32) GI Drugs » Antiulcer & Antacids » Protectants
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093221001     SUCRALFATE                             TABS         1GM        T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   58914017014     CARAFATE                               SUSP         1GM/10ML   T2




   (56:28.36) GI Drugs » Antiulcer & Antacids » PPIs
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00781223310     OMEPRAZOLE                             CPDR         20MG       T1

   00378521193     OMEPRAZOLE                             CPDR         10MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 136 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                    Comment

   00300370201     PREVPAC                                MISC         0; 0; 0     T2

   00186074331     PRILOSEC                               CPDR         40MG        T2


   Tier: T3
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                    Comment

   62856024330     ACIPHEX                                TBEC         20MG        T3            PA; MN; ST(#2:PPI)


   00186402001     NEXIUM                                 PACK         20MG        T3

   00186502031     NEXIUM                                 CPDR         20MG        T3

   00186504031     NEXIUM                                 CPDR         40MG        T3

   00186404001     NEXIUM                                 PACK         40MG        T3

   00300154130     PREVACID                               CPDR         15MG        T3            PA; MN; ST(#2:PPI); AL (max: 11y)


   00300304613     PREVACID                               CPDR         30MG        T3            PA; MN; ST(#2:PPI); AL (max: 11y)


   00300154311     PREVACID SOLUTAB                       TBDP         15MG        T3            PA; MN; AL (max: 11y)


   00300154411     PREVACID SOLUTAB                       TBDP         30MG        T3            PA; MN; AL (max: 11y)


   00008084381     PROTONIX                               TBEC         20MG        T3            PA; MN; ST(#2:PPI)


   00008084181     PROTONIX                               TBEC         40MG        T3            PA; MN; ST(#2:PPI)


   68012005230     ZEGERID                                PACK         20MG; 1680MG T3           PA; MN; ST(#2:PPI)


   68012005430     ZEGERID                                PACK         40MG; 1680MG T3           PA; MN; ST(#2:PPI)


   68012010230     ZEGERID                                CAPS         20MG; 1100MG T3           PA; MN; ST(#2:PPI)


   68012010430     ZEGERID                                CAPS         40MG; 1100MG T3           PA; MN; ST(#2:PPI)




   (56:32) GI Drugs » Prokinetics
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                    Comment

   60432062216     METOCLOPRAMIDE HCL                     SOLN         5MG/5ML     T1

   00093220305     METOCLOPRAMIDE HCL                     TABS         10MG        T1

   50111051701     METOCLOPRAMIDE HCL                     TABS         5MG         T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                   Page 137 of 285
   00703450204     METOCLOPRAMIDE HCL                     SOLN         5MG/ML     T1




   (56:36) GI Drugs » Anti-inflammatories
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093688871     MESALAMINE                             ENEM         4GM        T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00149075215     ASACOL                                 TBEC         400MG      T2

   58914050156     CANASA                                 SUPP         1000MG     T2

   65649010102     COLAZAL                                CAPS         750MG      T2

   50474060001     DIPENTUM                               CAPS         250MG      T2

   54092047612     LIALDA                                 TBEC         1.2GM      T2

   54092018981     PENTASA                                CPCR         250MG      T2

   54092019112     PENTASA                                CPCR         500MG      T2




   (56:92) GI Drugs » Misc
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00173069005     LOTRONEX                               TABS         1MG        T2

   00173073800     LOTRONEX                               TABS         0.5MG      T2

   00004025652     XENICAL                                CAPS         120MG      T2




   (60:00) Gold Compounds
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   65483009306     RIDAURA                                CAPS         3MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 138 of 285
   (64:00) Heavy Metal Antagonists
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   11098050701     CYANIDE ANTIDOTE PKG                   KIT          5MIN/0.3ML;   T1
                                                                       300MG/10ML;
                                                                       12.5GM/50ML


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   67386020111     CHEMET                                 CAPS         100MG         T2

   00006067268     CUPRIMINE                              CAPS         125MG         T2

   25010070515     CUPRIMINE                              CAPS         250MG         T2

   00037440101     DEPEN TITRATABS                        TABS         250MG         T2

   00078046915     EXJADE                                 TBSO         250MG         T2

   00078047015     EXJADE                                 TBSO         500MG         T2

   00078046815     EXJADE                                 TBSO         125MG         T2

   25010071015     SYPRINE                                CAPS         250MG         T2




   (68:04) Hormones & Synthetic Subs » Adrenals
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00409568502     A-METHAPRED                            SOLR         125MG         T1

   00143120201     CORTISONE ACETATE                      TABS         25MG          T1

   00054418225     DEXAMETHASONE                          TABS         1.5MG         T1

   60432046608     DEXAMETHASONE                          ELIX         0.5MG/5ML     T1

   00054417925     DEXAMETHASONE                          TABS         0.5MG         T1

   00054418625     DEXAMETHASONE                          TABS         6MG           T1

   00054418025     DEXAMETHASONE                          TABS         0.75MG        T1

   00054418425     DEXAMETHASONE                          TABS         4MG           T1

   63323016530     DEXAMETHASONE SODIUM PHOSPHATE         SOLN         4MG/ML        T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 139 of 285
   00095008651     DEXPAK 13 DAY                          TABS         1.5MG        T1

   00115703301     FLUDROCORTISONE ACETATE                TABS         0.1MG        T1

   00143125401     HYDROCORTISONE                         TABS         20MG         T1

   59366280702     HYDROCORTISONE                         TABS         5MG          T1

   00603459315     METHYLPREDNISOLONE                     TABS         4MG          T1

   00603459321     METHYLPREDNISOLONE                     TABS         4MG          T1

   66993084225     METHYLPREDNISOLONE                     TABS         8MG          T1

   55390021901     METHYLPREDNISOLONE SODIUMSUCCINATE SOLR             1GM          T1

   55390021801     METHYLPREDNISOLONE SODIUMSUCCINATE SOLR             500MG        T1

   50383004248     PREDNISOLONE                           SYRP         15MG/5ML     T1

   58177091203     PREDNISOLONE                           SYRP         5MG/5ML      T1

   00591505901     PREDNISOLONE                           TABS         5MG          T1

   50383004004     PREDNISOLONE SODIUM PHOSPHATE          LIQD         6.7MG/5ML    T1

   58177093205     PREDNISOLONE SODIUM PHOSPHATE          SOLN         15MG/5ML     T1

   00591544205     PREDNISONE                             TABS         10MG         T1

   00591544301     PREDNISONE                             TABS         20MG         T1

   00054474125     PREDNISONE                             TABS         1MG          T1

   00054474225     PREDNISONE                             TABS         2.5MG        T1

   00603533815     PREDNISONE                             TABS         10MG         T1

   00591505210     PREDNISONE                             TABS         5MG          T1

   00603533715     PREDNISONE                             TABS         5MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   00456067299     AEROBID                                AERS         250MCG/ACT   T2            QL (3.00 per 30 days)


   00456067099     AEROBID-M                              AERS         250MCG/ACT   T2            QL (3.00 per 30 days)


   00085134101     ASMANEX 120 METERED DOSES              AEPB         220MCG/INH   T2            QL (1.00 per 30 days)


   00085134104     ASMANEX 14 METERED DOSES               AEPB         220MCG/INH   T2            QL (9.00 per 30 days)


   00085134103     ASMANEX 30 METERED DOSES               AEPB         220MCG/INH   T2            QL (4.00 per 30 days)


   00085134102     ASMANEX 60 METERED DOSES               AEPB         220MCG/INH   T2            QL (2.00 per 30 days)


   60598006160     AZMACORT                               AERS         75MCG/ACT    T2            QL (2.00 per 30 days)



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 140 of 285
   00085094205     CELESTONE                              SOLN         0.6MG/5ML     T2

   00085056605     CELESTONE-SOLUSPAN                     SUSP         3MG/ML;       T2
                                                                       3MG/ML
   00009003101     CORTEF                                 TABS         10MG          T2

   00009347501     DEPO-MEDROL                            SUSP         80MG/ML       T2

   00009307301     DEPO-MEDROL                            SUSP         40MG/ML       T2

   00054418125     DEXAMETHASONE                          TABS         1MG           T2

   00054418325     DEXAMETHASONE                          TABS         2MG           T2

   00054317763     DEXAMETHASONE                          SOLN         0.5MG/5ML     T2

   00054317644     DEXAMETHASONE INTENSOL                 CONC         1MG/ML        T2

   00095008635     DEXPAK JR 10 DAY                       TABS         1.5MG         T2

   65483070210     ENTOCORT EC                            CP24         3MG           T2

   00173060002     FLOVENT DISKUS                         AEPB         50MCG/BLIST   T2   QL (240.00 per 30 days)


   00173071920     FLOVENT HFA                            AERO         110MCG/ACT    T2   QL (2.00 per 30 days)


   00173071820     FLOVENT HFA                            AERO         44MCG/ACT     T2   QL (2.00 per 30 days)


   00173072020     FLOVENT HFA                            AERO         220MCG/ACT    T2   QL (2.00 per 30 days)


   00003049420     KENALOG-10                             SUSP         10MG/ML       T2

   00003029305     KENALOG-40                             SUSP         40MG/ML       T2

   00009017601     MEDROL                                 TABS         32MG          T2

   00009004902     MEDROL                                 TABS         2MG           T2

   00009007301     MEDROL                                 TABS         16MG          T2

   68188048002     ORAPRED ODT                            TBDP         10MG          T2

   68188048202     ORAPRED ODT                            TBDP         15MG          T2

   68188048402     ORAPRED ODT                            TBDP         30MG          T2

   00054372250     PREDNISONE                             SOLN         5MG/5ML       T2

   00054001925     PREDNISONE                             TABS         50MG          T2

   00054372144     PREDNISONE INTENSOL                    CONC         5MG/ML        T2

   00186199004     PULMICORT                              SUSP         1MG/2ML       T2

   00186198904     PULMICORT                              SUSP         0.5MG/2ML     T2   QL (60.00 per 30 days)


   00186198804     PULMICORT                              SUSP         0.25MG/2ML    T2   QL (120.00 per 30 days)


   00186091706     PULMICORT FLEXHALER                    INHA         90MCG/ACT     T2   QL (2.00 per 30 days)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                        Page 141 of 285
   00186091612     PULMICORT FLEXHALER                    INHA         180MCG/ACT    T2            QL (2.00 per 30 days)


   59310017540     QVAR                                   AERS         40MCG/ACT     T2            QL (4.00 per 30 days)


   59310017780     QVAR                                   AERS         80MCG/ACT     T2            QL (2.00 per 30 days)


   00009090013     SOLU-CORTEF                            SOLR         100MG         T2

   00009090908     SOLU-CORTEF                            SOLR         250MG         T2

   00009082501     SOLU-CORTEF                            SOLR         100MG         T2

   00009011319     SOLU-MEDROL                            SOLR         40MG          T2

   00009338901     SOLU-MEDROL                            SOLR         1000MG        T2

   00009076502     SOLU-MEDROL ACT-O-VIAL                 SOLR         500MG         T2

   00186037220     SYMBICORT                              AERO         80MCG/ACT;    T2            QL (1.00 per 30 days)
                                                                       4.5MCG/ACT
   00186037020     SYMBICORT                              AERO         160MCG/ACT;   T2            QL (1.00 per 30 days)
                                                                       4.5MCG/ACT




   (68:08) Hormones & Synthetic Subs » Androgens
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   00832008600     ANDROXY                                TABS         10MG          T1

   00555063502     DANAZOL                                CAPS         200MG         T1

   00555063302     DANAZOL                                CAPS         50MG          T1

   00555063402     DANAZOL                                CAPS         100MG         T1

   00591354401     OXANDROLONE                            TABS         2.5MG         T1

   00591354560     OXANDROLONE                            TABS         10MG          T1

   00591322379     TESTOSTERONE CYPIONATE                 OIL          200MG/ML      T1

   00781307370     TESTOSTERONE CYPIONATE                 OIL          100MG/ML      T1

   00591322126     TESTOSTERONE ENANTHATE                 OIL          200MG/ML      T1

   00187090101     TESTRED                                CAPS         10MG          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   68220005510     ANADROL-50                             TABS         50MG          T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 142 of 285
   52544046960     ANDRODERM                              PT24         2.5MG/24HR   T2

   52544047030     ANDRODERM                              PT24         5MG/24HR     T2

   00051842530     ANDROGEL                               GEL          25MG/2.5GM   T2

   00051845030     ANDROGEL                               GEL          50MG/5GM     T2

   00051848888     ANDROGEL PUMP                          GEL          1%           T2

   65628002001     FIRST-TESTOSTERONE                     OINT         2%           T2

   65628002101     FIRST-TESTOSTERONE MC COMPOUNDING      CREA         2%           T2
                   KIT
   00115703701     METHITEST                              TABS         10MG         T2

   55056306001     STRIANT                                MISC         30MG         T2

   66887000105     TESTIM                                 GEL          1%           T2




   (68:12) Hormones & Synthetic Subs » Contraceptives
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00555904358     APRI                                   TABS         0.15MG;      T1
                                                                       30MCG
   00555906667     ARANELLE                               TABS         0; 0         T1

   00555904558     AVIANE                                 TABS         20MCG; 0.1MG T1

   00555034458     ERRIN                                  TABS         0.35MG       T1

   00555905058     KARIVA                                 TABS         0; 0         T1

   52544027928     LEVORA 0.15/30-28                      TABS         30MCG;       T1
                                                                       0.15MG
   52544084728     LOW-OGESTREL                           TABS         30MCG; 0.3MG T1

   52544095121     MICROGESTIN 1.5/30                     TABS         30MCG; 1.5MG T1

   52544095021     MICROGESTIN 1/20                       TABS         20MCG; 1MG   T1

   52544063028     MICROGESTIN FE                         TABS         20MCG; 75MG; T1
                                                                       1MG
   52544063128     MICROGESTIN FE 1.5/30                  TABS         30MCG; 75MG; T1
                                                                       1.5MG
   52544055028     NECON 0.5/35-28                        TABS         35MCG; 0.5MG T1

   52544055228     NECON 1/35-28                          TABS         35MCG; 1MG   T1

   52544024531     NECON 1/50-28                          TABS         50MCG; 1MG   T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 143 of 285
   52544055428     NECON 10/11-28                         TABS         35MCG; 0      T1

   52544093628     NECON 7/7/7                            TABS         0; 0          T1

   52544084828     OGESTREL                               TABS         50MCG; 0.5MG T1

   00555901658     SPRINTEC 28                            TABS         35MCG;        T1
                                                                       0.25MG
   52544093528     TRINESSA                               TABS         0; 0          T1

   52544029128     TRIVORA-28                             TABS         0; 0          T1

   00555905167     VELIVET                                TABS         0; 0          T1

   52544038328     ZOVIA 1/35E                            TABS         35MCG; 1MG    T1

   52544038428     ZOVIA 1/50E                            TABS         50MCG; 1MG    T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   00008111730     LYBREL                                 TABS         20MCG;        T2            MN
                                                                       90MCG
   00052027303     NUVARING                               RING         0.015MG/24HR T2
                                                                       ; 0.12MG/24HR
   00062192015     ORTHO EVRA                             PTWK         20MCG/24HR; T2
                                                                       150MCG/24HR
   00062125115     ORTHO TRI-CYCLEN LO                    TABS         0; 0          T2

   51285076993     PLAN B                                 TABS         0.75MG        T2            GL (f); AL (min: 17y)


   50419040203     YASMIN 28                              TABS         3MG; 0.03MG   T2

   50419040503     YAZ                                    TABS         3MG; 0.02MG   T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   00555903458     BALZIVA                                TABS         35MCG; 0.4MG T3

   00430057014     ESTROSTEP FE                           TABS         0; 75MG; 1MG T3             MN


   00430048214     FEMCON FE                              CHEW         35MCG; 0;     T3
                                                                       0.4MG
   00555912366     JOLESSA                                TABS         0.03MG;       T3
                                                                       0.15MG
   00430053014     LOESTRIN 24 FE                         TABS         20MCG; 75MG; T3             MN
                                                                       1MG
   00430058014     OVCON-35                               TABS         35MCG; 0.4MG T3             MN


   00430058514     OVCON-50 28                            TABS         50MCG; 1MG    T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 144 of 285
   52544096691     QUASENSE                               TABS         0.03MG;       T3
                                                                       0.15MG
   51285005866     SEASONALE                              TABS         0.03MG;       T3            MN
                                                                       0.15MG
   51285008787     SEASONIQUE                             TABS         0; 0          T3            MN


   00555903270     TRI-LEGEST FE                          TABS         0; 75MG; 1MG T3

   52544021028     ZENCHENT                               TABS         35MCG; 0.4MG T3




   (68:16.04) Hormones & Synthetic Subs » Estrogens & Antiestrogens » Estrogens
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   51991007901     ESTERIFIED                             TABS         1.25MG;       T1
                   ESTROGENS/METHYLTESTOSTERONE DS                     2.5MG
   51991007801     ESTERIFIED                             TABS         0.625MG;      T1
                   ESTROGENS/METHYLTESTOSTERONE HS                     1.25MG
   00378336199     ESTRADIOL                              PTWK         0.06MG/24HR   T1

   00555088602     ESTRADIOL                              TABS         1MG           T1

   00555088702     ESTRADIOL                              TABS         2MG           T1

   00555089902     ESTRADIOL                              TABS         0.5MG         T1

   00378334999     ESTRADIOL                              PTWK         0.025MG/24HR T1

   00378335099     ESTRADIOL                              PTWK         0.05MG/24HR   T1

   00378335299     ESTRADIOL                              PTWK         0.1MG/24HR    T1

   00378335199     ESTRADIOL                              PTWK         0.075MG/24HR T1

   00378336099     ESTRADIOL                              PTWK         37.5MCG/24HR T1

   00591041501     ESTROPIPATE                            TABS         1.5MG         T1

   00591041601     ESTROPIPATE                            TABS         3MG           T1

   00591041401     ESTROPIPATE                            TABS         0.75MG        T1

   61570007201     MENEST                                 TABS         0.3MG         T1

   61570007550     MENEST                                 TABS         2.5MG         T1

   00078034445     VIVELLE-DOT                            PTTW         0.05MG/24HR   T1

   00078036545     VIVELLE-DOT                            PTTW         0.025MG/24HR T1

   00078034645     VIVELLE-DOT                            PTTW         0.1MG/24HR    T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 145 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00169517401     ACTIVELLA                              TABS         1MG; 0.5MG     T2

   00169517511     ACTIVELLA                              TABS         0.5MG; 0.1MG   T2

   50419048303     ANGELIQ                                TABS         0.5MG; 1MG     T2

   51285044302     CENESTIN                               TABS         0.9MG          T2

   51285044202     CENESTIN                               TABS         0.625MG        T2

   51285044402     CENESTIN                               TABS         1.25MG         T2

   51285044102     CENESTIN                               TABS         0.3MG          T2

   51285044602     CENESTIN                               TABS         0.45MG         T2

   50419049104     CLIMARA PRO                            PTWK         0.045MG/DAY; T2
                                                                       0.015MG/DAY
   00078037742     COMBIPATCH                             PTTW         0.05MG/DAY;    T2
                                                                       0.14MG/DAY
   00078037842     COMBIPATCH                             PTTW         0.05MG/DAY;    T2
                                                                       0.25MG/DAY
   42023011101     DELESTROGEN                            OIL          20MG/ML        T2

   61570018201     DELESTROGEN                            OIL          40MG/ML        T2

   42023011001     DELESTROGEN                            OIL          10MG/ML        T2

   00009027101     DEPO-ESTRADIOL                         OIL          5MG/ML         T2

   00245088030     DIVIGEL                                GEL          0.25MG/0.25G T2
                                                                       M
   00245088130     DIVIGEL                                GEL          0.5MG/0.5GM    T2

   00245088230     DIVIGEL                                GEL          1MG/GM         T2

   00482490002     ELESTRIN                               GEL          0.06%          T2

   51285040802     ENJUVIA                                TABS         0.625MG        T2

   51285041002     ENJUVIA                                TABS         1.25MG         T2

   51285040602     ENJUVIA                                TABS         0.3MG          T2

   51285040702     ENJUVIA                                TABS         0.45MG         T2

   00430375414     ESTRACE                                CREA         0.1MG/GM       T2

   15456032556     ESTRASORB                              EMUL         4.35MG/1.74G T2
                                                                       M
   00013215036     ESTRING                                RING         2MG            T2

   17139061740     ESTROGEL                               GEL          0.06%          T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 146 of 285
   00430054414     FEMHRT 1/5                             TABS         5MCG; 1MG      T2

   00430014514     FEMHRT LOW DOSE                        TABS         2.5MCG;        T2
                                                                       0.5MG
   00430620140     FEMRING                                RING         0.05MG/24HR    T2

   00430620240     FEMRING                                RING         0.1MG/24HR     T2

   00430038924     FEMTRACE                               TABS         0.45MG         T2

   00430039024     FEMTRACE                               TABS         0.9MG          T2

   00430039124     FEMTRACE                               TABS         1.8MG          T2

   66500015801     GYNODIOL                               TABS         1.5MG          T2

   61570007401     MENEST                                 TABS         1.25MG         T2

   61570007301     MENEST                                 TABS         0.625MG        T2

   50419045504     MENOSTAR                               PTWK         14MCG/24HR     T2

   51285006390     PREFEST                                TABS         0; 0           T2

   00046110481     PREMARIN                               TABS         1.25MG         T2

   00046110181     PREMARIN                               TABS         0.45MG         T2

   00046110081     PREMARIN                               TABS         0.3MG          T2

   00046110381     PREMARIN                               TABS         0.9MG          T2

   00046110281     PREMARIN                               TABS         0.625MG        T2

   00046087293     PREMARIN W/APPLICATOR                  CREA         0.625MG/GM     T2

   00046257911     PREMPHASE                              TABS         0.625MG; 5MG T2

   00046087506     PREMPRO                                TABS         0.625MG;       T2
                                                                       2.5MG
   00046093709     PREMPRO                                TABS         0.45MG;        T2
                                                                       1.5MG
   00046097506     PREMPRO                                TABS         0.625MG; 5MG T2

   00046093809     PREMPRO                                TABS         0.3MG; 1.5MG   T2

   00169517304     VAGIFEM                                TABS         25MCG          T2

   00078034545     VIVELLE-DOT                            PTTW         0.075MG/24HR T2

   00078034345     VIVELLE-DOT                            PTTW         0.0375MG/24H T2
                                                                       R




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com               Page 147 of 285
   (68:16.12) Hormones & Synthetic Subs » Estrogens & Antiestrogens » Estrogen Agonists-Antagonists
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                  Comment

   00591078130     CLOMIPHENE CITRATE                     TABS         50MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                  Comment

   00002416530     EVISTA                                 TABS         60MG        T2




   (68:18) Hormones & Synthetic Subs » Gonadotropins
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                  Comment

   55566150101     NOVAREL                                SOLR         10000UNIT/10 T1
                                                                       ML


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details                  Comment

   00052030902     FOLLISTIM AQ                           SOLN         150UNIT/0.5M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   00052031301     FOLLISTIM AQ                           SOLN         300UNT/0.36M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   00052031601     FOLLISTIM AQ                           SOLN         600UNT/0.72M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   00052030802     FOLLISTIM AQ                           SOLN         75UNIT/0.5ML T2           PA; QL (3600.00 per dispensing)


   00052032601     FOLLISTIM AQ                           SOLN         900UNT/1.08M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   44087903001     GONAL-F                                SOLR         450UNIT     T2            PA; QL (3600.00 per dispensing)


   44087907001     GONAL-F                                SOLR         1050UNIT    T2            PA; QL (3600.00 per dispensing)


   44087900506     GONAL-F RFF                            SOLR         75UNIT      T2            PA; QL (3600.00 per dispensing)


   44087111401     GONAL-F RFF PEN                        SOLN         900UNIT/1.5M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   44087111301     GONAL-F RFF PEN                        SOLN         300UNIT/0.5M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   44087111201     GONAL-F RFF PEN                        SOLN         450UNT/0.75M T2           PA; QL (3600.00 per dispensing)
                                                                       L
   44087137501     LUVERIS                                SOLR         75UNIT      T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                 Page 148 of 285
   55566750102     MENOPUR                                SOLR         75UNIT       T2            PA; QL (3600.00 per dispensing)


   44087115001     OVIDREL                                INJ          250MCG/0.5ML T2

   55566718502     REPRONEX                               SOLR         75UNIT       T2            PA; QL (3600.00 per dispensing)


   00025016608     SYNAREL                                SOLN         2MG/ML       T2


   Tier: T3
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details                          Comment

   55566850506     BRAVELLE                               SOLR         75UNIT       T3            PA; GL (m); QL (3600.00 per dispensing)




   (68:20.02) Hormones & Synthetic Subs » Antidiabetics » a-Glucosidase Inhib
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details                          Comment

   00009501201     GLYSET                                 TABS         25MG         T2

   00009501301     GLYSET                                 TABS         50MG         T2

   00009501401     GLYSET                                 TABS         100MG        T2

   00026286251     PRECOSE                                TABS         100MG        T2

   00026286351     PRECOSE                                TABS         25MG         T2

   00026286151     PRECOSE                                TABS         50MG         T2




   (68:20.03) Hormones & Synthetic Subs » Antidiabetics » Amylinomimetics
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details                          Comment

   66780011001     SYMLIN                                 SOLN         600MCG/ML    T2            PA


   66780012102     SYMLINPEN 120                          SOLN         1000MCG/ML   T2            PA


   66780011502     SYMLINPEN 60                           SOLN         1000MCG/ML   T2            PA




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                          Page 149 of 285
   (68:20.04) Hormones & Synthetic Subs » Antidiabetics » Biguanides
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00781505201     METFORMIN HCL                          TABS         1000MG        T1

   00172433180     METFORMIN HCL                          TABS         500MG         T1

   00172433060     METFORMIN HCL                          TABS         850MG         T1

   00093726701     METFORMIN HCL ER                       TB24         500MG         T1

   00555010702     METFORMIN HCL ER                       TB24         750MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   59630057560     FORTAMET                               TB24         1000MG        T2

   59630057460     FORTAMET                               TB24         500MG         T2

   13913000213     GLUMETZA                               TB24         500MG         T2

   10631020602     RIOMET                                 SOLN         500MG/5ML     T2




   (68:20.05) Hormones & Synthetic Subs » Antidiabetics » DPP-4 Inhibitors
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00006027731     JANUVIA                                TABS         100MG         T2

   00006011231     JANUVIA                                TABS         50MG          T2

   00006022131     JANUVIA                                TABS         25MG          T2




   (68:20.06) Hormones & Synthetic Subs » Antidiabetics » Incretin Mimetics
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   66780021007     BYETTA                                 SOLN         5MCG/0.02ML   T2            PA


   66780021008     BYETTA                                 SOLN         10MCG/0.04ML T2             PA




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 150 of 285
   (68:20.08) Hormones & Synthetic Subs » Antidiabetics » Insulins
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00088250052     APIDRA                                 SOLN         100UNIT/ML    T2

   00088250033     APIDRA                                 SOLN         100UNIT/ML    T2

   00069005019     EXUBERA COMBINATION PACK 12            POWD         0             T2

   00069005053     EXUBERA COMBINATION PACK 15            POWD         0             T2

   00069005085     EXUBERA KIT                            POWD         0             T2

   00069070737     EXUBERA PATIENT PACK                   POWD         1MG/BLISTER   T2

   00069072437     EXUBERA PATIENT PACK                   POWD         3MG/BLISTER   T2

   00002751659     HUMALOG                                SOLN         100UNIT/ML    T2

   00002751001     HUMALOG                                SOLN         100UNIT/ML    T2

   00002751201     HUMALOG MIX 50/50                      SUSP         50%; 50%      T2

   00002879359     HUMALOG MIX 50/50 PEN                  SUSP         50%; 50%      T2

   00002751101     HUMALOG MIX 75/25                      SUSP         25%; 75%      T2

   00002879459     HUMALOG MIX 75/25 PEN                  SUSP         25%; 75%      T2

   00002872559     HUMALOG PEN                            SOLN         100UNIT/ML    T2

   00002951501     HUMULIN 50/50                          SUSP         50%; 50%      T2

   00002871501     HUMULIN 70/30                          SUSP         30%; 70%      T2

   00002877059     HUMULIN 70/30 PEN                      SUSP         30%; 70%      T2

   00002831501     HUMULIN N                              SUSP         100UNIT/ML    T2

   00002873059     HUMULIN N U-100 PEN                    SUSP         100UNIT/ML    T2

   00002821501     HUMULIN R                              SOLN         100UNIT/ML    T2

   00002850101     HUMULIN R U-500 (CONCENTRATED)         SOLN         500UNIT/ML    T2

   00088222033     LANTUS                                 SOLN         100UNIT/ML    T2

   00088222052     LANTUS FOR OPTICLIK                    SOLN         100UNIT/ML    T2

   00088222060     LANTUS SOLOSTAR                        SOLN         100UNIT/ML    T2

   00169368712     LEVEMIR                                SOLN         100UNIT/ML    T2

   00169643910     LEVEMIR FLEXPEN                        SOLN         100UNIT/ML    T2

   00169347718     NOVOLIN 70/30 PENFILL                  SUSP         30%; 70%      T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 151 of 285
   00169347418     NOVOLIN N U-100 PENFILL                SUSP         100UNIT/ML   T2

   00169231321     NOVOLIN R INNOLET                      SOLN         100UNIT/ML   T2

   00169347318     NOVOLIN R U-100 PENFILL                SOLN         100UNIT/ML   T2

   00169750111     NOVOLOG                                SOLN         100UNIT/ML   T2

   00169633910     NOVOLOG FLEXPEN                        SOLN         100UNIT/ML   T2

   00169368512     NOVOLOG MIX 70/30                      SUSP         30%; 70%     T2

   00169368213     NOVOLOG MIX 70/30 PENFILL              SUSP         30%; 70%     T2

   00169369619     NOVOLOG MIX 70/30 PREFILLED FLEXPEN    SUSP         30%; 70%     T2

   00169330312     NOVOLOG PENFILL                        SOLN         100UNIT/ML   T2




   (68:20.16) Hormones & Synthetic Subs » Antidiabetics » Meglitinides
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00169008281     PRANDIN                                TABS         1MG          T2

   00169008481     PRANDIN                                TABS         2MG          T2

   00169008181     PRANDIN                                TABS         0.5MG        T2

   00078035105     STARLIX                                TABS         60MG         T2

   00078035205     STARLIX                                TABS         120MG        T2




   (68:20.20) Hormones & Synthetic Subs » Antidiabetics » Sulfonylureas
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00378019701     CHLORPROPAMIDE                         TABS         100MG        T1

   00378021001     CHLORPROPAMIDE                         TABS         250MG        T1

   55111032001     GLIMEPIRIDE                            TABS         1MG          T1

   55111032101     GLIMEPIRIDE                            TABS         2MG          T1

   55111032201     GLIMEPIRIDE                            TABS         4MG          T1

   00378110505     GLIPIZIDE                              TABS         5MG          T1

   00378111005     GLIPIZIDE                              TABS         10MG         T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 152 of 285
   00591084401     GLIPIZIDE ER                           TB24         5MG           T1

   00591084501     GLIPIZIDE ER                           TB24         10MG          T1

   00591090030     GLIPIZIDE ER                           TB24         2.5MG         T1

   00781530601     GLIPIZIDE/METFORMIN HCL                TABS         5MG; 500MG    T1

   00093745501     GLIPIZIDE/METFORMIN HCL                TABS         2.5MG; 250MG T1

   00781530501     GLIPIZIDE/METFORMIN HCL                TABS         2.5MG; 500MG T1

   00093834301     GLYBURIDE                              TABS         2.5MG         T1

   00093834410     GLYBURIDE                              TABS         5MG           T1

   00093947753     GLYBURIDE                              TABS         1.25MG        T1

   00093803601     GLYBURIDE MICRONIZED                   TABS         6MG           T1

   67253046010     GLYBURIDE MICRONIZED                   TABS         1.5MG         T1

   00093803501     GLYBURIDE MICRONIZED                   TABS         3MG           T1

   00228275311     GLYBURIDE/METFORMIN HCL                TABS         5MG; 500MG    T1

   00093571001     GLYBURIDE/METFORMIN HCL                TABS         1.25MG;       T1
                                                                       250MG
   00172571110     GLYBURIDE/METFORMIN HCL                TABS         2.5MG; 500MG T1

   00378021701     TOLAZAMIDE                             TABS         250MG         T1

   00378055101     TOLAZAMIDE                             TABS         500MG         T1

   00378021501     TOLBUTAMIDE                            TABS         500MG         T1




   (68:20.28) Hormones & Synthetic Subs » Antidiabetics » Thiazolidinediones
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   64764015860     ACTOPLUS MET                           TABS         850MG; 15MG   T2

   64764015560     ACTOPLUS MET                           TABS         500MG; 15MG   T2

   64764015104     ACTOS                                  TABS         15MG          T2

   64764045124     ACTOS                                  TABS         45MG          T2

   64764030114     ACTOS                                  TABS         30MG          T2

   00007316318     AVANDAMET                              TABS         1000MG; 2MG   T2

   00007316718     AVANDAMET                              TABS         500MG; 2MG    T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 153 of 285
   00007316818     AVANDAMET                              TABS         500MG; 4MG    T2

   00007316418     AVANDAMET                              TABS         1000MG; 4MG   T2

   00007315213     AVANDARYL                              TABS         2MG; 4MG      T2

   00007315313     AVANDARYL                              TABS         4MG; 4MG      T2

   00007314913     AVANDARYL                              TABS         4MG; 8MG      T2

   00007315113     AVANDARYL                              TABS         1MG; 4MG      T2

   00029315913     AVANDIA                                TABS         4MG           T2

   00029316013     AVANDIA                                TABS         8MG           T2

   00029315818     AVANDIA                                TABS         2MG           T2

   64764030230     DUETACT                                TABS         2MG; 30MG     T2

   64764030430     DUETACT                                TABS         4MG; 30MG     T2




   (68:20.92) Hormones & Synthetic Subs » Antidiabetics » Antidiabetics, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00006057761     JANUMET                                TABS         1000MG; 50MG T2

   00006057561     JANUMET                                TABS         500MG; 50MG   T2




   (68:22.12) Hormones & Synthetic Subs » Antihypoglycemics » Glycogenolytics
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   55390000401     GLUCAGEN DIAGNOSTIC KIT                SOLR         1MG           T2

   00002803101     GLUCAGON EMERGENCY KIT                 KIT          1MG           T2




   (68:24) Hormones & Synthetic Subs » Parathyroid
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00078014923     MIACALCIN                              SOLN         200UNIT/ML    T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 154 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00002897101     FORTEO                                 SOLN         750MCG/3ML    T2

   00078031154     MIACALCIN                              SOLN         200UNIT/ACT   T2




   (68:28) Hormones & Synthetic Subs » Pituitary
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00555023202     DESMOPRESSIN ACETATE                   TABS         0.1MG         T1

   24208034205     DESMOPRESSIN ACETATE                   SOLN         0.01%         T1

   55566502001     DESMOPRESSIN ACETATE                   SOLN         0.01%         T1

   00555023302     DESMOPRESSIN ACETATE                   TABS         0.2MG         T1

   55566504001     DESMOPRESSIN ACETATE                   SOLN         4MCG/ML       T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   63004773101     ACTHAR HP                              GEL          80UNIT/ML     T2

   00053245300     STIMATE                                SOLN         1.5MG/ML      T2




   (68:30.04) Hormones & Synthetic Subs » Somatotropin Agonists & Antagonists » Somatotropin Agonists
   Tier:
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   16249000101     IPLEX                                  SOLN         36MG/0.6ML                  PA


   16249000102     IPLEX                                  SOLN         36MG/0.6ML                  PA




   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   15054104005     INCRELEX                               SOLN         40MG/4ML      T2            PA


   00169776811     NORDITROPIN CARTRIDGE                  SOLN         5MG/1.5ML     T2            PA


   00169777011     NORDITROPIN CARTRIDGE                  SOLN         15MG/1.5ML    T2            PA




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 155 of 285
   00169770511     NORDITROPIN NORDIFLEX PEN              SOLN         10MG/1.5ML   T2            PA


   00169770811     NORDITROPIN NORDIFLEX PEN              SOLN         15MG/1.5ML   T2            PA


   00169770411     NORDITROPIN NORDIFLEX PEN              SOLN         5MG/1.5ML    T2            PA


   50242001821     NUTROPIN                               SOLR         10MG         T2            PA


   50242002220     NUTROPIN AQ                            SOLN         10MG/2ML     T2            PA


   50242004314     NUTROPIN AQ PEN                        SOLN         10MG/2ML     T2            PA


   44087000607     SEROSTIM                               SOLR         6MG          T2            PA


   57844071319     TEV-TROPIN                             SOLR         5MG          T2            PA


   44087338807     ZORBTIVE                               SOLR         8.8MG        T2            PA




   Tier: T3
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00013262681     GENOTROPIN                             SOLR         5.8MG        T3            PA; MN


   00013264681     GENOTROPIN                             SOLR         13.8MG       T3            PA; MN


   00013265102     GENOTROPIN MINIQUICK                   SOLR         0.6MG        T3            PA; MN


   00013265202     GENOTROPIN MINIQUICK                   SOLR         0.8MG        T3            PA; MN


   00013265802     GENOTROPIN MINIQUICK                   SOLR         2MG          T3            PA; MN


   00013264902     GENOTROPIN MINIQUICK                   SOLR         0.2MG        T3            PA; MN


   00013265002     GENOTROPIN MINIQUICK                   SOLR         0.4MG        T3            PA; MN


   00013265402     GENOTROPIN MINIQUICK                   SOLR         1.2MG        T3            PA; MN


   00013265602     GENOTROPIN MINIQUICK                   SOLR         1.6MG        T3            PA; MN


   00013265302     GENOTROPIN MINIQUICK                   SOLR         1MG          T3            PA; MN


   00013265502     GENOTROPIN MINIQUICK                   SOLR         1.4MG        T3            PA; MN


   00013265702     GENOTROPIN MINIQUICK                   SOLR         1.8MG        T3            PA; MN


   00002814901     HUMATROPE                              SOLR         24MG         T3            PA; MN


   00002814801     HUMATROPE                              SOLR         12MG         T3            PA; MN


   00002814701     HUMATROPE                              SOLR         6MG          T3            PA; MN


   00002733516     HUMATROPE COMBO PACK                   SOLR         5MG          T3            PA; MN


   00781400436     OMNITROPE                              SOLR         5.8MG        T3            PA; MN


   00781401471     OMNITROPE                              SOLR         5.8MG        T3            PA; MN


   44087108801     SAIZEN                                 SOLR         8.8MG        T3            PA; MN



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 156 of 285
   44087100502     SAIZEN                                 SOLR         5MG         T3            PA; MN


   44087108001     SAIZEN CLICK.EASY                      SOLR         8.8MG       T3            PA; MN




   (68:30.08) Hormones & Synthetic Subs » Somatotropin Agonists & Antagonists » Somatotropin Antagonists
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   00009517601     SOMAVERT                               SOLR         10MG        T2

   00009518001     SOMAVERT                               SOLR         20MG        T2

   00009517801     SOMAVERT                               SOLR         15MG        T2




   (68:32) Hormones & Synthetic Subs » Progestins
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   59762453701     MEDROXYPROGESTERONE ACETATE            SUSP         150MG/ML    T1            QL (1.00 per 30 days)


   00555087302     MEDROXYPROGESTERONE ACETATE            TABS         5MG         T1

   59762374001     MEDROXYPROGESTERONE ACETATE            TABS         2.5MG       T1

   00555077902     MEDROXYPROGESTERONE ACETATE            TABS         10MG        T1

   00703681121     MEDROXYPROGESTERONE ACETATE            SUSP         150MG/ML    T1            QL (1.00 per 90 days)


   00555021110     NORETHINDRONE ACETATE                  TABS         5MG         T1

   55056040601     PROCHIEVE                              GEL          4%          T1

   00591312879     PROGESTERONE                           OIL          50MG/ML     T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   55056081802     CRINONE                                GEL          8%          T2

   00009062601     DEPO-PROVERA                           SUSP         400MG/ML    T2

   00009470901     DEPO-SUBQ PROVERA 104                  SUSP         104MG/0.65ML T2           QL (1.00 per 90 days)


   55566650003     ENDOMETRIN                             INST         100MG       T2

   65628006201     FIRST-PROGESTERONE VGS 100             SUPP         100MG       T2
                   COMPOUNDING KIT



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 157 of 285
   65628006301     FIRST-PROGESTERONE VGS 200             SUPP         200MG       T2
                   COMPOUNDING KIT
   65628006001     FIRST-PROGESTERONE VGS 25              SUPP         25MG        T2
                   COMPOUNDING KIT
   65628006101     FIRST-PROGESTERONE VGS 50              SUPP         50MG        T2
                   COMPOUNDING KIT
   49884094969     MEGACE ES                              SUSP         625MG/5ML   T2

   00032170801     PROMETRIUM                             CAPS         100MG       T2

   00032171101     PROMETRIUM                             CAPS         200MG       T2




   (68:36.04) Hormones & Synthetic Subs » Thyroid & Antithyroid Agents » Thyroid Agents
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00378180301     LEVOTHYROXINE SODIUM                   TABS         50MCG       T1

   00378181101     LEVOTHYROXINE SODIUM                   TABS         112MCG      T1

   00378182101     LEVOTHYROXINE SODIUM                   TABS         300MCG      T1

   00378180501     LEVOTHYROXINE SODIUM                   TABS         75MCG       T1

   00378180901     LEVOTHYROXINE SODIUM                   TABS         100MCG      T1

   00378181301     LEVOTHYROXINE SODIUM                   TABS         125MCG      T1

   00378181501     LEVOTHYROXINE SODIUM                   TABS         150MCG      T1

   00781519101     LEVOTHYROXINE SODIUM                   TABS         137MCG      T1

   00378180001     LEVOTHYROXINE SODIUM                   TABS         25MCG       T1

   00378180701     LEVOTHYROXINE SODIUM                   TABS         88MCG       T1

   00378181701     LEVOTHYROXINE SODIUM                   TABS         175MCG      T1

   00378181901     LEVOTHYROXINE SODIUM                   TABS         200MCG      T1

   55390088110     LEVOTHYROXINE SODIUM                   SOLR         500MCG      T1

   64727331201     NATURE-THROID                          TABS         195MG       T1

   64727330001     NATURE-THROID                          TABS         65MG        T1

   64727329901     NATURE-THROID                          TABS         32.5MG      T1

   00904076160     THYROID                                TABS         65MG        T1

   00904076260     THYROID                                TABS         130MG       T1

   00904076360     THYROID                                TABS         195MG       T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 158 of 285
   64727708002     WESTHROID                              TABS         130MG      T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00456046101     ARMOUR THYROID                         TABS         120MG      T2

   00456045701     ARMOUR THYROID                         TABS         15MG       T2

   00456046301     ARMOUR THYROID                         TABS         240MG      T2

   00456046401     ARMOUR THYROID                         TABS         300MG      T2

   00456045801     ARMOUR THYROID                         TABS         30MG       T2

   00456046001     ARMOUR THYROID                         TABS         90MG       T2

   00456045901     ARMOUR THYROID                         TABS         60MG       T2

   00456046201     ARMOUR THYROID                         TABS         180MG      T2

   60793011501     CYTOMEL                                TABS         5MCG       T2

   60793011601     CYTOMEL                                TABS         25MCG      T2

   60793011701     CYTOMEL                                TABS         50MCG      T2

   00456005001     THYROLAR-1                             TABS         60MG       T2

   00456004501     THYROLAR-1/2                           TABS         30MG       T2

   00456004001     THYROLAR-1/4                           TABS         15MG       T2

   00456005501     THYROLAR-2                             TABS         120MG      T2

   00456006001     THYROLAR-3                             TABS         180MG      T2




   (68:36.08) Hormones & Synthetic Subs » Thyroid & Antithyroid Agents » Antithyroid Agents
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   49884064001     METHIMAZOLE                            TABS         5MG        T1

   49884064101     METHIMAZOLE                            TABS         10MG       T1

   00228234810     PROPYLTHIOURACIL                       TABS         50MG       T1

   00245000331     SSKI                                   SOLN         1GM/ML     T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 159 of 285
   (76:00) Oxytocics
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00078005405     METHERGINE                             TABS         0.2MG      T2

   00009082703     PROSTIN E2                             SUPP         20MG       T2




   (8:08) Anti-infectives » Anthelmintics
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00093910729     MEBENDAZOLE                            CHEW         100MG      T1

   00006003220     STROMECTOL                             TABS         3MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00007550040     ALBENZA                                TABS         200MG      T2

   00085174701     BILTRICIDE                             TABS         600MG      T2

   00006090736     MINTEZOL                               CHEW         500MG      T2




   (8:12.02) Anti-infectives » Antibacterials » Aminoglycosides
   Tier: T1
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00703903203     AMIKACIN SULFATE                       SOLN         250MG/ML   T1

   63323051302     GENTAMICIN SULFATE                     SOLN         10MG/ML    T1

   63323017302     GENTAMICIN SULFATE                     SOLN         10MG/ML    T1

   00409120703     GENTAMICIN SULFATE                     SOLN         40MG/ML    T1

   63323035903     KANAMYCIN SULFATE                      SOLN         333MG/ML   T1

   00093117701     NEOMYCIN SULFATE                       TABS         500MG      T1

   00703940204     TOBRAMYCIN SULFATE                     SOLN         40MG/ML    T1

   63323030351     TOBRAMYCIN SULFATE                     SOLR         1.2GM      T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 160 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00078049471     TOBI                                   NEBU         300MG/5ML   T2




   (8:12.06.04) Anti-infectives » Antibacterials » Cephalosporins » Cephalosporins - 1st Gen
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00093319601     CEFADROXIL                             CAPS         500MG       T1

   00093405953     CEFADROXIL                             TABS         1GM         T1

   63304097404     CEFADROXIL                             SUSR         500MG/5ML   T1

   63304097304     CEFADROXIL                             SUSR         250MG/5ML   T1

   00591355068     CEFAZOLIN SODIUM                       SOLR         10GM        T1

   60505074904     CEFAZOLIN SODIUM                       SOLR         1GM         T1

   63323023610     CEFAZOLIN SODIUM                       SOLR         500MG       T1

   00093314501     CEPHALEXIN                             CAPS         250MG       T1

   00093314705     CEPHALEXIN                             CAPS         500MG       T1

   00093224001     CEPHALEXIN                             TABS         500MG       T1

   00093417574     CEPHALEXIN                             SUSR         125MG/5ML   T1

   00093417774     CEPHALEXIN                             SUSR         250MG/5ML   T1

   00093223801     CEPHALEXIN                             TABS         250MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   11042011540     KEFLEX                                 CAPS         750MG       T2




   (8:12.06.08) Anti-infectives » Antibacterials » Cephalosporins » Cephalosporins - 2nd Gen
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   63304065801     CEFACLOR                               CAPS         250MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 161 of 285
   63304065901     CEFACLOR                               CAPS         500MG       T1

   63304095402     CEFACLOR                               SUSR         125MG/5ML   T1

   63304095704     CEFACLOR                               SUSR         375MG/5ML   T1

   63304095602     CEFACLOR                               SUSR         250MG/5ML   T1

   00093108701     CEFACLOR ER                            TB12         500MG       T1

   00093107853     CEFPROZIL                              TABS         500MG       T1

   00093107673     CEFPROZIL                              SUSR         250MG/5ML   T1

   00093107573     CEFPROZIL                              SUSR         125MG/5ML   T1

   00093107701     CEFPROZIL                              TABS         250MG       T1

   63304075220     CEFUROXIME AXETIL                      TABS         500MG       T1

   63304075120     CEFUROXIME AXETIL                      TABS         250MG       T1

   66860003103     CEFUROXIME SODIUM                      SOLR         1.5GM       T1

   00884455730     RANICLOR                               CHEW         250MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00173074100     CEFTIN                                 SUSR         250MG/5ML   T2

   00173074000     CEFTIN                                 SUSR         125MG/5ML   T2




   (8:12.06.12) Anti-infectives » Antibacterials » Cephalosporins » Cephalosporins - 3rd Gen
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00781607861     CEFDINIR                               SUSR         250MG/5ML   T1

   00781607761     CEFDINIR                               SUSR         125MG/5ML   T1

   00781217660     CEFDINIR                               CAPS         300MG       T1

   00143993322     CEFOTAXIME SODIUM                      SOLR         2GM         T1

   64679098601     CEFOTAXIME SODIUM                      SOLR         1GM         T1

   10019068001     CEFOTAXIME SODIUM                      SOLR         500MG       T1

   63304096604     CEFPODOXIME PROXETIL                   SUSR         100MG/5ML   T1

   63304052120     CEFPODOXIME PROXETIL                   TABS         200MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 162 of 285
   63304052020     CEFPODOXIME PROXETIL                   TABS         100MG       T1

   63304096504     CEFPODOXIME PROXETIL                   SUSR         50MG/5ML    T1

   00781317895     CEFTAZIDIME                            SOLR         2GM         T1

   00781317796     CEFTAZIDIME                            SOLR         1GM         T1

   60505075104     CEFTRIAXONE SODIUM                     SOLR         500MG       T1

   60505075000     CEFTRIAXONE SODIUM                     SOLR         250MG       T1

   60505075304     CEFTRIAXONE SODIUM                     SOLR         2GM         T1

   60505075204     CEFTRIAXONE SODIUM                     SOLR         1GM         T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   45809040120     CEDAX                                  CAPS         400MG       T2

   45809080160     CEDAX                                  SUSR         90MG/5ML    T2

   00173037810     FORTAZ                                 SOLR         1GM         T2

   00173037710     FORTAZ                                 SOLR         500MG       T2

   10122080160     SPECTRACEF                             TABS         200MG       T2

   68180020203     SUPRAX                                 SUSR         100MG/5ML   T2

   27437020603     SUPRAX                                 SUSR         200MG/5ML   T2




   (8:12.06.16) Anti-infectives » Antibacterials » Cephalosporins » Cephalosporins - 4th Gen
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   60505068104     CEFEPIME                               SOLR         2GM         T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   51479005420     MAXIPIME                               SOLR         1GM         T2

   51479005430     MAXIPIME                               SOLR         1GM         T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 163 of 285
   (8:12.07.08) Anti-infectives » Antibacterials » ß-Lactams, Misc » Carbapenems
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00006384371     INVANZ                                 SOLR         1GM          T2

   00310032130     MERREM                                 SOLR         1GM          T2

   00006358275     PRIMAXIN I.M.                          SOLR         500MG; 500MG T2

   00006351458     PRIMAXIN IV                            SOLR         250MG; 250MG T2

   00006351659     PRIMAXIN IV                            SOLR         500MG; 500MG T2




   (8:12.07.12) Anti-infectives » Antibacterials » ß-Lactams, Misc » Cephamycins
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   60505075905     CEFOXITIN SODIUM                       SOLR         1GM          T1




   (8:12.07.16) Anti-infectives » Antibacterials » ß-Lactams, Misc » Monobactams
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   51479004115     AZACTAM                                SOLR         1GM          T2




   (8:12.12.04) Anti-infectives » Antibacterials » Macrolides » Erythromycins
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00074634620     ERYTHROCIN STEARATE                    TABS         250MG        T1

   00074630113     ERYTHROMYCIN                           CPEP         250MG        T1

   00555044521     ERYTHROMYCIN /SULFISOXAZOLE            SUSR         200MG/5ML;   T1
                                                                       600MG/5ML
   00074374816     ERYTHROMYCIN ETHYLSUCCINATE            SUSP         400MG/5ML    T1

   00074258913     ERYTHROMYCIN ETHYLSUCCINATE            TABS         400MG        T1

   00074374716     ERYTHROMYCIN ETHYLSUCCINATE            SUSP         200MG/5ML    T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 164 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00074632013     ERY-TAB                                TBEC         333MG         T2

   00074630413     ERY-TAB                                TBEC         250MG         T2

   00074632113     ERY-TAB                                TBEC         500MG         T2

   00074630350     ERYPED                                 SUSR         100MG/2.5ML   T2

   00074630213     ERYPED 200                             SUSR         200MG/5ML     T2

   00074630553     ERYPED 400                             SUSR         400MG/5ML     T2

   00074631613     ERYTHROCIN STEARATE                    TABS         500MG         T2

   00074632613     ERYTHROMYCIN BASE                      TABS         250MG         T2

   00074622713     ERYTHROMYCIN BASE                      TABS         500MG         T2

   00074338913     PCE                                    TBEC         500MG         T2

   00074629060     PCE                                    TBEC         333MG         T2




   (8:12.12.12) Anti-infectives » Antibacterials » Macrolides » Ketolides
   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00088222320     KETEK                                  TABS         300MG         T3            MN


   00088222541     KETEK                                  TABS         400MG         T3            MN




   (8:12.12.92) Anti-infectives » Antibacterials » Macrolides » Macrolides, Other
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   59762311001     AZITHROMYCIN                           SUSR         100MG/5ML     T1

   59762307001     AZITHROMYCIN                           TABS         500MG         T1

   59762308001     AZITHROMYCIN                           TABS         600MG         T1

   59762306001     AZITHROMYCIN                           TABS         250MG         T1

   59762312001     AZITHROMYCIN                           SUSR         200MG/5ML     T1

   68774012060     CLARITHROMYCIN                         TABS         250MG         T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 165 of 285
   68774030235     CLARITHROMYCIN                         SUSR         125MG/5ML   T1

   68774030335     CLARITHROMYCIN                         SUSR         250MG/5ML   T1

   00093715806     CLARITHROMYCIN                         TABS         500MG       T1

   00093724406     CLARITHROMYCIN ER                      TB24         500MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00069305175     ZITHROMAX                              PACK         1GM         T2


   Tier: T3
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00069417021     ZMAX                                   SUSR         2GM         T3            MN




   (8:12.16.04) Anti-infectives » Antibacterials » Penicillins » PCNs, Natural
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00781613595     PENICILLIN G POTASSIUM                 SOLR         5MU         T1

   00093117410     PENICILLIN V POTASSIUM                 TABS         500MG       T1

   00093117201     PENICILLIN V POTASSIUM                 TABS         250MG       T1

   00093412574     PENICILLIN V POTASSIUM                 SOLR         125MG/5ML   T1

   00093412774     PENICILLIN V POTASSIUM                 SOLR         250MG/5ML   T1

   00049053028     PFIZERPEN-G                            SOLR         20MU        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   60793060210     BICILLIN C-R                           SUSP         900000UNIT/M T2
                                                                       L;
                                                                       300000UNIT/M
                                                                       L
   60793060110     BICILLIN C-R                           SUSP         300000UNIT/M T2
                                                                       L;
                                                                       300000UNIT/M
                                                                       L
   60793070010     BICILLIN L-A                           SUSP         600000UNIT/M T2
                                                                       L


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 166 of 285
   60793070110     BICILLIN L-A                           SUSP         1200000UNIT/ T2
                                                                       2ML
   60793070210     BICILLIN L-A                           SUSP         2400000UNIT/ T2
                                                                       4ML
   60793013010     PENICILLIN G PROCAINE                  SUSP         600000UNIT/M T2
                                                                       L




   (8:12.16.08) Anti-infectives » Antibacterials » Penicillins » Aminopenicillins
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093226301     AMOXICILLIN                            TABS         500MG         T1

   00093226801     AMOXICILLIN                            CHEW         250MG         T1

   00093310905     AMOXICILLIN                            CAPS         500MG         T1

   00093415080     AMOXICILLIN                            SUSR         125MG/5ML     T1

   00093416173     AMOXICILLIN                            SUSR         400MG/5ML     T1

   63304076301     AMOXICILLIN                            TABS         875MG         T1

   00093226701     AMOXICILLIN                            CHEW         125MG         T1

   00093310705     AMOXICILLIN                            CAPS         250MG         T1

   00093415580     AMOXICILLIN                            SUSR         250MG/5ML     T1

   00093416073     AMOXICILLIN                            SUSR         200MG/5ML     T1

   63304076020     AMOXICILLIN                            CHEW         200MG         T1

   63304076120     AMOXICILLIN                            CHEW         400MG         T1

   00093867575     AMOXICILLIN/CLAVULANATE POTASSIUM      SUSR         600MG/5ML;    T1
                                                                       42.9MG/5ML
   00093227234     AMOXICILLIN/CLAVULANATE POTASSIUM      CHEW         400MG; 57MG   T1

   00781187431     AMOXICILLIN/CLAVULANATE POTASSIUM      TABS         250MG; 125MG T1

   00781161966     AMOXICILLIN/POTASSIUM CLAVULANATE      CHEW         200MG;        T1
                                                                       28.5MG
   00781610246     AMOXICILLIN/POTASSIUM CLAVULANATE      SUSR         200MG/5ML;    T1
                                                                       28.5MG/5ML
   00781610446     AMOXICILLIN/POTASSIUM CLAVULANATE      SUSR         400MG/5ML;    T1
                                                                       57MG/5ML
   00093227434     AMOXICILLIN/POTASSIUM CLAVULANATE      TABS         500MG; 125MG T1

   00781185220     AMOXICILLIN/POTASSIUM CLAVULANATE      TABS         875MG; 125MG T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 167 of 285
   00093514601     AMPICILLIN                             CAPS         500MG         T1

   00093514501     AMPICILLIN                             CAPS         250MG         T1

   67253018210     AMPICILLIN                             SUSR         125MG/5ML     T1

   67253018320     AMPICILLIN                             SUSR         250MG/5ML     T1

   63323038910     AMPICILLIN SODIUM                      SOLR         1GM           T1

   00781340795     AMPICILLIN SODIUM                      SOLR         500MG         T1

   00781340895     AMPICILLIN SODIUM                      SOLR         2GM           T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00029603839     AMOXIL                                 SUSR         50MG/ML       T2

   00029607447     AUGMENTIN                              CHEW         250MG;        T2
                                                                       62.5MG
   00029608522     AUGMENTIN                              SUSR         125MG/5ML;    T2
                                                                       31.25MG/5ML
   00029609022     AUGMENTIN                              SUSR         250MG/5ML;    T2
                                                                       62.5MG/5ML
   00029609660     AUGMENTIN XR                           TB12         1000MG;       T2
                                                                       62.5MG




   (8:12.16.12) Anti-infectives » Antibacterials » Penicillins » PCNs, Penicillinase-resistant
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093312301     DICLOXACILLIN SODIUM                   CAPS         250MG         T1

   00093312501     DICLOXACILLIN SODIUM                   CAPS         500MG         T1

   00781312646     NAFCILLIN SODIUM                       SOLR         10GM          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00781310195     OXACILLIN SODIUM                       SOLR         2GM           T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 168 of 285
   (8:12.16.16) Anti-infectives » Antibacterials » Penicillins » PCNs, Extended-spectrum
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   00206885216     ZOSYN                                  SOLR         2GM; 0.25GM   T2




   (8:12.18) Anti-infectives » Antibacterials » Quinolones
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   00378174589     CIPROFLOXACIN ER                       TB24         1000MG; 0     T1

   00378174389     CIPROFLOXACIN EXTENDED-RELEASE         TB24         500MG; 0      T1

   55111012850     CIPROFLOXACIN HCL                      TABS         750MG         T1

   55111012506     CIPROFLOXACIN HCL                      TABS         100MG         T1

   55111012601     CIPROFLOXACIN HCL                      TABS         250MG         T1

   63304071001     CIPROFLOXACIN HCL                      TABS         500MG         T1

   63304071550     OFLOXACIN                              TABS         300MG         T1

   63304071650     OFLOXACIN                              TABS         200MG         T1

   63304071701     OFLOXACIN                              TABS         400MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details        Comment

   00085173301     AVELOX                                 TABS         400MG         T2

   00085177701     CIPRO                                  SUSR         5GM/100ML     T2

   00085177301     CIPRO                                  SUSR         500MG/5ML     T2

   67707032005     FACTIVE                                TABS         320MG         T2            QL (7.00 per 30 days)


   00045151501     LEVAQUIN                               SOLN         25MG/ML       T2

   00045153020     LEVAQUIN                               TABS         750MG         T2

   00045152050     LEVAQUIN                               TABS         250MG         T2

   00045152550     LEVAQUIN                               TABS         500MG         T2

   00045006951     LEVAQUIN                               SOLN         25MG/ML       T2

   00006070520     NOROXIN                                TABS         400MG         T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 169 of 285
   13913000130     PROQUIN XR                             TB24         500MG         T2




   (8:12.20) Anti-infectives » Antibacterials » Sulfonamides
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00185075701     SULFADIAZINE                           TABS         500MG         T1

   00527144201     SULFAMETHOXAZOLE /TRIMETHOPRIM         TABS         400MG; 80MG   T1

   00527144305     SULFAMETHOXAZOLE/TRIMETHOPRIM DS       TABS         800MG; 160MG T1

   00591079605     SULFASALAZINE                          TABS         500MG         T1

   00472128516     SULFATRIM                              SUSP         200MG/5ML;    T1
                                                                       40MG/5ML
   00603580321     SULFAZINE EC                           TBEC         500MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00004100328     GANTRISIN PEDIATRIC                    SUSP         500MG/5ML     T2




   (8:12.24) Anti-infectives » Antibacterials » Tetracyclines
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00115211101     DEMECLOCYCLINE HCL                     TABS         150MG         T1

   00115212214     DEMECLOCYCLINE HCL                     TABS         300MG         T1

   00172362648     DOXYCYCLINE HYCLATE                    TABS         100MG         T1

   00591544005     DOXYCYCLINE HYCLATE                    CAPS         100MG         T1

   00591553550     DOXYCYCLINE HYCLATE                    CAPS         50MG          T1

   00781226950     DOXYCYCLINE HYCLATE                    CPEP         100MG         T1

   00781226860     DOXYCYCLINE HYCLATE                    CPEP         75MG          T1

   53489064701     DOXYCYCLINE HYCLATE                    TABS         20MG          T1

   00378612493     DOXYCYCLINE MONOHYDRATE                TABS         150MG         T1

   00185080501     DOXYCYCLINE MONOHYDRATE                CAPS         50MG          T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 170 of 285
   00185081053     DOXYCYCLINE MONOHYDRATE                CAPS         100MG                 T1

   49884009201     DOXYCYCLINE MONOHYDRATE                TABS         75MG                  T1

   00527133501     DOXYCYCLINE MONOHYDRATE                TABS         50MG                  T1

   49884009303     DOXYCYCLINE MONOHYDRATE                TABS         100MG                 T1

   49884051303     MINOCYCLINE HCL                        TABS         100MG                 T1

   00093316501     MINOCYCLINE HCL                        CAPS         50MG                  T1

   00093316753     MINOCYCLINE HCL                        CAPS         100MG                 T1

   49884051101     MINOCYCLINE HCL                        TABS         50MG                  T1

   63304069501     MINOCYCLINE HCL                        CAPS         75MG                  T1

   49884051201     MINOCYCLINE HCL                        TABS         75MG                  T1

   00172241680     TETRACYCLINE HCL                       CAPS         250MG                 T1

   00172240760     TETRACYCLINE HCL                       CAPS         500MG                 T1


   Tier: T2
   NDC             Product Name                           Form         Strength              Pref   Cost   Coverage Details   Comment

   10337081506     ADOXA                                  CAPS         150MG                 T2

   54799053466     ALODOX CONVENIENCE KIT                 KIT          20MG                  T2

   14168261002     CLEERAVUE-M                            KIT          0;   0;   0;   0; 0;   T2
                                                                       0;   0;   0;   50MG;
                                                                       0;   0;   0;   0; 0;
                                                                       0;   0;   0;   0; 0; 0
   00430011120     DORYX                                  TBEC         75MG                  T2

   00430011224     DORYX                                  TBEC         100MG                 T2

   14290055098     MINOCIN PAC                            KIT          0; 0; 0; 0; 0;        T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0; 0;
                                                                       100MG; 0; 0;
                                                                       0; 0; 0; 0
   14290055198     MINOCIN PAC                            KIT          0;   0;   0;   0; 0;   T2
                                                                       0;   0;   0;   0; 0;
                                                                       0;   0;   0;   50MG;
                                                                       0;   0;   0;   0; 0; 0
   16110007501     MONODOX                                CAPS         75MG                  T2

   64682000901     ORACEA                                 CPDR         40MG                  T2

   99207046030     SOLODYN                                TB24         45MG                  T2

   99207046130     SOLODYN                                TB24         90MG                  T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                            Page 171 of 285
   99207046230     SOLODYN                                TB24         135MG       T2

   00069097193     VIBRAMYCIN                             SYRP         50MG/5ML    T2

   00069097065     VIBRAMYCIN                             SUSR         25MG/5ML    T2




   (8:12.28.08) Anti-infectives » Antibacterials » Antibacterials, Other » Bacitracins
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00009023301     BACITRACIN                             SOLR         50000UNIT   T1




   (8:12.28.16) Anti-infectives » Antibacterials » Antibacterials, Other » Glycopeptides
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00409653301     VANCOMYCIN HCL                         SOLR         1000MG      T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   66593312502     VANCOCIN HCL                           CAPS         125MG       T2

   66593312602     VANCOCIN HCL                           CAPS         250MG       T2




   (8:12.28.20) Anti-infectives » Antibacterials » Antibacterials, Other » Lincomycins
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   63304069201     CLINDAMYCIN HCL                        CAPS         150MG       T1

   63304069301     CLINDAMYCIN HCL                        CAPS         300MG       T1

   00409405101     CLINDAMYCIN PHOSPHATE                  SOLN         150MG/ML    T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00009033102     CLEOCIN                                CAPS         75MG        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 172 of 285
   00009076004     CLEOCIN PEDIATRIC GRANULES             SOLR         75MG/5ML     T2

   00009055501     LINCOCIN                               SOLN         300MG/ML     T2




   (8:12.28.24) Anti-infectives » Antibacterials » Antibacterials, Other » Oxazolidinones
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00009513601     ZYVOX                                  SUSR         100MG/5ML    T2

   00009513502     ZYVOX                                  TABS         600MG        T2




   (8:12.28.28) Anti-infectives » Antibacterials » Antibacterials, Other » Polymyxins
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00574085801     COLISTIMETHATE SODIUM                  SOLR         150MG        T1

   55390013910     POLYMYXIN B SULFATE                    SOLR         500000UNIT   T1




   (8:12.28.30) Anti-infectives » Antibacterials » Antibacterials, Other » Rifamycins
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   65649030103     XIFAXAN                                TABS         200MG        T2




   (8:14.04) Anti-infectives » Antifungals » Antifungals -Allylamines
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   60505257203     TERBINAFINE HCL                        TABS         250MG        T1            PA




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 173 of 285
   (8:14.08) Anti-infectives » Antifungals » Antifungals - Azoles
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00172541146     FLUCONAZOLE                            TABS         100MG        T1

   00172541211     FLUCONAZOLE                            TABS         150MG        T1

   63304097605     FLUCONAZOLE                            SUSR         40MG/ML      T1

   68462010430     FLUCONAZOLE                            TABS         200MG        T1

   63304097505     FLUCONAZOLE                            SUSR         10MG/ML      T1

   68462010130     FLUCONAZOLE                            TABS         50MG         T1

   00185055030     ITRACONAZOLE                           CAPS         100MG        T1            PA


   00093090001     KETOCONAZOLE                           TABS         200MG        T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00085132801     NOXAFIL                                SUSP         40MG/ML      T2

   50458029515     SPORANOX                               SOLN         10MG/ML      T2

   50458029801     SPORANOX                               KIT          250MG        T2            PA


   00049316044     VFEND                                  SUSR         40MG/ML      T2

   00049317030     VFEND                                  TABS         50MG         T2

   00049318030     VFEND                                  TABS         200MG        T2




   (8:14.28) Anti-infectives » Antifungals » Antifungals - Polyenes
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   53489040001     NYSTATIN                               TABS         500000UNIT   T1

   60432053716     NYSTATIN                               SUSP         100000UNIT/M T1
                                                                       L


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   57665010141     ABELCET                                SUSP         5MG/ML       T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 174 of 285
   (8:14.32) Anti-infectives » Antifungals » Antifungals - Pyrimidines
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00187355410     ANCOBON                                CAPS         250MG       T2




   (8:14.92) Anti-infectives » Antifungals » Antifungals, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00062021460     GRIFULVIN V                            TABS         500MG       T1

   00884076304     GRIS-PEG                               TABS         125MG       T1

   00884077304     GRIS-PEG                               TABS         250MG       T1

   10147081004     GRISEOFULVIN MICROSIZE                 SUSP         125MG/5ML   T1




   (8:16.04) Anti-infectives » Antimycobacterials » Antituberculers
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00555092302     ETHAMBUTOL HCL                         TABS         400MG       T1

   23155010001     ETHAMBUTOL HCL                         TABS         100MG       T1

   61748001760     ISONARIF                               CAPS         150MG; 300MG T1

   00555006602     ISONIAZID                              TABS         100MG       T1

   00555007102     ISONIAZID                              TABS         300MG       T1

   46287000901     ISONIAZID                              SYRP         50MG/5ML    T1

   67253066010     PYRAZINAMIDE                           TABS         500MG       T1

   00185080130     RIFAMPIN                               CAPS         150MG       T1

   00185079930     RIFAMPIN                               CAPS         300MG       T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 175 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   00013530117     MYCOBUTIN                              CAPS         150MG       T2

   00088057641     RIFATER                                TABS         50MG; 300MG; T2
                                                                       120MG
   00002060440     SEROMYCIN                              CAPS         250MG       T2

   00008411701     TRECATOR                               TABS         250MG       T2




   (8:16.92) Anti-infectives » Antimycobacterials » Antimycobacterials, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   49938010101     DAPSONE                                TABS         100MG       T2

   49938010201     DAPSONE                                TABS         25MG        T2




   (8:18.04) Anti-infectives » Antivirals » Antivirals - Adamantanes
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   00781502901     RIMANTADINE HCL                        TABS         100MG       T1




   (8:18.08.04) Anti-infectives » Antivirals » Antiretrovirals » HIV Fusion Inhibitors
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   00004038039     FUZEON                                 KIT          90MG        T2            QL (1.00 per 30 days)


   00069080760     SELZENTRY                              TABS         150MG       T2




   (8:18.08.08) Anti-infectives » Antivirals » Antiretrovirals » HIV Protease Inhibitors
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details        Comment

   00597000302     APTIVUS                                CAPS         250MG       T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 176 of 285
   00006057354     CRIXIVAN                               CAPS         400MG         T2

   00004024515     INVIRASE                               CAPS         200MG         T2

   00004024451     INVIRASE                               TABS         500MG         T2

   00074679922     KALETRA                                TABS         200MG; 50MG   T2

   00074395646     KALETRA                                SOLN         400MG/5ML;    T2
                                                                       100MG/5ML
   00173072100     LEXIVA                                 TABS         700MG         T2

   00074663330     NORVIR                                 CAPS         100MG         T2

   59676056001     PREZISTA                               TABS         300MG         T2

   00003362312     REYATAZ                                CAPS         100MG         T2

   00003362212     REYATAZ                                CAPS         300MG         T2

   00003362412     REYATAZ                                CAPS         150MG         T2

   00003363112     REYATAZ                                CAPS         200MG         T2

   63010002770     VIRACEPT                               TABS         625MG         T2

   63010001030     VIRACEPT                               TABS         250MG         T2




   (8:18.08.16) Anti-infectives » Antivirals » Antiretrovirals » Nonnucleoside RTIs
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   63010002036     RESCRIPTOR                             TABS         100MG         T2

   63010002118     RESCRIPTOR                             TABS         200MG         T2

   00056051030     SUSTIVA                                TABS         600MG         T2

   00056047492     SUSTIVA                                CAPS         200MG         T2

   00597004660     VIRAMUNE                               TABS         200MG         T2




   (8:18.08.20) Anti-infectives » Antivirals » Antiretrovirals » Nucleoside/Nucleotide RTIs
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00555058901     DIDANOSINE                             CPDR         250MG         T1

   00555059001     DIDANOSINE                             CPDR         400MG         T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 177 of 285
   65862010701     ZIDOVUDINE                             CAPS         100MG       T1

   65862004824     ZIDOVUDINE                             SYRP         50MG/5ML    T1

   63304092060     ZIDOVUDINE                             TABS         300MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00173059500     COMBIVIR                               TABS         150MG; 300MG T2

   61958060101     EMTRIVA                                CAPS         200MG       T2

   00173071400     EPIVIR                                 TABS         300MG       T2

   00173047001     EPIVIR                                 TABS         150MG       T2

   00173047100     EPIVIR                                 SOLN         10MG/ML     T2

   00173066300     EPIVIR HBV                             SOLN         5MG/ML      T2

   00173066200     EPIVIR HBV                             TABS         100MG       T2

   00173074200     EPZICOM                                TABS         600MG; 300MG T2

   00173069100     TRIZIVIR                               TABS         300MG;       T2
                                                                       150MG; 300MG
   61958070101     TRUVADA                                TABS         200MG; 300MG T2

   00087667117     VIDEX EC                               CPDR         125MG       T2

   00087663341     VIDEX PEDIATRIC                        SOLR         4GM         T2

   61958040101     VIREAD                                 TABS         300MG       T2

   00003196501     ZERIT                                  CAPS         20MG        T2

   00003196701     ZERIT                                  CAPS         40MG        T2

   00003196601     ZERIT                                  CAPS         30MG        T2

   00003196801     ZERIT                                  SOLR         1MG/ML      T2

   00173066101     ZIAGEN                                 TABS         300MG       T2

   00173066400     ZIAGEN                                 SOLN         20MG/ML     T2




   (8:18.08.92) Anti-infectives » Antivirals » Antiretrovirals » Antiretrovirals, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   15584010101     ATRIPLA                                TABS         600MG;       T2
                                                                       200MG; 300MG

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 178 of 285
   (8:18.20) Anti-infectives » Antivirals » Interferons
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00187200702     INFERGEN                               INJ          9MCG/0.3ML    T2

   00187200601     INFERGEN                               INJ          15MCG/0.5ML   T2

   00085130401     PEG-INTRON                             KIT          120MCG/0.5ML T2

   00085127901     PEG-INTRON                             KIT          150MCG/0.5ML T2

   00085129101     PEG-INTRON                             KIT          80MCG/0.5ML   T2

   00085136801     PEG-INTRON                             KIT          50MCG/0.5ML   T2

   00085137002     PEG-INTRON REDIPEN PAK 4               KIT          150MCG/0.5ML T2

   00085129702     PEG-INTRON REDIPEN PAK 4               KIT          120MCG/0.5ML T2

   00085132302     PEG-INTRON REDIPEN PAK 4               KIT          50MCG/0.5ML   T2

   00085131602     PEG-INTRON REDIPEN PAK 4               KIT          80MCG/0.5ML   T2

   00004035009     PEGASYS                                SOLN         180MCG/ML     T2

   00004035239     PEGASYS                                KIT          180MCG/0.5ML T2




   (8:18.28) Anti-infectives » Antivirals » Neuraminidase Inhibitors
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00173068101     RELENZA DISKHALER                      AEPB         5MG/BLISTER   T2

   00004080085     TAMIFLU                                CAPS         75MG          T2

   00004081095     TAMIFLU                                SUSR         12MG/ML       T2




   (8:18.32) Anti-infectives » Antivirals » Nucleosides & Nucleotides
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093894001     ACYCLOVIR                              CAPS         200MG         T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 179 of 285
   00093894301     ACYCLOVIR                              TABS         400MG       T1

   00093894701     ACYCLOVIR                              TABS         800MG       T1

   00472008216     ACYCLOVIR                              SUSP         200MG/5ML   T1

   63304063628     GANCICLOVIR                            CAPS         250MG       T1

   63304063728     GANCICLOVIR                            CAPS         500MG       T1

   00781204304     RIBAVIRIN                              CAPS         200MG       T1

   00093723281     RIBAVIRIN                              TABS         200MG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00003161112     BARACLUDE                              TABS         0.5MG       T2

   00003161212     BARACLUDE                              TABS         1MG         T2

   00003161412     BARACLUDE                              SOLN         0.05MG/ML   T2

   00078036615     FAMVIR                                 TABS         125MG       T2

   00078036815     FAMVIR                                 TABS         500MG       T2

   00078036715     FAMVIR                                 TABS         250MG       T2

   61958050101     HEPSERA                                TABS         10MG        T2

   49884033876     RIBAPAK                                TABS         400MG       T2

   49884007176     RIBAPAK                                MISC         0           T2

   49884034076     RIBAPAK                                TABS         600MG       T2

   00078053815     TYZEKA                                 TABS         600MG       T2

   00004003822     VALCYTE                                TABS         450MG       T2

   00173056504     VALTREX                                TABS         1GM         T2

   00173093308     VALTREX                                TABS         500MG       T2




   (8:30.04) Anti-infectives » Antiprotozoals » Amebicides
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   57664017508     PAROMOMYCIN SULFATE                    CAPS         250MG       T1

   00516009201     YODOXIN                                TABS         210MG       T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 180 of 285
   00516009301     YODOXIN                                TABS         650MG         T1




   (8:30.08) Anti-infectives » Antiprotozoals » Antimalarials
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00143212522     CHLOROQUINE PHOSPHATE                  TABS         500MG         T1

   00143119550     CHLOROQUINE PHOSPHATE                  TABS         250MG         T1

   00591069801     HYDROXYCHLOROQUINE SULFATE             TABS         200MG         T1

   00781507686     MEFLOQUINE HCL                         TABS         250MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00173020155     DARAPRIM                               TABS         25MG          T2

   00004016103     FANSIDAR                               TABS         25MG; 500MG   T2

   00173067501     MALARONE                               TABS         250MG; 100MG T2

   00173067601     MALARONE                               TABS         62.5MG; 25MG T2

   00024159601     PRIMAQUINE PHOSPHATE                   TABS         26.3MG        T2

   13310015307     QUALAQUIN                              CAPS         324MG         T2




   (8:30.92) Anti-infectives » Antiprotozoals » Antiprotozoals, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00093085101     METRONIDAZOLE                          TABS         250MG         T1

   50111088405     METRONIDAZOLE                          CAPS         375MG         T1

   50111033401     METRONIDAZOLE                          TABS         500MG         T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   67546011112     ALINIA                                 TABS         500MG         T2

   67546021221     ALINIA                                 SUSR         100MG/5ML     T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 181 of 285
   00025196130     FLAGYL ER                              TB24         750MG       T2

   00173066518     MEPRON                                 SUSP         750MG/5ML   T2

   63323087715     NEBUPENT                               SOLR         300MG       T2

   00178825040     TINDAMAX                               TABS         250MG       T2

   00178850020     TINDAMAX                               TABS         500MG       T2




   (8:36) Anti-infectives » Urinary Anti-infectives
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   64980011901     METHENAMINE HIPPURATE                  TABS         1GM         T1

   52152011202     METHENAMINE MANDELATE                  TABS         1GM         T1

   52152011102     METHENAMINE MANDELATE                  TABS         0.5GM       T1

   00378165001     NITROFURANTOIN MACROCRYSTALLINE        CAPS         50MG        T1

   00378170001     NITROFURANTOIN MACROCRYSTALLINE        CAPS         100MG       T1

   00378342201     NITROFURANTOIN MONOHYDRATE             CAPS         100MG       T1

   00093215801     TRIMETHOPRIM                           TABS         100MG       T1

   12539012010     URETRON D/S                            TABS         0.12MG;     T1
                                                                       120MG;
                                                                       10.8MG;
                                                                       36.2MG;
                                                                       40.8MG
   54859070110     URIN D/S                               TABS         0.12MG;     T1
                                                                       81.6MG;
                                                                       10.8MG;
                                                                       36.2MG;
                                                                       40.8MG
   12830030101     UROBLUE                                TABS         0.12MG;     T1
                                                                       81.6MG;
                                                                       10.8MG;
                                                                       36.2MG;
                                                                       40.8MG
   00485005101     UROGESIC-BLUE                          TABS         0.12MG;     T1
                                                                       81.6MG;
                                                                       10.8MG;
                                                                       36.2MG;
                                                                       40.8MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 182 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   59630045016     FURADANTIN                             SUSP         25MG/5ML    T2

   00149000705     MACRODANTIN                            CAPS         25MG        T2

   00456430008     MONUROL                                PACK         5.631GM     T2

   13551050105     PRIMSOL                                SOLN         50MG/5ML    T2

   15456080503     PROSED /DS                             TABS         9MG; 0.12MG; T2
                                                                       81.6MG;
                                                                       10.8MG;
                                                                       36.2MG
   00486111401     UROQID #2                              TABS         500MG; 500MG T2

   45985064601     UTA                                    CAPS         0.12MG;      T2
                                                                       120MG; 10MG;
                                                                       36MG; 40.8MG




   (8:92) Anti-infectives » Anti-infectives, Misc
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   65483049514     HELIDAC                                MISC         0; 0; 0     T2

   58914060021     PYLERA                                 CAPS         140MG;       T2
                                                                       125MG; 125MG




   (80:04) Serums, Toxoids, & Vaccines » Serums
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   13533063106     HYPERRHO S/D                           INJ          50MCG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00562780501     RHOGAM ULTRA-FILTERED PLUS             INJ          300MCG      T2

   44206030001     RHOPHYLAC                              SOLN         1500UNIT/2ML T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 183 of 285
   (80:12) Serums, Toxoids, & Vaccines » Vaccines
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00006404500     GARDASIL                               SUSP         0             T2

   00006494300     PNEUMOVAX 23/1 DOSE                    INJ          25MCG/0.5ML   T2

   58337000301     VIVOTIF BERNA                          CPDR         0             T2

   00006496300     ZOSTAVAX                               SOLR         19400UNT/0.6 T2
                                                                       5ML




   (84:04.04) Topical Agents » Anti-infectives » Antibacterials
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00462027740     CLINDAMAX                              CREA         2%            T1

   00168020160     CLINDAMYCIN PHOSPHATE                  SOLN         1%            T1

   45802026337     CLINDAMYCIN PHOSPHATE                  SWAB         1%            T1

   00168020260     CLINDAMYCIN PHOSPHATE                  GEL          1%            T1

   00168020360     CLINDAMYCIN PHOSPHATE                  LOTN         1%            T1

   00168021630     ERYTHROMYCIN                           GEL          2%            T1

   60432067160     ERYTHROMYCIN                           SOLN         2%            T1

   59366287806     ERYTHROMYCIN                           PADS         2%            T1

   45802008386     ERYTHROMYCIN/BENZOYL PEROXIDE          GEL          5%; 3%        T1

   00168007115     GENTAMICIN SULFATE                     CREA         0.1%          T1

   00168007815     GENTAMICIN SULFATE                     OINT         0.1%          T1

   00168038360     METRONIDAZOLE                          LOTN         0.75%         T1

   00168027545     METRONIDAZOLE                          GEL          0.75%         T1

   00168032346     METRONIDAZOLE                          CREA         0.75%         T1

   00781707787     METRONIDAZOLE VAGINAL                  GEL          0.75%         T1

   00093101042     MUPIROCIN                              OINT         2%            T1

   68032010006     RE 10 WASH                             LIQD         10%           T1

   68032011001     SCALP TREATMENT                        KIT          10%; 10%      T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 184 of 285
   59366350001     SEB-PREV                               GEL          10%        T1

   59366340002     SEB-PREV                               CREA         10%        T1

   59366360001     SEB-PREV WASH                          LIQD         10%        T1

   00168038204     SULFACETAMIDE SODIUM                   SUSP         10%        T1

   68032010903     SULFACETAMIDE SODIUM                   LOTN         10%; 10%   T1

   68032014275     SULFACETAMIDE SODIUM W/UREA            PADS         10%; 10%   T1


   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   13548003025     AKNE-MYCIN                             OINT         2%         T2

   00007518022     ALTABAX                                OINT         1%         T2

   00029152725     BACTROBAN                              CREA         2%         T2

   00029152611     BACTROBAN NASAL                        OINT         2%         T2

   00066049450     BENZACLIN                              GEL          5%; 1%     T2

   00066057760     BENZAMYCINPAK                          PACK         5%; 3%     T2

   00009766701     CLEOCIN                                SUPP         100MG      T2

   00299450075     CLINDAGEL                              GEL          1%         T2

   65880050302     CLINDAREACH                            KIT          1%         T2

   64011012408     CLINDESSE                              CREA         2%         T2

   63032006100     EVOCLIN                                FOAM         1%         T2

   00299382060     METROGEL                               GEL          1%         T2

   00299382004     METROGEL 1% KIT                        KIT          1%         T2

   00066985060     NORITATE                               CREA         1%         T2

   23589002201     OVACE                                  FOAM         10%        T2




   (84:04.06) Topical Agents » Anti-infectives » Antivirals
   Tier: T2
   NDC             Product Name                           Form         Strength   Pref   Cost   Coverage Details   Comment

   00067602415     DENAVIR                                CREA         1%         T2

   64455099445     ZOVIRAX                                CREA         5%         T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 185 of 285
   64455099394     ZOVIRAX                                OINT         5%          T2




   (84:04.08.04) Topical Agents » Anti-infectives » Antifungals » Antifungal Allylamines
   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00078032882     LAMISIL                                SOLN         1%          T2

   00259477060     NAFTIN                                 GEL          1%          T2

   00259412630     NAFTIN                                 CREA         1%          T2




   (84:04.08.08) Topical Agents » Anti-infectives » Antifungals » Antifungal Azoles
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00054414622     CLOTRIMAZOLE                           TROC         10MG        T1

   00182503160     CLOTRIMAZOLE                           CREA         1%          T1

   51672127502     CLOTRIMAZOLE                           CREA         1%          T1

   51672126003     CLOTRIMAZOLE                           SOLN         1%          T1

   51672130803     CLOTRIMAZOLE/BETAMETHASONE             LOTN         0.05%; 1%   T1
                   DIPROPIONATE
   51672404806     CLOTRIMAZOLE/BETAMETHASONE             CREA         0.05%; 1%   T1
                   DIPROPIONATE
   00093084030     KETOCONAZOLE                           CREA         2%          T1

   45802046564     KETOCONAZOLE                           SHAM         2%          T1

   00472173803     MICONAZOLE 3                           SUPP         200MG       T1

   51672130406     TERCONAZOLE                            CREA         0.4%        T1

   45802071708     TERCONAZOLE                            SUPP         80MG        T1

   51672130200     TERCONAZOLE                            CREA         0.8%        T1


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   64011000108     GYNAZOLE-1                             CREA         2%          T2

   13478000301     XOLEGEL                                GEL          2%          T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 186 of 285
   13478000304     XOLEGEL DUO                            KIT          2%; 1%        T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00168031230     ECONAZOLE NITRATE                      CREA         1%            T3

   00062165003     ERTACZO                                CREA         2%            T3            MN


   00072820030     EXELDERM                               CREA         1%            T3            MN


   00072840030     EXELDERM                               SOLN         1%            T3            MN


   00462035830     OXISTAT                                CREA         1%            T3            MN


   00462035930     OXISTAT                                LOTN         1%            T3            MN


   13478000204     VUSION                                 OINT         0.25%;        T3            MN
                                                                       81.35%; 15%




   (84:04.08.12) Topical Agents » Anti-infectives » Antifungals » Antifungal Benzylamines
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00378615149     MENTAX                                 CREA         1%            T2




   (84:04.08.20) Topical Agents » Anti-infectives » Antifungals » Antifungal Hydroxypyridones
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00066800802     PENLAC NAIL LACQUER                    SOLN         8%            T2            PA




   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00168031460     CICLOPIROX                             SUSP         0.77%         T3

   00168031330     CICLOPIROX OLAMINE                     CREA         0.77%         T3

   99207001330     LOPROX                                 GEL          0.77%         T3            MN


   99207001010     LOPROX SHAMPOO                         SHAM         1%            T3            MN




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 187 of 285
   (84:04.08.28) Topical Agents » Anti-infectives » Antifungals » Antifungal Polyenes
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00472016630     NYSTATIN                               OINT         100000UNIT/G T1
                                                                       M
   00472016330     NYSTATIN                               CREA         100000UNIT/G T1
                                                                       M
   51285053422     NYSTATIN VAGINAL                       TABS         100000UNIT   T1




   (84:04.08.92) Topical Agents » Anti-infectives » Antifungals » Antifungals, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00316012301     ALA-QUIN                               CREA         3%; 0.5%     T1

   00603780176     CLIOQUINOL /HYDROCORTISONE             CREA         3%; 1%       T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   63801010709     BENSAL HP                              OINT         6%; 3%       T2

   51724000120     HALOTIN                                CREA         1%           T2




   (84:04.12) Topical Agents » Anti-infectives » Scabicides & Pediculicides
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   68188093590     LINDANE                                LOTN         1%           T1

   45802026937     PERMETHRIN                             CREA         5%           T1

   00472524267     PERMETHRIN                             LOTN         1%           T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00072210360     EURAX                                  CREA         10%          T2

   00072220360     EURAX                                  LOTN         10%          T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 188 of 285
   68188093190     LINDANE                                SHAM         1%          T2

   51672527604     OVIDE                                  LOTN         0.5%        T2




   (84:04.92) Topical Agents » Anti-infectives » Local Anti-infectives, Misc
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   10337080641     BENZASHAVE 10                          CREA         10%         T1

   10337080541     BENZASHAVE 5                           CREA         5%          T1

   59366274301     BENZOYL PEROXIDE                       GEL          5%          T1

   59366274401     BENZOYL PEROXIDE                       GEL          10%         T1

   68032014375     BENZOYL PEROXIDE                       PADS         4.5%; 10%   T1

   68032011812     BENZOYL PEROXIDE                       CREA         6.5%; 10%   T1

   68032014475     BENZOYL PEROXIDE                       PADS         6.5%; 10%   T1

   59366274201     BENZOYL PEROXIDE                       GEL          2.5%        T1

   59366274601     BENZOYL PEROXIDE                       GEL          10%         T1

   68032011312     BENZOYL PEROXIDE                       GEL          4.5%; 10%   T1

   68032011612     BENZOYL PEROXIDE                       GEL          8.5%; 10%   T1

   18754074451     BENZOYL PEROXIDE CLEANSER              LIQD         4.5%; 10%   T1

   18754074551     BENZOYL PEROXIDE CLEANSER              LIQD         8.5%; 10%   T1

   18754075151     BENZOYL PEROXIDE CLEANSER              LIQD         6.5%; 10%   T1

   59366274108     BENZOYL PEROXIDE WASH                  LIQD         10%         T1

   45802090734     BENZOYL PEROXIDE WASH                  LIQD         2.5%        T1

   59366273908     BENZOYL PEROXIDE WASH                  LIQD         5%          T1

   51927100400     BORIC ACID                             GRAN         0           T1

   00234057508     HIBICLENS                              LIQD         4%          T1

   59366270601     HYDROCORTISONE /IODOQUINOL             CREA         1%; 1%      T1

   66993091306     LAVOCLEN-4 CREAMY WASH                 LIQD         4%          T1

   66993091406     LAVOCLEN-8 CREAMY WASH                 LIQD         8%          T1

   66993091630     OSCION                                 PADS         3%          T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 189 of 285
   66993091830     OSCION                                 PADS         9%            T1

   66993091730     OSCION                                 PADS         6%            T1

   66993090706     OSCION CLEANSER                        LOTN         6%            T1

   66993090606     OSCION CLEANSER                        LOTN         3%            T1

   51674013005     RELAGARD                               GEL          0.9%; 0.025% T1

   45802004064     SELENIUM SULFIDE                       LOTN         2.5%          T1

   68032012718     SELENIUM SULFIDE                       SHAM         0; 2.25%; 0   T1

   00591081055     SILVER SULFADIAZINE                    CREA         1%            T1

   63717003011     ZACLIR CLEANSING                       LOTN         4%            T1

   63717003111     ZACLIR CLEANSING                       LOTN         8%            T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   68040070513     ALCORTIN A                             GEL          1%; 2%; 1%    T2

   13453024050     BENZIQ                                 GEL          5.25%         T2

   13453022550     BENZIQ LS                              GEL          2.75%         T2

   13453020018     BENZIQ WASH                            LIQD         5.25%         T2

   00145238406     BREVOXYL                               GEL          8%            T2

   00145237406     BREVOXYL                               GEL          4%            T2

   00145257406     BREVOXYL-4 ACNE WASH KIT               KIT          4%            T2

   00145258406     BREVOXYL-8 ACNE WASH KIT               KIT          8%            T2

   58552010401     BUCALSEP                               LIQD         600MG/30ML;   T2
                                                                       30MG/30ML;
                                                                       45MG/30ML;
                                                                       30MG/30ML
   58552010301     BUCALSEP                               SOLN         600MG/30ML;   T2
                                                                       30MG/30ML;
                                                                       45MG/30ML;
                                                                       30MG/30ML
   00496085745     CLINAC BPO                             GEL          7%            T2

   68712001301     INOVA                                  PADS         4%            T2

   66993091498     LAVOCLEN-8 ACNE WASH KIT               KIT          8%            T2

   67402002045     NEOBENZ MICRO                          CREA         3.5%          T2

   67402002245     NEOBENZ MICRO                          CREA         8.5%          T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 190 of 285
   67402002145     NEOBENZ MICRO                          CREA         5.5%        T2

   67402002206     NEOBENZ MICRO SD                       CREA         8.5%        T2

   67402002006     NEOBENZ MICRO SD                       CREA         3.5%        T2

   67402002106     NEOBENZ MICRO SD                       CREA         5.5%        T2

   00024153506     PHISOHEX                               LIQD         3%          T2

   51079062381     SULFAMYLON                             CREA         85MG/GM     T2

   23710022570     TERSI FOAM                             FOAM         2.25%       T2

   99207020809     TRIAZ CLEANSER                         LOTN         9%          T2

   10337074021     ZODERM                                 CREA         4.5%; 10%   T2

   10337074921     ZODERM                                 GEL          6.5%; 10%   T2

   10337075410     ZODERM                                 PADS         8.5%; 10%   T2

   10337074121     ZODERM                                 CREA         8.5%; 10%   T2




   (84:06) Topical Agents » Anti-inflammatories
   Tier: T1
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details   Comment

   00316014001     ALA-SCALP                              LOTN         2%          T1

   51672130601     ALCLOMETASONE DIPROPIONATE             CREA         0.05%       T1

   00168026415     ALCLOMETASONE DIPROPIONATE             OINT         0.05%       T1

   51672405403     AMCINONIDE                             CREA         0.1%        T1

   00168027960     AMCINONIDE                             OINT         0.1%        T1

   00168028060     AMCINONIDE                             LOTN         0.1%        T1

   00713050312     ANUCORT-HC                             SUPP         25MG        T1

   00462039560     APEXICON E                             CREA         0.05%       T1

   45802037632     AUGMENTED BETAMETHASONE                CREA         0.05%       T1
                   DIPROPIONATE
   00168026760     AUGMENTED BETAMETHASONE                LOTN         0.05%       T1
                   DIPROPIONATE
   00168026850     AUGMENTED BETAMETHASONE                OINT         0.05%       T1
                   DIPROPIONATE
   00168005760     BETAMETHASONE DIPROPIONATE             LOTN         0.05%       T1

   00168026650     BETAMETHASONE DIPROPIONATE             GEL          0.05%       T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                  Page 191 of 285
   00472038145     BETAMETHASONE DIPROPIONATE             OINT         0.05%    T1

   00472038045     BETAMETHASONE DIPROPIONATE             CREA         0.05%    T1

   00168004046     BETAMETHASONE VALERATE                 CREA         0.1%     T1

   00168003346     BETAMETHASONE VALERATE                 OINT         0.1%     T1

   00168004160     BETAMETHASONE VALERATE                 LOTN         0.1%     T1

   51672125903     CLOBETASOL PROPIONATE                  OINT         0.05%    T1

   00168029360     CLOBETASOL PROPIONATE                  GEL          0.05%    T1

   51672125803     CLOBETASOL PROPIONATE                  CREA         0.05%    T1

   60432013350     CLOBETASOL PROPIONATE                  SOLN         0.05%    T1

   00168030160     CLOBETASOL PROPIONATE EMOLLIENT        CREA         0.05%    T1

   51672128101     DESONIDE                               OINT         0.05%    T1

   00168031004     DESONIDE                               LOTN         0.05%    T1

   51672128001     DESONIDE                               CREA         0.05%    T1

   51672127003     DESOXIMETASONE                         CREA         0.25%    T1

   51672126101     DESOXIMETASONE                         GEL          0.05%    T1

   51672126203     DESOXIMETASONE                         OINT         0.25%    T1

   51672127103     DESOXIMETASONE                         CREA         0.05%    T1

   00168024360     DIFLORASONE DIACETATE                  OINT         0.05%    T1

   00168024260     DIFLORASONE DIACETATE                  CREA         0.05%    T1

   00168005960     FLUOCINOLONE ACETONIDE                 SOLN         0.01%    T1

   00168005860     FLUOCINOLONE ACETONIDE                 CREA         0.01%    T1

   00168006460     FLUOCINOLONE ACETONIDE                 OINT         0.025%   T1

   00168006060     FLUOCINOLONE ACETONIDE                 CREA         0.025%   T1

   00093026639     FLUOCINONIDE                           SOLN         0.05%    T1

   51672126403     FLUOCINONIDE                           OINT         0.05%    T1

   00168013515     FLUOCINONIDE                           GEL          0.05%    T1

   51672125303     FLUOCINONIDE                           CREA         0.05%    T1

   51672125403     FLUOCINONIDE-E                         CREA         0.05%    T1

   45802022211     FLUTICASONE PROPIONATE                 CREA         0.05%    T1

   45802022137     FLUTICASONE PROPIONATE                 OINT         0.005%   T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com         Page 192 of 285
   45802012932     HALOBETASOL PROPIONATE                 CREA         0.05%        T1

   45802013132     HALOBETASOL PROPIONATE                 OINT         0.05%        T1

   00093916871     HYDROCORTISONE                         ENEM         100MG/60ML   T1

   00168014630     HYDROCORTISONE                         OINT         2.5%         T1

   59366270704     HYDROCORTISONE                         LOTN         1%           T1

   00168008031     HYDROCORTISONE                         CREA         2.5%         T1

   00168001531     HYDROCORTISONE                         CREA         1%           T1

   00168002031     HYDROCORTISONE                         OINT         1%           T1

   00168028802     HYDROCORTISONE                         LOTN         2.5%         T1

   51672406104     HYDROCORTISONE BUTYRATE                SOLN         0.1%         T1

   51672408306     HYDROCORTISONE BUTYRATE                OINT         0.1%         T1

   51672407406     HYDROCORTISONE BUTYRATE                CREA         0.1%         T1

   46287000316     HYDROCORTISONE IN ABSORBASE            OINT         1%           T1

   51672129001     HYDROCORTISONE VALERATE                CREA         0.2%         T1

   51672129201     HYDROCORTISONE VALERATE                OINT         0.2%         T1

   51991027141     KERATOL HC                             CREA         1%; 10%      T1

   60258004206     LIDOCAINE HCL/HYDROCORTISONE           LOTN         0.5%; 3%     T1
                   ACETATE
   60258004101     LIDOCAINE HCL/HYDROCORTISONE           CREA         0.5%; 3%     T1
                   ACETATE
   45802011846     MOMETASONE FUROATE                     SOLN         0.1%         T1

   45802025735     MOMETASONE FUROATE                     CREA         0.1%         T1

   45802011942     MOMETASONE FUROATE                     OINT         0.1%         T1

   51672126302     NYSTATIN/TRIAMCINOLONE                 CREA         100000UNIT/G T1
                                                                       M; 0.1%
   51672127201     NYSTATIN/TRIAMCINOLONE                 OINT         100000UNIT/G T1
                                                                       M; 0.1%
   00168038160     PREDNICARBATE                          CREA         0.1%         T1

   00168041060     PREDNICARBATE                          OINT         0.1%         T1

   64980030230     PROCTO-PAK                             CREA         1%           T1

   00603813611     PROCTOSERT HC                          SUPP         30MG         T1

   10631040701     PROCTOSOL HC                           CREA         2.5%         T1

   45802004935     TRIAMCINOLONE ACETONIDE                OINT         0.5%         T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com             Page 193 of 285
   45802005435     TRIAMCINOLONE ACETONIDE                OINT         0.025%        T1

   00168000315     TRIAMCINOLONE ACETONIDE                CREA         0.025%        T1

   60432056160     TRIAMCINOLONE ACETONIDE                LOTN         0.1%          T1

   00168000215     TRIAMCINOLONE ACETONIDE                CREA         0.5%          T1

   00168000415     TRIAMCINOLONE ACETONIDE                CREA         0.1%          T1

   00168000680     TRIAMCINOLONE ACETONIDE                OINT         0.1%          T1

   60432056060     TRIAMCINOLONE ACETONIDE                LOTN         0.025%        T1

   51672126705     TRIAMCINOLONE IN ORABASE               PSTE         0.1%          T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00299550004     CAPEX                                  SHAM         0.01%         T2

   00299384902     CLOBEX                                 LIQD         0.05%         T2

   00299384802     CLOBEX                                 LOTN         0.05%         T2

   00299384704     CLOBEX                                 SHAM         0.05%         T2

   13548003145     CLODERM                                CREA         0.1%          T2

   16110005260     CORDRAN                                LOTN         0.05%         T2

   16110003530     CORDRAN SP                             CREA         0.05%         T2

   55515001480     CORDRAN TAPE                           TAPE         4MCG/SQCM     T2

   51674011702     CORTANE-B                              LOTN         1MG/ML;       T2
                                                                       10MG/ML;
                                                                       10MG/ML
   00091069520     CORTIFOAM                              FOAM         90MG          T2

   61570003150     CORTISPORIN                            OINT         400UNIT/GM;   T2
                                                                       1%; 0.5%;
                                                                       5000UNIT/GM
   61570003275     CORTISPORIN                            CREA         0.5%; 0.5%;  T2
                                                                       10000UNIT/GM
   00462033330     CUTIVATE                               OINT         0.005%        T2

   00462043404     CUTIVATE                               LOTN         0.05%         T2

   00462033230     CUTIVATE                               CREA         0.05%         T2

   28105015004     DERMA-SMOOTHE/FS BODY OIL              OIL          0.01%         T2

   28105014904     DERMA-SMOOTHE/FS SCALP OIL             OIL          0.01%         T2

   67402005060     DESONATE                               GEL          0.05%         T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 194 of 285
   00091074010     EPIFOAM                                FOAM         1%; 1%       T2

   65628001001     FIRST-HYDROCORTISONE                   GEL          10%          T2

   00003024830     HALOG                                  OINT         0.1%         T2

   00003024920     HALOG                                  SOLN         0.1%         T2

   00003148230     HALOG                                  CREA         0.1%         T2

   00003050162     KENALOG                                AERS         0            T2

   00496082145     LOCOID LIPOCREAM                       CREA         0.1%         T2

   63032002100     LUXIQ                                  FOAM         0.12%        T2

   68040070426     NOVACORT                               GEL          1%; 2%; 1%   T2

   66992018043     NUZON                                  GEL          0; 2%        T2

   63032003100     OLUX                                   FOAM         0.05%        T2

   63032010100     OLUX-E                                 FOAM         0.05%        T2

   00462015315     PANDEL                                 CREA         0.1%         T2

   00496071604     PRAMOSONE                              CREA         1%; 1%       T2

   00496072904     PRAMOSONE                              LOTN         1%; 1%       T2

   00496071704     PRAMOSONE                              CREA         2.5%; 1%     T2

   00496077704     PRAMOSONE                              OINT         2.5%; 1%     T2

   00496072604     PRAMOSONE                              LOTN         2.5%; 1%     T2

   00496076304     PRAMOSONE                              OINT         1%; 1%       T2

   10631040601     PROCTO-KIT                             CREA         2.5%         T2

   00066027231     PSORCON E                              CREA         0.05%        T2

   00430323015     TACLONEX                               OINT         0.064%;      T2
                                                                       0.005%
   68712001101     TEXACORT                               SOLN         2.5%         T2

   46287001016     TRIAMCINOLONE ACETONIDE IN ABSORBASE OINT           0.05%        T2

   99207052560     VANOS                                  CREA         0.1%         T2

   11086003201     VANOXIDE-HC                            LOTN         5%; 0.5%     T2

   63032011100     VERDESO                                FOAM         0.05%        T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com             Page 195 of 285
   (84:08) Topical Agents » Antipruritics & Local Anesthetics
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   63736037882     AMERICAINE                             AERO         20%           T1

   10223020101     CETACAINE                              AERO         14%; 2%; 2% T1

   00168020437     LIDOCAINE                              OINT         5%            T1

   60258004001     LIDOCAINE                              CREA         3%            T1

   00054350547     LIDOCAINE HCL                          SOLN         4%            T1

   17478071130     LIDOCAINE HCL JELLY                    GEL          2%            T1

   68032012420     LIDOCAINE HCL/HYDROCORTISONE           KIT          0.5%; 3%      T1
                   ACETATE
   68032012820     LIDOCAINE HCL/HYDROCORTISONE           KIT          1%; 3%        T1
                   ACETATE
   68032011101     LIDOCAINE HCL/HYDROCORTISONE           CREA         0.5%; 3%      T1
                   ACETATE
   68032019320     LIDOCAINE HCL/HYDROCORTISONE           KIT          2.5%; 3%      T1
                   ACETATE
   00168035730     LIDOCAINE/PRILOCAINE                   CREA         2.5%; 2.5%    T1

   54859050401     ORASEP                                 SOLN         600MG/30ML;   T1
                                                                       30MG/30ML;
                                                                       30MG/30ML;
                                                                       300MG/30ML
   54859050301     ORASEP                                 SOLN         600MG/30ML;   T1
                                                                       30MG/30ML;
                                                                       30MG/30ML;
                                                                       300MG/30ML
   00603514121     PHENAZOPYRIDINE HCL                    TABS         100MG         T1

   00603514221     PHENAZOPYRIDINE HCL                    TABS         200MG         T1

   51991025133     PHENAZOPYRIDINE PLUS                   TABS         15MG; 0.3MG; T1
                                                                       150MG


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00496077804     ANALPRAM-HC                            CREA         1%; 1%        T2

   00496080004     ANALPRAM-HC                            CREA         2.5%; 1%      T2

   00496082904     ANALPRAM-HC                            LOTN         2.5%; 1%      T2

   00496080064     ANALPRAM-HC SINGLES                    CREA         2.5%; 1%      T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 196 of 285
   00496077864     ANALPRAM-HC SINGLES                    CREA         1%; 1%       T2

   65628005001     FIRST-MOUTHWASH BLM                    SUSP         3.15GM/237ML T2
                                                                       ;
                                                                       0.2GM/237ML;
                                                                       1.6GM/237ML;
                                                                       3.15GM/237ML
                                                                       ;
                                                                       0.315GM/237M
                                                                       L
   10337070510     LIDAMANTLE                             LOTN         3%           T2

   63481068706     LIDODERM                               PTCH         5%           T2

   00067581296     NUPERCAINAL                            OINT         1%           T2

   00482480124     PERANEX HC                             KIT          2%; 2%       T2

   49452522002     PHENOL                                 LIQD         0            T2

   00409186602     PONTOCAINE                             SOLN         2%           T2

   00091475020     PROCTOFOAM                             FOAM         1%           T2

   00091069010     PROCTOFOAM HC                          FOAM         1%; 1%       T2

   63481086410     SYNERA                                 PTCH         70MG; 70MG   T2

   10337080403     ZONALON                                CREA         5%           T2




   (84:12) Topical Agents » Astringents
   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   00096070960     XERAC AC                               SOLN         6.25%        T2




   (84:16) Topical Agents » Cell Stimulants & Proliferants
   Tier: T1
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   45802036242     TRETINOIN                              GEL          0.01%        T1            AL (max: 35y)


   14290024245     TRETINOIN                              CREA         0.05%        T1            AL (max: 35y)


   14290024345     TRETINOIN                              CREA         0.025%       T1            AL (max: 35y)


   45802018342     TRETINOIN                              CREA         0.1%         T1            AL (max: 35y)




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 197 of 285
   45802036342     TRETINOIN                              GEL          0.025%           T1            AL (max: 35y)


   66530024740     TRETINOIN EMOLLIENT                    CREA         0.05%            T1            AL (max: 35y)




   Tier: T2
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00062018702     RENOVA                                 CREA         0.02%            T2            AL (max: 35y)


   00062020403     RETIN-A MICRO                          GEL          0.04%            T2            AL (max: 35y)


   00062019003     RETIN-A MICRO                          GEL          0.1%             T2            AL (max: 35y)


   14290035297     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2            AL (max: 35y)
                                                                       0.025%
   14290035197     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2            AL (max: 35y)
                                                                       0.05%
   14290035497     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2            AL (max: 35y)
                                                                       0.01%
   14290035397     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2            AL (max: 35y)
                                                                       0.025%
   14290035097     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2            AL (max: 35y)
                                                                       0.1%




   (84:24.04) Topical Agents » Emollients, Demulcents, & Protectants » Basic Lotions & Liniments
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   45802041926     AMMONIUM LACTATE                       LOTN         12%              T1

   45802049326     AMMONIUM LACTATE                       CREA         12%              T1

   64980031036     LACTIC ACID                            LOTN         10%              T1


   Tier: T2
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00245002216     AMLACTIN XL                            LOTN         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0
   63717003610     HYLIRA                                 LOTN         0.1%             T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 198 of 285
   (84:24.08) Topical Agents » Emollients, Demulcents, & Protectants » Basic Oils & Other Solvents
   Tier: T1
   NDC             Product Name                           Form         Strength           Pref   Cost   Coverage Details   Comment

   64980030912     LACTIC ACID E                          CREA         10%;         T1
                                                                       3500UNIT/30G
                                                                       M




   (84:24.12) Topical Agents » Emollients, Demulcents, & Protectants » Basic Ointments & Protectants
   Tier: T1
   NDC             Product Name                           Form         Strength           Pref   Cost   Coverage Details   Comment

   11701005032     CRITIC-AID                             PSTE         20%                T1


   Tier: T2
   NDC             Product Name                           Form         Strength           Pref   Cost   Coverage Details   Comment

   13453010011     ATOPICLAIR                             CREA         0;   0; 0; 0; 0;   T2
                                                                       0;   0; 0; 0; 0;
                                                                       0;   0; 0; 0; 0;
                                                                       0;   0
   00496059801     ELETONE                                CREA         0; 0; 0; 0; 0; 0 T2

   00145420002     MIMYX                                  CREA         0; 0; 0; 0; 0;     T2
                                                                       0; 0; 0; 0; 0
   00430350011     MOISTUREL                              CREA         10%;    10%;       T2
                                                                       10%;    10%;
                                                                       10%;    10%;
                                                                       10%;    10%;
                                                                       10%




   (84:28) Topical Agents » Keratolytics
   Tier: T1
   NDC             Product Name                           Form         Strength           Pref   Cost   Coverage Details   Comment

   00245016901     CLENIA                                 CREA         10%; 5%            T1

   12539053104     EXODERM                                LOTN         1%; 25%            T1

   66993090212     PRASCION                               EMUL         10%; 5%            T1

   66993090530     PRASCION FC                            PADS         10%; 5%            T1

   66993090445     PRASCION RA WITH SUNSCREENS            CREA         10%; 5%            T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 199 of 285
   68032014714     RE SA 6%                               LOTN         6%           T1

   68032010406     ROSADERM                               EMUL         10%; 5%      T1

   59366272405     SODIUM SULFACETAMIDE/SULFUR            SUSP         10%; 5%      T1

   59366273103     SODIUM SULFACETAMIDE/SULFUR            LOTN         10%; 5%      T1

   59366276205     SODIUM SULFACETAMIDE/SULFUR            LOTN         10%; 5%      T1

   51991017245     SULFATOL                               GEL          10%; 5%;     T1
                                                                       10%
   45802017156     UREA                                   GEL          40%          T1

   50383066403     UREA                                   CREA         40%          T1

   50383066308     UREA                                   LOTN         40%          T1

   68032012118     UREA NAIL                              GEL          50%          T1

   50383070105     UREALAC                                CREA         50%          T1

   50383073145     UREALAC                                OINT         50%          T1

   50383069911     UREALAC                                LOTN         35%          T1


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details   Comment

   65880000145     AVAR                                   GEL          10%; 5%      T2

   16781015460     CLARIFOAM EF                           FOAM         10%; 5%      T2

   23710004075     HYDRO 40 FOAM                          FOAM         40%          T2

   16781015760     KERAFOAM                               FOAM         30%          T2

   10337064810     KERALAC NAILSTIK                       SOLN         50%          T2

   11086003040     KERALYT                                GEL          6%           T2

   10337064510     KEROL                                  SUSP         0; 0; 50%    T2

   10337064910     KEROL REDI-CLOTHS                      MISC         42%          T2

   00145268105     ROSAC WASH                             EMUL         10%; 1%      T2

   10337066212     ROSULA                                 EMUL         10%; 5%; 0   T2

   10337066716     ROSULA CLARIFYING WASH                 EMUL         10%; 4%;     T2
                                                                       10%
   13548001206     SALEX                                  SHAM         6%           T2

   13548001013     SALEX                                  CREA         6%           T2

   13613073035     ULTRALYTIC 2                           FOAM         12%; 20%     T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 200 of 285
   13613023004     ULTRALYTIC 2                           CREA         12%; 20%      T2

   68712000401     UMECTA                                 EMUL         40%           T2

   68712000501     UMECTA                                 SUSP         40%           T2

   68712001001     UMECTA NAIL FILM                       SUSP         40%           T2

   68712001702     UMECTA PD                              EMUL         40%           T2

   68712001802     UMECTA PD                              SUSP         40%           T2




   (84:32) Topical Agents » Keratoplastics
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00072420008     BALNETAR LIQUIM                        EMUL         2.5%          T2

   38779061005     COAL TAR                               SOLN         20%           T2




   (84:50.04) Topical Agents » Depigmenting & Pigmenting Agents » Depigmenting Agents
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   58980058020     ALPHAQUIN HP                           CREA         5%; 4%; 7.5% T1

   59366278503     HYDROQUINONE                           CREA         4%            T1

   45802097564     HYDROQUINONE /SUNSCREENS               CREA         3%; 4%; 2%;   T1
                                                                       8%
   59366278303     HYDROQUINONE/SUNSCREENS                GEL          30MG/GM;      T1
                                                                       40MG/GM;
                                                                       50MG/GM
   59366278903     HYDROQUINONE/SUNSCREENS                CREA         4%; 4%; 4%;   T1
                                                                       8%
   58980047310     MELPAQUE HP                            CREA         4%            T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   68712000301     ACLARO                                 EMUL         4%            T2

   68712001502     ACLARO PD                              EMUL         4%            T2

   00187038034     BENOQUIN                               CREA         20%           T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 201 of 285
   00145251605     CLARIPEL                               CREA         3%; 4%;       T2
                                                                       7.5%; 6%
   67402001030     EPIQUIN MICRO                          CREA         4%            T2

   00187042146     GLYQUIN XM                             CREA         3%; 4%; 8%;   T2
                                                                       4%
   51672132703     LUSTRA-AF                              CREA         0; 4%; 0      T2

   51672132802     LUSTRA-ULTRA                           CREA         4%            T2

   60336003530     REMERGENT HQ                           CREA         4%            T2

   13478000101     SOLAGE                                 SOLN         2%; 0.01%     T2

   00299595030     TRI-LUMA                               CREA         0.01%; 4%;    T2
                                                                       0.05%




   (84:50.06) Topical Agents » Depigmenting & Pigmenting Agents » Pigmenting Agents
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00187040231     OXSORALEN                              LOTN         1%            T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00187065142     8-MOP                                  CAPS         10MG          T2

   00187065042     OXSORALEN ULTRA                        CAPS         10MG          T2




   (84:92) Topical Agents » Misc
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   13279010233     ALLANENZYME                            LIQD         830000UNIT/G T1
                                                                       M; 10%
   13279010333     ALLANFILLENZYME                        LIQD         0.5%;        T1
                                                                       521700UNIT/G
                                                                       M; 10%
   00555105586     CLARAVIS                               CAPS         20MG          T1

   58177080402     ETHEZYME                               OINT         1.1MU/GM;     T1
                                                                       100MG/GM
   58177081602     ETHEZYME 830                           OINT         0.83MMU/GM;   T1
                                                                       100MG/GM


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 202 of 285
   51672406301     FLUOROURACIL                           SOLN         5%               T1

   51672406201     FLUOROURACIL                           SOLN         2%               T1

   68682000431     FLUOROURACIL                           CREA         5%               T1

   00603127054     GRANUL-DERM                            AERS         650MG/0.82ML T1
                                                                       ;
                                                                       72.5MG/0.82M
                                                                       L;
                                                                       0.1MG/0.82ML
   58980015020     HYPERCARE                              SOLN         20%              T1

   58980072211     KOVIA 6.5                              OINT         650000UNIT/G T1
                                                                       M; 10%
   00574060115     PODOCON 25 IN BENZOIN TINCTURE         SOLN         25%              T1

   00591320413     PODOFILOX                              SOLN         0.5%             T1

   53303002130     RADIGEL                                GEL          0; 0; 0; 0; 0;   T1
                                                                       0; 0; 0
   10631058631     SOTRET                                 CAPS         40MG             T1

   10631058431     SOTRET                                 CAPS         10MG             T1

   58980077611     ZIOX 405                               OINT         0.5%;        T1
                                                                       405900UNIT/G
                                                                       M; 10%


   Tier: T2
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00064100134     ACCUZYME SE                            EMUL         830000UNIT/G T2
                                                                       M; 10%
   29336061012     ALDARA                                 CREA         5%               T2

   08213020012     ALLCLENZ                               LIQD         0; 0; 0; 0; 0;   T2
                                                                       0; 0
   00469002103     AMEVIVE                                SOLR         15MG             T2

   00023869430     AZELEX                                 CREA         20%              T2

   00062020502     BIAFINE                                EMUL         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0
   68712000901     BIONECT                                SOLN         0.2%             T2

   68712000702     BIONECT                                CREA         0.2%             T2

   68712000802     BIONECT                                GEL          0.2%             T2

   00066715030     CARAC                                  CREA         0.5%             T2

   55515010201     CONDYLOX                               GEL          0.5%             T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                       Page 203 of 285
   00299591045     DIFFERIN                               GEL          0.1%             T2

   00299591545     DIFFERIN                               CREA         0.1%             T2

   00299591845     DIFFERIN                               GEL          0.3%             T2

   00430302015     DOVONEX                                CREA         0.005%           T2   QL (300.00 per 30 days)


   00430303015     DOVONEX                                SOLN         0.005%           T2   QL (300.00 per 30 days)


   11086003501     DRITHO-SCALP                           CREA         0.5%             T2

   00078037546     ELIDEL                                 CREA         1%               T2

   10922082502     FINACEA                                GEL          15%              T2

   00023081230     FLUOROPLEX                             CREA         1%               T2

   24477001015     GELCLAIR                               GEL          0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0
   68712001401     INOVA 4/1 ACNE CONTROL THERAPY         PADS         4%; 1%           T2

   68712002101     INOVA 8/2 ACNE CONTROL THERAPY         PADS         8%; 2%           T2

   00259030350     MEDERMA                                GEL          0; 0; 0; 0; 0;   T2
                                                                       0; 0
   66992017043     NUOX                                   GEL          6%; 3%           T2

   16781011695     OPTASE                                 GEL          788MG/GM;        T2
                                                                       87MG/GM;
                                                                       0.12MG/GM
   00064341030     PANAFIL                                OINT         0.5%;        T2
                                                                       405900UNIT/G
                                                                       M; 10%
   00064351034     PANAFIL SE                             EMUL         0.5%;        T2
                                                                       405900UNIT/G
                                                                       M; 10%
   62856060122     PANRETIN                               GEL          0.1%             T2   QL (60.00 per 30 days)


   00006007131     PROPECIA                               TABS         1MG              T2

   00469520130     PROTOPIC                               OINT         0.03%            T2

   00469520230     PROTOPIC                               OINT         0.1%             T2

   65880041550     PSORIATEC                              CREA         1%               T2

   50242005804     RAPTIVA                                KIT          125MG            T2   PA


   00045081015     REGRANEX                               GEL          0.01%            T2   QL (15.00 per 30 days)


   53303001108     SALICEPT                               SUSR         0                T2

   00064501030     SANTYL                                 OINT         250UNIT/GM       T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                           Page 204 of 285
   10337080301     SOLARAZE                               GEL          3%                 T2

   10631044731     SOTRET                                 CAPS         30MG               T2

   00145351807     SULFOXYL REGULAR                       LOTN         5%; 2%             T2

   00145351907     SULFOXYL STRONG                        LOTN         10%; 5%            T2

   62856060422     TARGRETIN                              GEL          1%                 T2

   00023915530     TAZORAC                                CREA         0.05%              T2            QL (60.00 per 30 days)


   00023915630     TAZORAC                                CREA         0.1%               T2            QL (60.00 per 30 days)


   00023004203     TAZORAC                                GEL          0.1%               T2            QL (100.00 per 30 days)


   00023833503     TAZORAC                                GEL          0.05%              T2            QL (100.00 per 30 days)


   67402004030     VANIQA                                 CREA         13.9%              T2

   08514001001     XCLAIR                                 CREA         0;   0; 0; 0; 0;   T2
                                                                       0;   0; 0; 0; 0;
                                                                       0;   0; 0; 0; 0;
                                                                       0;   0
   00064390060     XENADERM                               OINT         788MG/GM;          T2
                                                                       87MG/GM;
                                                                       90UNIT/GM
   99207030060     ZIANA                                  GEL          1.2%; 0.025% T2                  AL (max: 35y)




   (86:12) Smooth Muscle Relaxants » GU
   Tier: T1
   NDC             Product Name                           Form         Strength           Pref   Cost   Coverage Details          Comment

   00115181101     FLAVOXATE HCL                          TABS         100MG              T1

   50111045601     OXYBUTYNIN CHLORIDE                    TABS         5MG                T1

   60432009216     OXYBUTYNIN CHLORIDE                    SYRP         5MG/5ML            T1

   00378660501     OXYBUTYNIN CHLORIDE ER                 TB24         5MG                T1

   00378661001     OXYBUTYNIN CHLORIDE ER                 TB24         10MG               T1

   00093520801     OXYBUTYNIN CHLORIDE ER                 TB24         15MG               T1


   Tier: T2
   NDC             Product Name                           Form         Strength           Pref   Cost   Coverage Details          Comment

   00009519001     DETROL LA                              CP24         2MG                T2

   00009519101     DETROL LA                              CP24         4MG                T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                Page 205 of 285
   00078042015     ENABLEX                                TB24         15MG          T2

   00078041915     ENABLEX                                TB24         7.5MG         T2

   51248015001     VESICARE                               TABS         5MG           T2

   51248015101     VESICARE                               TABS         10MG          T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00009454402     DETROL                                 TABS         2MG           T3            MN


   00009454102     DETROL                                 TABS         1MG           T3            MN


   52544092008     OXYTROL                                PTTW         3.9MG/24HR    T3            MN


   15456098004     SANCTURA                               TABS         20MG          T3            MN




   (86:16) Smooth Muscle Relaxants » Respiratory
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00677000301     AMINOPHYLLINE                          TABS         100MG         T1

   00677000701     AMINOPHYLLINE                          TABS         200MG         T1

   58173003816     BRONDIL                                LIQD         100MG/15ML;   T1
                                                                       100MG/15ML
   60258037116     DY-G                                   LIQD         100MG/5ML;    T1
                                                                       100MG/5ML
   10892015065     DYLIX                                  ELIX         100MG/15ML    T1

   51991037501     DYPHYLLINE-GG                          TABS         200MG; 200MG T1

   00603119058     DYPHYLLINE-GG                          ELIX         100MG/15ML;   T1
                                                                       100MG/15ML
   00456064416     ELIXOPHYLLIN                           ELIX         80MG/15ML     T1

   50111048201     THEOPHYLLINE CR                        TB12         200MG         T1

   50111048301     THEOPHYLLINE CR                        TB12         100MG         T1

   50111045901     THEOPHYLLINE ER                        TB12         300MG         T1

   50111051801     THEOPHYLLINE ER                        TB12         450MG         T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 206 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   45985064701     DIFIL-G                                TABS         200MG; 300MG T2

   00485005916     ED-BRON G                              SYRP         100MG/15ML;   T2
                                                                       300MG/15ML
   00037073192     LUFYLLIN                               TABS         400MG         T2

   00037052192     LUFYLLIN                               TABS         200MG         T2

   00525037616     PANFIL-G                               SYRP         100MG/5ML;    T2
                                                                       50MG/5ML
   50474030001     THEO-24                                CP24         300MG         T2

   50474040001     THEO-24                                CP24         400MG         T2

   50474010001     THEO-24                                CP24         100MG         T2

   50474020001     THEO-24                                CP24         200MG         T2

   67781025101     UNIPHYL                                TB24         400MG         T2

   67781025201     UNIPHYL                                TB24         600MG         T2




   (88:08) Vitamins » Vitamin B Complex
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   60258084150     AMINOBENZOATE POTASSIUM                PACK         2GM           T1

   66213054060     ANIMI-3                                CAPS         500MCG;      T1
                                                                       350MG; 35MG;
                                                                       1MG; 500MG;
                                                                       200MG;
                                                                       12.5MG
   30727030080     B-COMPLEX 100                          SOLN         2%; 2MG/ML;   T1
                                                                       100MG/ML;
                                                                       2MG/ML;
                                                                       2MG/ML;
                                                                       100MG/ML
   63323004401     CYANOCOBALAMIN                         SOLN         1000MCG/ML    T1

   51991008490     FOLBEE                                 TABS         1MG; 2.5MG;   T1
                                                                       25MG
   51991038490     FOLBIC                                 TABS         2MG; 2.5MG;   T1
                                                                       25MG
   68308032410     FOLCAPS                                TABS         0.5MG; 2.2MG; T1
                                                                       25MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 207 of 285
   00591521610     FOLIC ACID                             TABS         1MG           T1

   63323018410     FOLIC ACID                             SOLN         5MG/ML        T1

   00536384301     FOLIC ACID                             TABS         800MCG        T1

   00591288830     HYDROXOCOBALAMIN                       SOLN         1000MCG/ML    T1

   49326044090     NERVO B-12 SL                          LOZG         200MCG;       T1
                                                                       1000MCG;
                                                                       500MCG;
                                                                       2000MCG;
                                                                       1500MCG
   00245006711     NIACOR                                 TABS         500MG         T1

   00536407401     NICOTINIC ACID SR                      CPCR         250MG         T1

   63323018001     PYRIDOXINE HCL                         SOLN         100MG/ML      T1

   00536468001     THIAMINE HCL                           TABS         100MG         T1

   63323001302     THIAMINE HCL                           SOLN         100MG/ML      T1

   54022111201     VITAMIN B-12                           SUBL         2500MCG       T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00525050390     CEREFOLIN                              TABS         1MG;          T2
                                                                       5.635MG;
                                                                       50MG; 5MG
   00245019111     FOLGARD RX                             TABS         1MG; 2.2MG;   T2
                                                                       25MG
   68220001890     FOLPACE RX                             TABS         100UNIT;      T2
                                                                       2.05MG;
                                                                       425MCG;
                                                                       100MG; 25MG
   66869012210     FOLTRATE                               TABS         500MCG; 1MG   T2

   00525801990     METANX                                 TABS         2.8MG; 2MG;   T2
                                                                       25MG
   67871773305     NASCOBAL                               SOLN         500MCG/0.1ML T2

   53879020210     NEURIN-SL                              SUBL         600MCG;       T2
                                                                       600MCG
   00516005125     POTABA                                 CAPS         500MG         T2

   00516005401     POTABA                                 TABS         500MG         T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 208 of 285
   (88:16) Vitamins » Vitamin D
   Tier: T1
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   00054312041     CALCITRIOL                             SOLN         1MCG/ML        T1

   00093065701     CALCITRIOL                             CAPS         0.25MCG        T1

   00093065801     CALCITRIOL                             CAPS         0.5MCG         T1

   50111099001     VITAMIN D                              CAPS         50000UNIT      T1


   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   58468012001     HECTOROL                               CAPS         0.5MCG         T2

   58468012101     HECTOROL                               CAPS         2.5MCG         T2

   00074431430     ZEMPLAR                                CAPS         2MCG           T2

   00074431530     ZEMPLAR                                CAPS         4MCG           T2

   00074431730     ZEMPLAR                                CAPS         1MCG           T2




   (88:24) Vitamins » Vitamin K Activity
   Tier: T2
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   25010040515     MEPHYTON                               TABS         5MG            T2




   (88:28) Vitamins » Multivitamins
   Tier: T1
   NDC             Product Name                           Form         Strength       Pref   Cost   Coverage Details   Comment

   10542001010     DIALYVITE                              TABS         100MG;         T1
                                                                       0.3MG;
                                                                       0.006MG;
                                                                       1MG; 20MG;
                                                                       10MG; 10MG;
                                                                       1.7MG; 1.5MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                     Page 209 of 285
   51991008290     FOLBEE PLUS                            TABS         60MG;        T1
                                                                       300MCG;
                                                                       10MG; 1MG;
                                                                       5MG; 20MG;
                                                                       50MG; 1.5MG;
                                                                       1.5MG
   52083084030     LYSIPLEX                               TABS         200MG;       T1
                                                                       50MCG;
                                                                       500MCG;
                                                                       200MG; 20MG;
                                                                       4MG; 6MG;
                                                                       20MG;
                                                                       40UNIT; 30MG
   12830080001     M-VIT                                  TABS         500MG;       T1   GL (f); AL (max: 35y)
                                                                       150MCG;
                                                                       25MG; 0.1MG;
                                                                       3MG; 50MCG;
                                                                       27MG; 1MG;
                                                                       50MG; 50MG;
                                                                       5MG; 100MG;
                                                                       25MG; 20MG;
                                                                       50MCG; 20MG;
                                                                       30UNIT;
                                                                       5000UNIT;
                                                                       22.5MG
   52152015002     MULTI VITA-BETS/FLUORIDE               CHEW         60MG;       T1
                                                                       4.5MCG;
                                                                       0.25MG;
                                                                       0.3MG;
                                                                       13.5MG;
                                                                       1.05MG;
                                                                       1.2MG;
                                                                       1.05MG;
                                                                       15UNIT;
                                                                       2500UNIT;
                                                                       400UNIT
   00603471421     MULTI-VITAMIN/FLUORIDE                 CHEW         400UNIT;     T1
                                                                       4.5MCG;
                                                                       0.3MG;
                                                                       13.5MG;
                                                                       1.05MG;
                                                                       1.2MG; 60MG;
                                                                       0.5MG;
                                                                       1.05MG;
                                                                       2500UNIT;
                                                                       15UNIT
   58177007304     NATACAPS                               CAPS         10MG; 0.8MG; T1   AL (max: 35y)
                                                                       15MCG;
                                                                       106MG; 1MG;
                                                                       1.3MG; 30MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 210 of 285
   58177041826     NATALCARE GLOSSTABS                    TABS         120MG; 0;     T1   GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       50MG; 1MG;
                                                                       90MG; 30MG;
                                                                       20MG; 20MG;
                                                                       3.4MG; 3MG;
                                                                       30UNIT;
                                                                       2700UNIT;
                                                                       25MG
   58177025804     NATALCARE PIC FORTE                    TABS         80MG; 250MG; T1    GL (f); AL (max: 35y)
                                                                       2MG; 12MCG;
                                                                       400UNIT;
                                                                       1MG; 60MG;
                                                                       10MG; 20MG;
                                                                       0.2MG; 4MG;
                                                                       3.4MG; 3MG;
                                                                       5000UNIT;
                                                                       30UNIT; 25MG
   58177022504     NATALCARE PLUS                         TABS         120MG; 0;    T1    GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       27MG; 1MG;
                                                                       20MG; 10MG;
                                                                       3MG; 1.84MG;
                                                                       22MG;
                                                                       4000UNIT;
                                                                       25MG
   58177032804     NATATAB CFE                            TABS         120MG; 0;    T1    GL (f); AL (max: 35y)
                                                                       200MG; 8MCG;
                                                                       1MG; 50MG;
                                                                       20MG;
                                                                       150MCG; 3MG;
                                                                       3MG; 3MG;
                                                                       30UNIT;
                                                                       4000UNIT;
                                                                       400UNIT;
                                                                       15MG
   58177032904     NATATAB FA                             TABS         120MG; 0;    T1    GL (f); AL (max: 35y)
                                                                       200MG; 8MCG;
                                                                       29MG; 1MG;
                                                                       20MG;
                                                                       150MCG; 3MG;
                                                                       3MG; 3MG;
                                                                       30UNIT;
                                                                       4000UNIT;
                                                                       400UNIT;
                                                                       15MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 211 of 285
   58177037626     NATATAB RX                             TABS         120MG;       T1    GL (f); AL (max: 35y)
                                                                       4000UNIT;
                                                                       30MCG;
                                                                       200MG;
                                                                       400UNIT;
                                                                       3MG; 8MCG;
                                                                       1MG; 29MG;
                                                                       100MG; 20MG;
                                                                       7MG; 150MCG;
                                                                       3MG; 3MG;
                                                                       3MG; 30UNIT;
                                                                       15MG
   59528031701     NEPHPLEX RX                            TABS         60MG;         T1
                                                                       300MCG; 6MG;
                                                                       1MG; 20MG;
                                                                       10MG; 10MG;
                                                                       1.7MG; 1.5MG;
                                                                       12.5MG
   00536730001     NEPHRO-VITE                            TABS         60MG;        T1
                                                                       300MCG;
                                                                       6MCG;
                                                                       800MCG;
                                                                       20MG; 10MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG
   49326032560     NERVIDOX-6 NR                          TABS         200MCG;      T1    AL (max: 35y)
                                                                       1000MCG;
                                                                       0.5MG;
                                                                       200MG; 150MG
   58177035126     NUTRINATE                              CHEW         120MG; 0;    T1    GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       12MCG; 29MG;
                                                                       1MG; 20MG;
                                                                       10MG; 3MG;
                                                                       2MG; 11UNIT;
                                                                       1000UNIT
   58177046326     NUTRISPIRE                             TABS         120MG;       T1    GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       8MCG; 1MG;
                                                                       29MG; 20MG;
                                                                       150MCG; 3MG;
                                                                       3MG; 3MG;
                                                                       30UNIT; 15MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 212 of 285
   00813020201     O-CAL PRENATAL                         TABS         70MG; 0;     T1    GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       15MG; 1MG;
                                                                       100MG; 17MG;
                                                                       150MCG;
                                                                       12MG; 1.6MG;
                                                                       1.5MG;
                                                                       2500UNIT;
                                                                       30UNIT; 15MG
   50383064150     POLY-VITAMIN                           SOLN         35MG/ML;      T1
                                                                       400UNIT/ML;
                                                                       2MCG/ML;
                                                                       0.5MG/ML;
                                                                       8MG/ML;
                                                                       0.4MG/ML;
                                                                       0.6MG/ML;
                                                                       0.5MG/ML;
                                                                       5UNIT/ML;
                                                                       1500UNIT/ML
   50383063450     POLY-VITAMIN /IRON /FLUORIDE           SOLN         35MG/ML;      T1
                                                                       400UNIT/ML;
                                                                       0.25MG/ML;
                                                                       10MG/ML;
                                                                       8MG/ML;
                                                                       0.4MG/ML;
                                                                       0.6MG/ML;
                                                                       0.5MG/ML;
                                                                       5UNIT/ML;
                                                                       1500UNIT/ML
   50383064250     POLY-VITAMIN/FLUORIDE                  SOLN         35MG/ML;     T1
                                                                       50MCG/ML;
                                                                       2MCG/ML;
                                                                       0.25MG/ML;
                                                                       8MG/ML;
                                                                       3MG/ML;
                                                                       0.4MG/ML;
                                                                       0.6MG/ML;
                                                                       0.5MG/ML;
                                                                       1500UNIT/ML;
                                                                       400UNIT/ML;
                                                                       5UNIT/ML
   60258017809     PRENAFIRST                             TABS         120MG; 0;    T1    GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       8MCG; 17MG;
                                                                       1MG; 20MG;
                                                                       150MCG; 3MG;
                                                                       3MG; 3MG;
                                                                       30UNIT;
                                                                       4000UNIT;
                                                                       15MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 213 of 285
   60258019601     PRENATAL 19                            TABS         100MG;       T1   GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       12MCG; 25MG;
                                                                       29MG; 1MG;
                                                                       15MG; 7MG;
                                                                       20MG; 3MG;
                                                                       3MG;
                                                                       1000UNIT;
                                                                       30UNIT; 20MG
   60258019701     PRENATAL 19                            CHEW         100MG;       T1   GL (f); AL (max: 35y)
                                                                       1000UNIT;
                                                                       200MG; 7MG;
                                                                       12MCG; 25MG;
                                                                       29MG; 1MG;
                                                                       6MG; 20MG;
                                                                       3MG; 3MG;
                                                                       400UNIT;
                                                                       30UNIT; 20MG
   58177021204     PRENATAL MR 90 FE                      TBCR         120MG;       T1   GL (f); AL (max: 35y)
                                                                       250MG; 2MG;
                                                                       12MCG; 50MG;
                                                                       1MG; 0.15MG;
                                                                       90MG; 20MG;
                                                                       20MG; 3.4MG;
                                                                       3MG;
                                                                       4000UNIT;
                                                                       400UNIT;
                                                                       30UNIT; 25MG
   58177031604     PRENATAL MTR/SELENIUM                  TABS         120MG; 0;    T1   GL (f); AL (max: 35y)
                                                                       30MCG;
                                                                       200MG;
                                                                       25MCG; 2MG;
                                                                       12MCG; 27MG;
                                                                       1MG; 25MG;
                                                                       5MG; 25MCG;
                                                                       20MG; 10MG;
                                                                       150MCG;
                                                                       10MG; 3.4MG;
                                                                       20MCG; 3MG;
                                                                       30UNIT;
                                                                       5000UNIT;
                                                                       400UNIT;
                                                                       25MG
   00603536121     PRENATAL PLUS                          TABS         120MG;       T1   GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       65MG; 1MG;
                                                                       20MG; 10MG;
                                                                       3MG; 1.84MG;
                                                                       22MG;
                                                                       4000UNIT;
                                                                       25MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 214 of 285
   52152017120     PRENATAL RX                            TABS         40MG; 0;     T1    GL (f); AL (max: 35y)
                                                                       0.015MG;
                                                                       100MG;
                                                                       1.5MG;
                                                                       1.25MCG;
                                                                       0.5MG; 27MG;
                                                                       50MG; 8.5MG;
                                                                       3.5MG; 2MG;
                                                                       0.8MG;
                                                                       0.75MG;
                                                                       2000UNIT;
                                                                       200UNIT;
                                                                       7.5UNIT;
                                                                       12.5MG
   58177021604     PRENATAL RX 1                          TABS         80MG;         T1   GL (f); AL (max: 35y)
                                                                       0.03MG;
                                                                       200MG; 3MG;
                                                                       2.5MCG;
                                                                       400UNIT;
                                                                       1MG; 60MG;
                                                                       100MG; 17MG;
                                                                       7MG; 4MG;
                                                                       1.6MG; 1.5MG;
                                                                       4000UNIT;
                                                                       15UNIT; 25MG
   60258018701     PRENATAL-H                             CAPS         0.8MG;        T1   GL (f); AL (max: 35y)
                                                                       15MCG;
                                                                       106MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG; 10MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG;
                                                                       18.2MG
   60258017901     PRENATAL-U                             CAPS         10MG; 0.8MG; T1    GL (f); AL (max: 35y)
                                                                       15MCG;
                                                                       106MG; 1MG;
                                                                       1.3MG; 30MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG
   60258016101     RENA-VITE RX                           TABS         60MG;        T1
                                                                       300MCG;
                                                                       6MCG; 1MG;
                                                                       20MG; 10MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG
   60258016201     RENAL                                  CAPS         100MG;       T1
                                                                       150MCG;
                                                                       6MCG; 1MG;
                                                                       20MG; 5MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 215 of 285
   50383063750     TRI-VITAMIN/FLUORIDE                   SOLN         35MG/ML;     T1
                                                                       0.25MG/ML;
                                                                       1500UNIT/ML;
                                                                       400UNIT/ML
   58177029204     ULTRA NATALCARE                        TABS         120MG; 0;    T1   GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       50MG; 1MG;
                                                                       90MG; 20MG;
                                                                       150MCG;
                                                                       20MG; 3.4MG;
                                                                       3MG;
                                                                       2700UNIT;
                                                                       30UNIT; 25MG
   51991046690     VINATE AZ                              TABS         120MG;       T1   GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       30MCG;
                                                                       150MG; 8MG;
                                                                       400UNIT;
                                                                       2.5MG;
                                                                       12MCG; 27MG;
                                                                       1MG; 75MG;
                                                                       20MG; 30MG;
                                                                       3.5MG; 3MG;
                                                                       30UNIT; 15MG
   51991017801     VINATE II                              TABS         120MG;       T1   GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       29MG; 1MG;
                                                                       25MG; 20MG;
                                                                       25MG; 4MG;
                                                                       1.8MG;
                                                                       30UNIT; 25MG
   52152007802     VITA CON FORTE                         CAPS         150MG; 10MG; T1   AL (max: 35y)
                                                                       10MCG; 1MG;
                                                                       70MG; 4MG;
                                                                       25MG; 2MG;
                                                                       5MG; 10MG;
                                                                       8000UNIT;
                                                                       50UNIT; 80MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 216 of 285
   53879020060     VITACEL                                TABS         500MG;       T1
                                                                       125MG;
                                                                       300MCG;
                                                                       25MG; 10MG;
                                                                       1MG; 33MG;
                                                                       50MG; 25MG;
                                                                       25MG; 50MCG;
                                                                       25MG;
                                                                       5000UNIT;
                                                                       200UNIT;
                                                                       100UNIT;
                                                                       80MG
   00642007912     VITAFOL-OB                             TABS         70MG;         T1           GL (f); AL (max: 35y)
                                                                       2700UNIT;
                                                                       100MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       65MG; 1MG;
                                                                       25MG; 18MG;
                                                                       2.5MG; 1.8MG;
                                                                       1.6MG;
                                                                       30UNIT; 25MG
   00642007812     VITAFOL-PN                             TABS         60MG; 125MG; T1            GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       5MCG; 65MG;
                                                                       1MG; 25MG;
                                                                       15MG; 2.5MG;
                                                                       1.8MG;
                                                                       65MCG;
                                                                       1.6MG;
                                                                       30UNIT;
                                                                       4000UNIT;
                                                                       15MG
   52152007602     VITAPLEX                               TABS         500MG; 18MG; T1            AL (max: 35y)
                                                                       5MCG; 0.5MG;
                                                                       100MG; 4MG;
                                                                       15MG; 15MG


   Tier: T2
   NDC             Product Name                           Form         Strength     Pref   Cost   Coverage Details        Comment

   58914001006     ADEKS                                  CHEW         60MG; 3MG;   T2
                                                                       50MCG;
                                                                       400UNIT;
                                                                       12MCG;
                                                                       0.2MG; 10MG;
                                                                       10MG;
                                                                       150MCG;
                                                                       1500MCG;
                                                                       1300MCG;
                                                                       1200MCG;
                                                                       4000UNIT;
                                                                       150UNIT;
                                                                       7.5MG

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                        Page 217 of 285
   55495011001     ATABEX PRENATAL                        TABS         120MG;        T2   GL (f); AL (max: 35y)
                                                                       200MG; 2MG;
                                                                       12MCG;
                                                                       400UNIT;
                                                                       1MG; 65MG;
                                                                       20MG; 10MG;
                                                                       3MG; 1.5MG;
                                                                       30UNIT;
                                                                       4000UNIT;
                                                                       25MG
   58177061866     CARENATAL DHA                          MISC         120MG;       T2    GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       0; 0; 1MG;
                                                                       29MG; 0;
                                                                       25MG; 20MG;
                                                                       250MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       30MG; 25MG
   10542001409     DIALYVITE 3000                         TABS         100MG;       T2
                                                                       300MCG;
                                                                       10MG;
                                                                       30UNIT; 3MG;
                                                                       1MG; 20MG;
                                                                       25MG; 1.7MG;
                                                                       70MCG;
                                                                       1.5MG; 15MG
   00525428190     DIATX ZN                               TABS         60MG;         T2
                                                                       300MCG;
                                                                       1.5MG; 2MG;
                                                                       5MG; 20MG;
                                                                       10MG; 50MG;
                                                                       1.5MG; 1.5MG;
                                                                       25MG
   66479083090     DUET                                   CHEW         120MG;       T2    GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       1MG; 29MG;
                                                                       25MG; 20MG;
                                                                       25MG; 4MG;
                                                                       1.8MG; 30MG;
                                                                       25MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 218 of 285
   66479084801     DUET                                   TABS         120MG;        T2      GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       0; 1MG; 29MG;
                                                                       0; 25MG;
                                                                       20MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       30MG; 25MG
   66479085530     DUET DHA                               MISC         120MG;        T2      GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       275MG; 0;
                                                                       1MG; 29MG; 0;
                                                                       25MG; 20MG;
                                                                       400MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       30MG; 25MG
   66479086130     DUET DHA EC                            MISC         120MG;        T2      GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       275MG; 0;
                                                                       1MG; 29MG; 0;
                                                                       25MG; 20MG;
                                                                       400MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       3MG; 25MG
   64011016636     ENCORA                                 MISC         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 10MG;
                                                                       100MG;
                                                                       650MG; 0;
                                                                       50UNIT
   00245015560     FOLGARD OS                             TABS         500MG;           T2
                                                                       300UNIT;
                                                                       250MCG;
                                                                       1.1MG;
                                                                       100MG;
                                                                       12.5MG;
                                                                       1.5MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                         Page 219 of 285
   00482015906     GLUTOFAC-ZX                            TABS         200MG;       T2
                                                                       200MCG;
                                                                       10MG;
                                                                       400UNIT;
                                                                       200MCG;
                                                                       2.5MG;
                                                                       2500MCG;
                                                                       100UNIT;
                                                                       2800MCG;
                                                                       500MCG;
                                                                       500MCG;
                                                                       100MG;
                                                                       2.5MG;
                                                                       100MG; 25MG;
                                                                       20MG;
                                                                       100MCG;
                                                                       20MG;
                                                                       5000UNIT;
                                                                       15MG
   11026274608     HEMATRON                               LIQD         25MCG/5ML;   T2
                                                                       50MG/5ML;
                                                                       1MG/5ML;
                                                                       150MG/5ML;
                                                                       10MG/5ML;
                                                                       5MG/5ML;
                                                                       2MG/5ML;
                                                                       2MG/5ML;
                                                                       10MG/5ML
   63717015003     ICAR PRENATAL COMBO PACK               MISC         120MG; 0;    T2   GL (f); AL (max: 35y)
                                                                       30MCG; 1MG;
                                                                       600MG; 5MG;
                                                                       200UNIT;
                                                                       100MCG; 2MG;
                                                                       120MG;
                                                                       180MG;
                                                                       1000MG; 1MG;
                                                                       29MG; 225MG;
                                                                       2MG; 75MCG;
                                                                       20MG; 65MCG;
                                                                       150MCG;
                                                                       10MG; 75MCG;
                                                                       3MG; 30UNIT;
                                                                       4000UNIT;
                                                                       15MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 220 of 285
   00682250001     MARNATAL-F PLUS DUO PACK               MISC         100MG;       T2    GL (f); AL (max: 35y)
                                                                       250MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       100MG;
                                                                       150MG;
                                                                       500MG; 1MG;
                                                                       25MG; 20MG;
                                                                       250MG; 60MG;
                                                                       200MCG; 5MG;
                                                                       3.4MG; 3MG;
                                                                       30UNIT;
                                                                       2000UNIT;
                                                                       25MG
   00430022640     NATAFORT                               TABS         120MG; 0;    T2    GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       12MCG; 1MG;
                                                                       60MG; 20MG;
                                                                       10MG; 3MG;
                                                                       2MG; 11UNIT;
                                                                       1000UNIT
   00525201090     NEEVO                                  TABS         80MG; 30MCG; T2    GL (f); AL (max: 35y)
                                                                       200MG; 7MG;
                                                                       400UNIT;
                                                                       2MG; 500MCG;
                                                                       400MCG; 1MG;
                                                                       40MG; 20MG;
                                                                       29MG; 2.6MG;
                                                                       3.4MG; 3MG;
                                                                       30UNIT; 15MG
   65880079260     NICOMIDE                               TABS         1.5MG;        T2
                                                                       500MCG;
                                                                       750MG; 25MG
   00813931601     O-CAL FA                               TABS         90MG; 200MG; T2    GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       27MG; 1MG;
                                                                       100MG; 20MG;
                                                                       150MCG; 4MG;
                                                                       3MG; 0.5MG;
                                                                       3MG;
                                                                       2500UNIT;
                                                                       30UNIT; 15MG
   68025001010     OB COMPLETE                            TABS         120MG;        T2   GL (f); AL (max: 35y)
                                                                       2100UNIT;
                                                                       315UNIT;
                                                                       1MG; 15MCG;
                                                                       20UNIT;
                                                                       1.25MG;
                                                                       50MG; 15MG;
                                                                       10MG; 10MG;
                                                                       3.4MG; 2MG;
                                                                       10MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 221 of 285
   68025002260     OB COMPLETE WITH DHA                   CAPS         120MG;       T2   GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       1MG; 15MCG;
                                                                       200MG; 28MG;
                                                                       1.25MG;
                                                                       10MG; 3.4MG;
                                                                       2MG; 30UNIT;
                                                                       25MG
   11026262606     OBSTETRIX EC                           TABS         120MG;       T2   GL (f); AL (max: 35y)
                                                                       2700UNIT;
                                                                       400UNIT;
                                                                       12MCG; 50MG;
                                                                       1MG; 29MG;
                                                                       30MG; 20MG;
                                                                       40MG; 3.4MG;
                                                                       65MCG; 3MG;
                                                                       18UNIT; 25MG
   67555014560     OBTREX                                 TABS         120MG;       T2   GL (f); AL (max: 35y)
                                                                       2700UNIT;
                                                                       400UNIT;
                                                                       2MCG; 50MG;
                                                                       1MG; 29MG;
                                                                       30MG; 20MG;
                                                                       40MG; 3.4MG;
                                                                       65MCG; 3MG;
                                                                       18UNIT; 25MG
   59630041230     OPTINATE                               MISC         120MG;       T2
                                                                       30MCG;
                                                                       200MG; 6MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       250MG; 50MG;
                                                                       400MCG;
                                                                       90MG;
                                                                       600MCG;
                                                                       30MG; 20MG;
                                                                       20MG; 3.4MG;
                                                                       3MG; 10UNIT;
                                                                       15MG
   64011002419     PRECARE                                CHEW         50MG; 250MG; T2   GL (f); AL (max: 35y)
                                                                       6MCG; 2MG;
                                                                       40MG; 1MG;
                                                                       50MG; 2MG;
                                                                       3.5MG; 15MG
   64011001419     PRECARE CONCEIVE                       TABS         60MG; 200MG; T2   GL (f); AL (max: 35y)
                                                                       2MG; 12MCG;
                                                                       1MG; 30MG;
                                                                       100MG; 20MG;
                                                                       50MG; 3.4MG;
                                                                       3MG; 30UNIT;
                                                                       15MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 222 of 285
   64011019519     PRECARE PREMIER                        TABS         50MG; 0;     T2    GL (f); AL (max: 35y)
                                                                       250MG; 0;
                                                                       6MCG; 2MG;
                                                                       12MCG; 50MG;
                                                                       30MG; 1MG;
                                                                       25MG; 20MG;
                                                                       50MG; 3.4MG;
                                                                       35MG; 3MG;
                                                                       3.5UNIT;
                                                                       15MG
   68220008890     PREFERA OB                             TABS         30MCG; 10MG; T2    AL (max: 35y)
                                                                       400UNIT;
                                                                       0.8MG;
                                                                       12MCG;
                                                                       10UNIT; 1MG;
                                                                       6MG; 17MG;
                                                                       22MG;
                                                                       175MCG;
                                                                       50MG; 1.6MG;
                                                                       65MCG;
                                                                       1.5MG; 15MG
   64011001919     PREMESIS RX                            TABS         200MG;        T2   GL (f); AL (max: 35y)
                                                                       12MCG; 1MG;
                                                                       75MG
   59630041435     PRENATE DHA                            CAPS         85MG; 150MG; T2    GL (f); AL (max: 35y)
                                                                       200UNIT;
                                                                       12MCG;
                                                                       300MG; 50MG;
                                                                       27MG;
                                                                       400MCG;
                                                                       600MCG;
                                                                       50MG; 25MG;
                                                                       10UNIT
   59630041190     PRENATE ELITE                          TABS         120MG;       T2    GL (f); AL (max: 35y)
                                                                       30MCG;
                                                                       200MG; 6MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       50MG;
                                                                       400MCG;
                                                                       90MG;
                                                                       600MCG;
                                                                       30MG; 20MG;
                                                                       20MG; 3.4MG;
                                                                       3MG; 10UNIT;
                                                                       15MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 223 of 285
   64011020428     PRIMACARE                              MISC         100MG;       T2    GL (f); AL (max: 35y)
                                                                       35MCG; 0;
                                                                       400MG; 0;
                                                                       400UNIT;
                                                                       45MCG;
                                                                       1.3MG;
                                                                       12MCG; 50MG;
                                                                       30MG; 1MG;
                                                                       30MG; 30MG;
                                                                       50MCG; 20MG;
                                                                       300MG; 7MG;
                                                                       50MG; 3.4MG;
                                                                       75MCG; 35MG;
                                                                       3MG; 30UNIT;
                                                                       90MCG; 11MG
   64011020019     PRIMACARE ONE                          CAPS         150MG; 25MG; T2    GL (f); AL (max: 35y)
                                                                       170UNIT;
                                                                       1MG; 27MG;
                                                                       30MG; 30MG;
                                                                       300MG; 25MG;
                                                                       30UNIT
   00642007790     SELECT-OB                              CHEW         60MG; 0;      T2   GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       5MCG; 1MG;
                                                                       25MG; 15MG;
                                                                       29MG; 2.5MG;
                                                                       1.8MG; 1.6MG;
                                                                       30UNIT;
                                                                       1700UNIT;
                                                                       15MG
   12539036060     SIDEROL                                TABS         250MG; 8MG; T2
                                                                       60MCG;
                                                                       100MG;
                                                                       150MG;
                                                                       400MCG; 3MG;
                                                                       20MG; 25MG;
                                                                       15MG; 15MG;
                                                                       50MG
   12539001308     SIDEROL                                LIQD         75MCG/15ML; T2
                                                                       514MG/15ML;
                                                                       0.825MG/15ML
                                                                       ; 300MG/15ML;
                                                                       30.6MG/15ML;
                                                                       30MG/15ML;
                                                                       15MG/15ML;
                                                                       6MG/15ML;
                                                                       6MG/15ML;
                                                                       30MG/15ML;
                                                                       6.9MG/15ML
   64011013722     STRONGSTART                            CHEW         50MG; 250MG; T2    GL (f); AL (max: 35y)
                                                                       6MCG; 2MG;
                                                                       35MG; 1MG;
                                                                       40MG; 50MG;
                                                                       3.5MG; 15MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 224 of 285
   00642020810     STROVITE ADVANCE                       TABS         0; 300MG; 0; T2    GL (f); AL (max: 35y)
                                                                       100MCG;
                                                                       15MG;
                                                                       3000UNIT;
                                                                       50MCG; 0;
                                                                       1.5MG;
                                                                       50MCG; 1MG;
                                                                       15MG; 5MG;
                                                                       50MG; 1.5MG;
                                                                       25MG; 25MG;
                                                                       5MG; 100MCG;
                                                                       30MG;
                                                                       400UNIT;
                                                                       100UNIT; 0;
                                                                       25MG
   11026284108     SUPERVITE                              LIQD         25MCG/15ML; T2
                                                                       20MG/15ML;
                                                                       1MG/15ML;
                                                                       1000MG/15ML;
                                                                       100MG/15ML;
                                                                       2MG/15ML;
                                                                       10MG/15ML;
                                                                       10MG/15ML;
                                                                       75MG/15ML
   52747090460     TANDEM DHA                             CAPS         215.12MG;     T2   AL (max: 35y)
                                                                       53.46MG;
                                                                       15MG; 1MG;
                                                                       310.1MG;
                                                                       15MG; 25MG;
                                                                       20MG
   52747090360     TANDEM OB                              CAPS         10MG; 0.8MG; T2    GL (f); AL (max: 35y)
                                                                       15MCG;
                                                                       162MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG;
                                                                       115.2MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG;
                                                                       18.2MG
   66869082010     UDAMIN SP                              TABS         250MCG; 1MG; T2
                                                                       2.5MG;
                                                                       12.5MG;
                                                                       100MCG;
                                                                       320MG;
                                                                       12.5MG;
                                                                       4.5MG;
                                                                       75UNIT;
                                                                       7.5MG
   54859070760     UROSEX                                 TABS         9MG; 500MCG; T2
                                                                       75MG; 2MG;
                                                                       2MG; 100MCG;
                                                                       5MG; 15UNIT;
                                                                       75MG; 100MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 225 of 285
   00642007630     VITAFOL-OB+DHA                         MISC         70MG;         T2            AL (max: 35y)
                                                                       2700UNIT;
                                                                       100MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       250MG; 65MG;
                                                                       1MG; 25MG;
                                                                       18MG; 2.5MG;
                                                                       1.8MG; 1.6MG;
                                                                       30UNIT; 25MG




   (92:00) Misc Agents
   Tier: T1
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   00378018105     ALLOPURINOL                            TABS         300MG         T1

   00378013701     ALLOPURINOL                            TABS         100MG         T1

   00781507501     AZATHIOPRINE                           TABS         50MG          T1

   00603305221     COLCHICINE                             TABS         0.6MG         T1

   60505013300     CYCLOSPORINE                           CAPS         25MG          T1

   60505013400     CYCLOSPORINE                           CAPS         100MG         T1

   60432014050     CYCLOSPORINE                           SOLN         100MG/ML      T1

   58177043240     ETHEDENT                               CHEW         0.25MG        T1

   58177043309     ETHEDENT                               CHEW         0.5MG         T1

   00378328691     ETIDRONATE DISODIUM                    TABS         200MG         T1

   00378328891     ETIDRONATE DISODIUM                    TABS         400MG         T1

   55566410001     EUFLEXXA                               SOLN         10MG/ML       T1

   00093735556     FINASTERIDE                            TABS         5MG           T1

   58223068424     FLURA-DROPS                            SOLN         0.25MG/DROP   T1

   00074647932     GENGRAF                                CAPS         100MG         T1

   00074646332     GENGRAF                                CAPS         25MG          T1

   00074726950     GENGRAF                                SOLN         100MG/ML      T1

   00781505631     LEFLUNOMIDE                            TABS         10MG          T1

   00781505731     LEFLUNOMIDE                            TABS         20MG          T1

   00555048401     LEUCOVORIN CALCIUM                     TABS         5MG           T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 226 of 285
   00555048527     LEUCOVORIN CALCIUM                     TABS         25MG          T1

   64980013009     LEVOCARNITINE                          TABS         330MG         T1

   64980050312     LEVOCARNITINE                          SOLN         1GM/10ML      T1

   60258015816     NEUTRAL SODIUM FLUORIDE                SOLN         0.2%          T1

   00703330104     OCTREOTIDE ACETATE                     SOLN         50MCG/ML      T1

   00703331104     OCTREOTIDE ACETATE                     SOLN         100MCG/ML     T1

   55390016401     OCTREOTIDE ACETATE                     SOLN         1000MCG/ML    T1

   55390016301     OCTREOTIDE ACETATE                     SOLN         200MCG/ML     T1

   60258015101     SF                                     GEL          1.1%          T1

   60258015001     SF 5000 PLUS                           CREA         1.1%          T1

   52152012805     SODIUM FLUORIDE                        CHEW         1MG           T1

   50383065650     SODIUM FLUORIDE                        SOLN         0.5MG/ML      T1

   00802392392     SODIUM FLUORIDE PLAIN                  GEL          1%            T1


   Tier: T2
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details   Comment

   64116001112     ACTIMMUNE                              SOLN         2000000UNIT/ T2
                                                                       0.5ML
   00149047101     ACTONEL                                TABS         5MG           T2

   00149047201     ACTONEL                                TABS         35MG          T2

   00149047701     ACTONEL                                TABS         75MG          T2

   00149047001     ACTONEL                                TABS         30MG          T2

   00149047501     ACTONEL WITH CALCIUM                   TABS         1250MG; 35MG T2

   51285052302     ANTABUSE                               TABS         250MG         T2

   51285052402     ANTABUSE                               TABS         500MG         T2

   67404010005     APHTHASOL                              PSTE         5%            T2

   59627000205     AVONEX                                 KIT          30MCG/0.5ML   T2

   59627000103     AVONEX                                 KIT          30MCG/VIAL    T2

   65649023141     AZASAN                                 TABS         75MG          T2

   65649024141     AZASAN                                 TABS         100MG         T2

   50419052325     BETASERON                              SOLR         0.3MG         T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                    Page 227 of 285
   00004018809     BONIVA                                 KIT          3MG/3ML       T2

   00004018523     BONIVA                                 TABS         2.5MG         T2

   00004018682     BONIVA                                 TABS         150MG         T2

   68220009990     CALAFOL RX                             TABS         600MG;       T2
                                                                       400UNIT;
                                                                       1.6MG;
                                                                       425MCG; 5MG;
                                                                       25MG
   12539086560     CARDIOVID PLUS                         CAPS         500MCG;       T2
                                                                       240MG;
                                                                       360MG;
                                                                       1000MG;
                                                                       800MCG;
                                                                       600MG; 20MG
   54482014801     CARNITOR SF                            SOLN         1GM/10ML      T2

   00004025901     CELLCEPT                               CAPS         250MG         T2

   00004026001     CELLCEPT                               TABS         500MG         T2

   00004026129     CELLCEPT                               SUSR         200MG/ML      T2

   00004029809     CELLCEPT INTRAVENOUS                   SOLR         500MG         T2

   00525051090     CEREFOLIN NAC                          TABS         600MG;        T2
                                                                       5.6MG; 2MG
   44087120301     CETROTIDE                              KIT          3MG           T2

   44087122501     CETROTIDE                              KIT          0.25MG        T2

   00088115330     COPAXONE                               KIT          20MG/ML       T2

   00172731146     CYCLOSPORINE MODIFIED                  CAPS         50MG          T2

   00378904005     CYSTAGON                               CAPS         50MG          T2

   00378904505     CYSTAGON                               CAPS         150MG         T2

   25010030515     DEMSER                                 CAPS         250MG         T2

   00525041030     DEPLIN                                 TABS         7.5MG         T2

   17314930001     ELMIRON                                CAPS         100MG         T2

   58406045504     ENBREL                                 SOLN         25MG/0.5ML    T2   PA; MN; QL (28.00 days supply per dispensing)


   58406042534     ENBREL                                 KIT          25MG          T2   PA; MN; QL (28.00 days supply per dispensing)


   58406043504     ENBREL                                 SOLN         50MG/ML       T2   PA; MN; QL (28.00 days supply per dispensing)


   58406044504     ENBREL SURECLICK                       SOLN         50MG/ML       T2   PA; MN; QL (28.00 days supply per dispensing)


   23594010010     FOLMOR                                 TABS         0; 2MG;       T2
                                                                       2.5MG; 0;
                                                                       25MG; 0

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                              Page 228 of 285
   00006093631     FOSAMAX                                TABS         10MG         T2

   00006003144     FOSAMAX                                TABS         70MG         T2

   00006092531     FOSAMAX                                TABS         5MG          T2

   00006383334     FOSAMAX                                SOLN         70MG/75ML    T2

   00006007744     FOSAMAX                                TABS         35MG         T2

   00006021231     FOSAMAX                                TABS         40MG         T2

   00006071044     FOSAMAX PLUS D                         TABS         70MG;        T2
                                                                       2800UNIT
   00006027044     FOSAMAX PLUS D                         TABS         70MG;        T2
                                                                       5600UNIT
   68040060316     FOSTEUM                                CAPS         200UNIT;     T2
                                                                       27MG; 20MG
   00052030151     GANIRELIX ACETATE                      SOLN         250MCG/0.5ML T2

   18860067870     GASTROCROM                             CONC         100MG/5ML    T2

   00074379902     HUMIRA                                 KIT          40MG/0.8ML   T2   PA; QL (4.00 per 28 days)


   00074433902     HUMIRA PEN                             KIT          40MG/0.8ML   T2   PA; QL (4.00 per 28 days)


   00074433906     HUMIRA PEN-CROHNS DISEASESTARTER       KIT          40MG/0.8ML   T2   PA; QL (6.00 per dispensing)


   55513017728     KINERET                                SOLN         100MG/0.67ML T2   PA; MN; QL (28.00 per 28 days)


   68135030002     KUVAN                                  TBSO         100MG        T2

   00054449710     LEUCOVORIN CALCIUM                     TABS         10MG         T2

   68040060216     LIMBREL                                CAPS         500MG        T2

   68040060116     LIMBREL                                CAPS         250MG        T2

   67108356509     MESNEX                                 TABS         400MG        T2

   00078038566     MYFORTIC                               TBEC         180MG        T2

   00078038666     MYFORTIC                               TBEC         360MG        T2

   66607100506     ORFADIN                                CAPS         5MG          T2

   66607101006     ORFADIN                                CAPS         10MG         T2

   66607100206     ORFADIN                                CAPS         2MG          T2

   00126007534     PREVIDENT 5000 BOOSTER                 PSTE         1.1%         T2

   00469061773     PROGRAF                                CAPS         1MG          T2

   00469065773     PROGRAF                                CAPS         5MG          T2

   00469060773     PROGRAF                                CAPS         0.5MG        T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                              Page 229 of 285
   00008104105     RAPAMUNE                               TABS         1MG           T2

   00008104205     RAPAMUNE                               TABS         2MG           T2

   00008103006     RAPAMUNE                               SOLN         1MG/ML        T2

   44087002203     REBIF                                  SOLN         22MCG/0.5ML   T2

   44087004403     REBIF                                  SOLN         44MCG/0.5ML   T2

   44087882201     REBIF TITRATION PACK                   SOLN         0             T2

   23594020010     RELAMINE                               TABS         0; 300MG;     T2
                                                                       400MG; 0; 0
   59572040500     REVLIMID                               CAPS         5MG           T2

   59572041000     REVLIMID                               CAPS         10MG          T2

   59572041500     REVLIMID                               CAPS         15MG          T2

   59572042500     REVLIMID                               CAPS         25MG          T2

   67457017750     RIMSO-50                               SOLN         50%           T2

   00078018101     SANDOSTATIN                            SOLN         100MCG/ML     T2

   00078018201     SANDOSTATIN                            SOLN         500MCG/ML     T2

   00078018001     SANDOSTATIN                            SOLN         50MCG/ML      T2

   00078034161     SANDOSTATIN LAR DEPOT                  KIT          20MG          T2

   00078034261     SANDOSTATIN LAR DEPOT                  KIT          30MG          T2

   00078034061     SANDOSTATIN LAR DEPOT                  KIT          10MG          T2

   55513007430     SENSIPAR                               TABS         60MG          T2

   55513007530     SENSIPAR                               TABS         90MG          T2

   55513007330     SENSIPAR                               TABS         30MG          T2

   00145380001     SORIATANE CK                           KIT          10MG; 0; 0    T2

   00145430001     SORIATANE CK                           KIT          25MG; 0; 0    T2

   54799091817     TEARS AGAIN HYDRATE                    CAPS         40MG; 500MG; T2
                                                                       1000MG
   59572020514     THALOMID                               CAPS         50MG          T2

   59572022016     THALOMID                               CAPS         200MG         T2

   59572021015     THALOMID                               CAPS         100MG         T2

   59572021513     THALOMID                               CAPS         150MG         T2

   00178090001     THIOLA                                 TABS         100MG         T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 230 of 285
   00024420010     UROXATRAL                              TB24         10MG                     T2


   Tier: T3
   NDC             Product Name                           Form         Strength                 Pref   Cost   Coverage Details          Comment

   00173071215     AVODART                                CAPS         0.5MG                    T3            MN


   00597005801     FLOMAX                                 CP24         0.4MG                    T3            MN




   (94:00) Devices
   Tier: T1
   NDC             Product Name                           Form         Strength                 Pref   Cost   Coverage Details          Comment

   08290326895     BD SINGLE USE SWABS REG                PADS                                  T1


   Tier: T2
   NDC             Product Name                           Form         Strength                 Pref   Cost   Coverage Details          Comment

   08290320109     BD ULTRAFINE III SHORT PEN NEEDLES/31G MISC                                  T2            QL (200.00 per 30 days)
                   X 5/16"




   (96:00) Pharmaceutical Aids
   Tier: T1
   NDC             Product Name                           Form         Strength                 Pref   Cost   Coverage Details          Comment

   00409397703     BACTERIOSTATIC WATER FOR INJECTION     SOLN         0                        T1

   63323024930     BACTERIOSTATIC WATER PARABENS          SOLN         0; 0                     T1

   00456070801     CEBO #2 GREEN                          CAPS         0                        T1

   49452338701     GLYCOLIC ACID                          SOLN         70%                      T1

   51927333800     PCCA LIPODERM BASE                     CREA         0;   0;   0;   0;   0;   T1
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0
   00574016816     SORBITOL                               SOLN         70%                      T1

   00409488710     STERILE WATER FOR INJECTION            SOLN         0                        T1

   51552092106     TROCHIBASE S                           FLAK         0; 0; 0; 0; 0            T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                      Page 231 of 285
   Tier: T2
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   38779074308     ORA PLUS                               LIQD         0; 0; 0; 0       T2

   51927333700     PCCA COSMETIC HRT BASE                 CREA         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0; 0; 0




   Unclassified
   Tier: T1
   NDC             Product Name                           Form         Strength         Pref   Cost   Coverage Details   Comment

   00603702073     A/B OTIC                               SOLN         5.4%; 1.4%       T1

   20254020004     ACETAMINOPHEN                          TABS         325MG            T1

   00338065604     ACETIC ACID 0.25%                      SOLN         0.25%            T1

   00316012301     ALA-QUIN                               CREA         3%; 0.5%         T1

   00573262148     ALAVERT                                TBDP         10MG             T1

   49326028904     ALBATUSSIN NN                          LIQD         0; 10MG/5ML; T1
                                                                       5MG/5ML;
                                                                       75MG/5ML;
                                                                       8.85MG/5ML; 0
   13279010233     ALLANENZYME                            LIQD         830000UNIT/G T1
                                                                       M; 10%
   13279010333     ALLANFILLENZYME                        LIQD         0.5%;        T1
                                                                       521700UNIT/G
                                                                       M; 10%
   58980058020     ALPHAQUIN HP                           CREA         5%; 4%; 7.5% T1

   00378400305     ALPRAZOLAM                             TABS         0.5MG            T1

   00228203150     ALPRAZOLAM                             TABS         1MG              T1

   00228202796     ALPRAZOLAM                             TABS         0.25MG           T1

   59762372201     ALPRAZOLAM                             TABS         2MG              T1

   59762005901     ALPRAZOLAM XR                          TB24         1MG              T1

   59762006801     ALPRAZOLAM XR                          TB24         3MG              T1

   59762005701     ALPRAZOLAM XR                          TB24         0.5MG            T1

   59762006601     ALPRAZOLAM XR                          TB24         2MG              T1

   63736037882     AMERICAINE                             AERO         20%              T1



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   00703903203     AMIKACIN SULFATE                       SOLN         250MG/ML      T1

   60258084150     AMINOBENZOATE POTASSIUM                PACK         2GM           T1

   00781187431     AMOXICILLIN/CLAVULANATE POTASSIUM      TABS         250MG; 125MG T1

   00781340795     AMPICILLIN SODIUM                      SOLR         500MG         T1

   00781340895     AMPICILLIN SODIUM                      SOLR         2GM           T1

   60258024101     ANEXTUSS                               TB12         60MG; 600MG; T1
                                                                       40MG
   66213054060     ANIMI-3                                CAPS         500MCG;      T1
                                                                       350MG; 35MG;
                                                                       1MG; 500MG;
                                                                       200MG;
                                                                       12.5MG
   00713041821     ANTI-DIARRHEAL                         TABS         2MG           T1

   00713050312     ANUCORT-HC                             SUPP         25MG          T1

   00555904358     APRI                                   TABS         0.15MG;       T1
                                                                       30MCG
   12870000101     ARZOL SILVER NITRATE APP LICATORS      MISC         25%; 75%      T1

   00536308641     ASPIRIN EC                             TBEC         81MG          T1

   00603236221     ASPIRIN/CODEINE                        TABS         325MG; 60MG   T1

   00603236121     ASPIRIN/CODEINE                        TABS         325MG; 30MG   T1

   24208075060     ATROPINE SULFATE                       SOLN         1%            T1

   00168006538     ATROPINE SULFATE                       OINT         1%            T1

   00781507501     AZATHIOPRINE                           TABS         50MG          T1

   59762312001     AZITHROMYCIN                           SUSR         200MG/5ML     T1

   30727030080     B-COMPLEX 100                          SOLN         2%; 2MG/ML;   T1
                                                                       100MG/ML;
                                                                       2MG/ML;
                                                                       2MG/ML;
                                                                       100MG/ML
   00168002938     BAC /POLY /NEOMY /HC                   OINT         400UNIT/GM; T1
                                                                       1%; 0.5%;
                                                                       10000UNIT/GM
   00168002638     BACITRACIN                             OINT         500UNIT/GM    T1

   24208055555     BACITRACIN/POLYMYXIN B                 OINT         500UNIT/GM; T1
                                                                       10000UNIT/GM
   00409397703     BACTERIOSTATIC WATER FOR INJECTION     SOLN         0             T1

   63323024930     BACTERIOSTATIC WATER PARABENS          SOLN         0; 0          T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 233 of 285
   08290326895     BD SINGLE USE SWABS REG                PADS                                  T1

   60258044901     BELLAHIST-D LA                         TB12         0.04MG; 8MG; T1
                                                                       0.19MG;
                                                                       20MG; 0.01MG
   59366274301     BENZOYL PEROXIDE                       GEL          5%                       T1

   59366274401     BENZOYL PEROXIDE                       GEL          10%                      T1

   68032014475     BENZOYL PEROXIDE                       PADS         6.5%; 10%                T1

   68032011812     BENZOYL PEROXIDE                       CREA         6.5%; 10%                T1

   68032014375     BENZOYL PEROXIDE                       PADS         4.5%; 10%                T1

   45802090734     BENZOYL PEROXIDE WASH                  LIQD         2.5%                     T1

   59366274108     BENZOYL PEROXIDE WASH                  LIQD         10%                      T1

   00603248221     BISACODYL EC                           TBEC         5MG                      T1

   00187049802     BONTRIL SR                             CP24         105MG                    T1

   41679093266     BOOST PLUS                             LIQD         0;   0;   0;   0;   0;   T1
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0
   51927100400     BORIC ACID                             GRAN         0                        T1

   10914091016     BROM TANN/DM TANN/PSE TANN             SUSP         8MG/5ML;                 T1
                                                                       60MG/5ML;
                                                                       90MG/5ML
   60258042830     BROMHIST PDX                           LIQD         1MG/ML;                  T1
                                                                       3MG/ML;
                                                                       12.5MG/ML
   60258044730     BROMHIST-DM                            LIQD         1MG/ML;                  T1
                                                                       4MG/ML;
                                                                       15MG/ML
   60258044616     BROMHIST-DM PEDIATRIC                  SYRP         2MG/5ML;                 T1
                                                                       5MG/5ML;
                                                                       50MG/5ML;
                                                                       30MG/5ML
   60258042916     BROMHIST-PDX                           SYRP         2MG/5ML;                 T1
                                                                       5MG/5ML;
                                                                       50MG/5ML;
                                                                       5MG/5ML
   66993022057     BROMPLEX DM                            SYRP         4MG/5ML;                 T1
                                                                       30MG/5ML;
                                                                       60MG/5ML
   66993022255     BROMPLEX HD                            SOLN         2MG/5ML;                 T1
                                                                       1.7MG/5ML;
                                                                       30MG/5ML



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                         Page 234 of 285
   58173003816     BRONDIL                                LIQD         100MG/15ML;   T1
                                                                       100MG/15ML
   00527155201     BUTAL/ASA/CAFF                         CAPS         325MG; 50MG; T1
                                                                       40MG
   00904514060     BUTAL/ASA/CAFF/COD                     CAPS         325MG; 50MG; T1
                                                                       40MG; 30MG
   00143111501     BUTALBITAL /ACETAMINOPHEN /CAFFEINE    TABS         500MG; 50MG; T1
                                                                       40MG
   00603254428     BUTALBITAL /APAP /CAFFEINE             TABS         325MG; 50MG; T1
                                                                       40MG
   00143178501     BUTALBITAL /ASPIRIN /CAFFEINE          TABS         325MG; 50MG; T1
                                                                       40MG
   00603254021     BUTALBITAL/ACETAMINOPHEN               TABS         325MG; 50MG   T1

   00603254621     BUTALBITAL/APAP/CAFFEINE               CAPS         325MG; 50MG; T1
                                                                       40MG
   00378963943     BUTORPHANOL TARTRATE                   SOLN         10MG/ML       T1   QL (4.00 per 30 days)


   00574015210     CAFFEINE CITRATE                       SOLN         20MG/ML       T1

   00054312041     CALCITRIOL                             SOLN         1MCG/ML       T1

   00093065701     CALCITRIOL                             CAPS         0.25MCG       T1

   00093065801     CALCITRIOL                             CAPS         0.5MCG        T1

   00536341410     CALCIUM CARBONATE                      TABS         650MG         T1

   51991008316     CARBETAPLEX                            SYRP         20MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       15MG/5ML
   00185074901     CARISOPRODOL /ASPIRIN /CODEINE         TABS         325MG;        T1
                                                                       200MG; 16MG
   00456070801     CEBO #2 GREEN                          CAPS         0             T1

   63304097404     CEFADROXIL                             SUSR         500MG/5ML     T1

   63323023610     CEFAZOLIN SODIUM                       SOLR         500MG         T1

   60505074904     CEFAZOLIN SODIUM                       SOLR         1GM           T1

   10019068001     CEFOTAXIME SODIUM                      SOLR         500MG         T1

   60505075104     CEFTRIAXONE SODIUM                     SOLR         500MG         T1

   59702065001     CEPHADYN                               TABS         650MG; 50MG   T1

   10223020101     CETACAINE                              AERO         14%; 2%; 2% T1

   00603107558     CHERATUSSIN AC                         SYRP         10MG/5ML;     T1
                                                                       100MG/5ML
   00603107858     CHERATUSSIN DAC                        SOLN         10MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       30MG/5ML


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 235 of 285
   00182142095     CHILDRENS ASPIRIN                      CHEW         81MG         T1

   60258024616     CHLORDEX GP                            SYRP         2MG/5ML;     T1
                                                                       7.5MG/5ML;
                                                                       100MG/5ML;
                                                                       10MG/5ML
   00603271421     CHLORDIAZEPOXIDE /CLIDINIUM            CAPS         5MG; 2.5MG   T1

   00555015802     CHLORDIAZEPOXIDE HCL                   CAPS         5MG          T1

   00555003302     CHLORDIAZEPOXIDE HCL                   CAPS         10MG         T1

   49884096001     CHLORDIAZEPOXIDE HCL                   CAPS         25MG         T1

   00116200116     CHLORHEXIDINE GLUCONATE                SOLN         0.12%        T1

   49483004101     CHLORPHENIRAMINE MALEATE ER            CPCR         8MG          T1

   49483004301     CHLORPHENIRAMINE MALEATE ER            CPCR         12MG         T1

   60258009008     CHOLINE MAGNESIUM TRISALICYLATE        LIQD         500MG/5ML    T1

   50111052801     CHOLINE MAGNESIUM TRISALICYLATE        TABS         500MG        T1

   50111052901     CHOLINE MAGNESIUM TRISALICYLATE        TABS         750MG        T1

   50111053001     CHOLINE MAGNESIUM TRISALICYLATE        TABS         1000MG       T1

   68774012060     CLARITHROMYCIN                         TABS         250MG        T1

   00093715806     CLARITHROMYCIN                         TABS         500MG        T1

   00409405101     CLINDAMYCIN PHOSPHATE                  SOLN         150MG/ML     T1

   00603780176     CLIOQUINOL /HYDROCORTISONE             CREA         3%; 1%       T1

   00591078130     CLOMIPHENE CITRATE                     TABS         50MG         T1

   00093083301     CLONAZEPAM                             TABS         1MG          T1

   00093083201     CLONAZEPAM                             TABS         0.5MG        T1

   00093083401     CLONAZEPAM                             TABS         2MG          T1

   49884030902     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         1MG          T1

   49884030602     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         0.125MG      T1

   49884030802     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         0.5MG        T1

   49884031002     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         2MG          T1

   49884030702     CLONAZEPAM ORALLY DISINTEGRATING       TBDP         0.25MG       T1

   00378003001     CLORAZEPATE DIPOTASSIUM                TABS         3.75MG       T1

   00378004001     CLORAZEPATE DIPOTASSIUM                TABS         7.5MG        T1

   00378007001     CLORAZEPATE DIPOTASSIUM                TABS         15MG         T1


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   51672126003     CLOTRIMAZOLE                           SOLN         1%             T1

   60258077116     CODAL-DM                               SYRP         10MG/5ML;      T1
                                                                       5MG/5ML;
                                                                       8.33MG/5ML
   10914081016     CODEINE PHOSPHATE 10MG/GUAI 300MG      LIQD         10MG/5ML;      T1
                                                                       300MG/5ML
   58177022304     CODEINE/GUAIFENESIN                    TABS         10MG; 300MG    T1

   51991022216     COLDCOUGH                              SYRP         2MG/5ML;       T1
                                                                       7.5MG/5ML;
                                                                       15MG/5ML
   51991022404     COLDCOUGH PD                           SYRP         2MG/5ML;       T1
                                                                       3MG/5ML;
                                                                       7.5MG/5ML
   60258068216     CORDRON-HC                             LIQD         2.5MG/5ML;     T1
                                                                       1.67MG/5ML;
                                                                       20MG/5ML
   10914095501     CPM                                    CP24         12MG           T1

   11701005032     CRITIC-AID                             PSTE         20%            T1

   11098050701     CYANIDE ANTIDOTE PKG                   KIT          5MIN/0.3ML;    T1
                                                                       300MG/10ML;
                                                                       12.5GM/50ML
   63323004401     CYANOCOBALAMIN                         SOLN         1000MCG/ML     T1

   00378077101     CYCLOBENZAPRINE HCL                    TABS         5MG            T1

   24208073506     CYCLOPENTOLATE HCL                     SOLN         1%             T1

   50111031401     CYPROHEPTADINE HCL                     TABS         4MG            T1

   60258024316     DACEX-DM                               SYRP         25MG/5ML;      T1
                                                                       175MG/5ML;
                                                                       12.5MG/5ML
   60258023916     DE-CHLOR DM                            SYRP         2MG/5ML;       T1
                                                                       15MG/5ML;
                                                                       10MG/5ML
   52152001402     DEXCHLORPHENIRAMINE MALEATE CR         TBCR         4MG            T1

   10542001010     DIALYVITE                              TABS         100MG;         T1
                                                                       0.3MG;
                                                                       0.006MG;
                                                                       1MG; 20MG;
                                                                       10MG; 10MG;
                                                                       1.7MG; 1.5MG
   00378027105     DIAZEPAM                               TABS         2MG            T1

   00378047705     DIAZEPAM                               TABS         10MG           T1

   00409321302     DIAZEPAM                               SOLN         5MG/ML         T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com               Page 237 of 285
   00409127332     DIAZEPAM                               SOLN         5MG/ML        T1

   00378034505     DIAZEPAM                               TABS         5MG           T1

   00591078201     DIETHYLPROPION HCL ER                  TB24         75MG          T1

   63323036601     DIMENHYDRINATE                         SOLN         50MG/ML       T1

   60758008710     DIPIVEFRIN HCL                         SOLN         0.1%          T1

   12830084001     DISPAS                                 TBDP         0.25MG        T1

   57896042401     DOCUSATE CALCIUM                       CAPS         240MG         T1

   00536375601     DOCUSATE SODIUM                        CAPS         100MG         T1

   12539058001     DOLOREX                                CAPS         300MG; 20MG; T1
                                                                       200MG
   00277018541     DONATUSSIN                             SYRP         2MG/5ML;      T1
                                                                       15MG/5ML;
                                                                       100MG/5ML;
                                                                       10MG/5ML
   60432065104     DOXEPIN HCL                            CONC         10MG/ML       T1

   00781226950     DOXYCYCLINE HYCLATE                    CPEP         100MG         T1

   00781226860     DOXYCYCLINE HYCLATE                    CPEP         75MG          T1

   00527133501     DOXYCYCLINE MONOHYDRATE                TABS         50MG          T1

   49963061501     DURAXIN                                CAPS         300MG; 20MG; T1
                                                                       200MG
   51991021116     DYNATUSS EX                            SYRP         30MG/5ML;     T1
                                                                       200MG/5ML;
                                                                       10MG/5ML
   00485006501     ED CYTE F                              TABS         50MG; 324MG; T1
                                                                       1MG
   00485006601     ED-FLEX                                CAPS         300MG; 20MG; T1
                                                                       200MG
   64125010101     EPIDRIN                                CAPS         325MG;        T1
                                                                       100MG; 65MG
   53489028101     ERGOLOID MESYLATES                     TABS         1MG           T1

   45802008386     ERYTHROMYCIN/BENZOYL PEROXIDE          GEL          5%; 3%        T1

   00093012901     ESTAZOLAM                              TABS         1MG           T1

   00093013001     ESTAZOLAM                              TABS         2MG           T1

   58177080402     ETHEZYME                               OINT         1.1MU/GM;     T1
                                                                       100MG/GM
   58177081602     ETHEZYME 830                           OINT         0.83MMU/GM;   T1
                                                                       100MG/GM
   00378328691     ETIDRONATE DISODIUM                    TABS         200MG         T1


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 238 of 285
   00378328891     ETIDRONATE DISODIUM                    TABS         400MG         T1

   55566410001     EUFLEXXA                               SOLN         10MG/ML       T1

   12539053104     EXODERM                                LOTN         1%; 25%       T1

   14629010201     EXTENDRYL JR                           TB12         4MG; 1.25MG; T1
                                                                       10MG
   00256011101     EXTENDRYL SR                           CP12         8MG; 2.5MG;   T1
                                                                       20MG
   64376080201     FE C PLUS                              TABS         250MG;        T1
                                                                       25MCG; 1MG;
                                                                       100MG
   00115051101     FENOFIBRATE                            CAPS         67MG          T1

   00115052201     FENOFIBRATE                            CAPS         134MG         T1

   00115053301     FENOFIBRATE                            CAPS         200MG         T1

   00555108001     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         200MCG        T1   QL (120.00 per 30 days)


   00555108101     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         400MCG        T1   QL (120.00 per 30 days)


   00555108301     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         800MCG        T1   QL (120.00 per 30 days)


   00555108201     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         600MCG        T1   QL (120.00 per 30 days)


   00555108401     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         1200MCG       T1   QL (120.00 per 30 days)


   00555108501     FENTANYL CITRATE ORAL TRANSMUCOSAL     LPOP         1600MCG       T1   QL (120.00 per 30 days)


   51991019811     FERREX 150 FORTE                       CAPS         25MCG; 1MG;   T1
                                                                       150MG
   53879020110     FERRO-PLEX HEMATINIC                   TABS         600MG;       T1
                                                                       25MCG; 50MG;
                                                                       345MG; 1MG;
                                                                       75MG; 30UNIT
   60258018901     FERROGELS FORTE                        CAPS         60MG; 10MCG; T1
                                                                       460MG; 1MG
   00536589001     FERROUS SULFATE                        TABS         325MG         T1

   00574060810     FERROUS SULFATE                        TBEC         324MG         T1

   00603076358     FERROUS SULFATE                        ELIX         220MG/5ML     T1

   10892011410     FETRIN                                 CPCR         60MG; 5MCG;   T1
                                                                       200MG; 0
   63304097505     FLUCONAZOLE                            SUSR         10MG/ML       T1

   60505066402     FLUPHENAZINE DECANOATE                 SOLN         25MG/ML       T1

   00378441501     FLURAZEPAM HCL                         CAPS         15MG          T1

   00378443001     FLURAZEPAM HCL                         CAPS         30MG          T1




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                        Page 239 of 285
   00093005601     FLUVOXAMINE MALEATE                    TABS         50MG          T1

   51991008490     FOLBEE                                 TABS         1MG; 2.5MG;   T1
                                                                       25MG
   51991008290     FOLBEE PLUS                            TABS         60MG;        T1
                                                                       300MCG;
                                                                       10MG; 1MG;
                                                                       5MG; 20MG;
                                                                       50MG; 1.5MG;
                                                                       1.5MG
   51991038490     FOLBIC                                 TABS         2MG; 2.5MG;   T1
                                                                       25MG
   68308032410     FOLCAPS                                TABS         0.5MG; 2.2MG; T1
                                                                       25MG
   63323018410     FOLIC ACID                             SOLN         5MG/ML        T1

   00536384301     FOLIC ACID                             TABS         800MCG        T1

   00591521610     FOLIC ACID                             TABS         1MG           T1

   64980010503     FOLITAB                                TBCR         500MG;       T1
                                                                       525MG; 0.8MG
   00185538076     FOLTRIN                                CAPS         75MG; 15MCG; T1
                                                                       110MG;
                                                                       0.5MG; 240MG
   10481105005     FORMADON                               SOLN         10%; 0        T1

   68032019403     FORMALAZ                               SOLN         10%; 0        T1

   12539085010     FRENADOL                               TABS         250MG; 600MG T1

   00277018101     FUMATINIC                              CPCR         60MG; 5MCG;   T1
                                                                       200MG; 0
   60258025616     GANDIDIN NR                            LIQD         100MG/5ML     T1

   60258026216     GANI-TUSS DM NR                        LIQD         10MG/5ML;     T1
                                                                       100MG/5ML
   63323017302     GENTAMICIN SULFATE                     SOLN         10MG/ML       T1

   60258026301     GFN 1200/DM 60                         TB12         60MG; 1200MG T1

   58552011016     GILTUSS HC                             LIQD         300MG/5ML;    T1
                                                                       5MG/5ML;
                                                                       10MG/5ML
   55111032001     GLIMEPIRIDE                            TABS         1MG           T1

   55111032101     GLIMEPIRIDE                            TABS         2MG           T1

   00093571001     GLYBURIDE/METFORMIN HCL                TABS         1.25MG;       T1
                                                                       250MG
   00228275311     GLYBURIDE/METFORMIN HCL                TABS         5MG; 500MG    T1

   49452338701     GLYCOLIC ACID                          SOLN         70%           T1



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 240 of 285
   00603127054     GRANUL-DERM                            AERS         650MG/0.82ML T1
                                                                       ;
                                                                       72.5MG/0.82M
                                                                       L;
                                                                       0.1MG/0.82ML
   10147081004     GRISEOFULVIN MICROSIZE                 SUSP         125MG/5ML     T1

   51991008716     GUIADEX DM                             LIQD         15MG/5ML;     T1
                                                                       300MG/5ML
   60258018001     HEMATINIC PLUS VITAMINS/MINERALS       TABS         10MG; 0.8MG; T1
                                                                       15MCG;
                                                                       324MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG; 5MG;
                                                                       6MG; 200MG;
                                                                       10MG; 18.2MG
   60258018101     HEMATINIC/FOLIC ACID                   TABS         324MG; 1MG    T1

   63044063119     HEMATOGEN                              CAPS         250MG;       T1
                                                                       10MCG;
                                                                       200MG; 100MG
   63044063217     HEMATOGEN FA                           CAPS         250MG;        T1
                                                                       10MCG;
                                                                       200MG; 1MG
   63323001710     HEP FLUSH-10                           SOLN         10UNIT/ML     T1

   00409115170     HEPARIN LOCK                           SOLN         10UNIT/ML     T1

   00409115278     HEPARIN LOCK                           SOLN         100UNIT/ML    T1

   68883010005     HEPARIN LOCK FLUSH                     SOLN         100UNIT/ML    T1

   68883001003     HEPARIN LOCK FLUSH                     SOLN         10UNIT/ML     T1

   00641041025     HEPARIN SODIUM                         SOLN         10000UNIT/ML T1

   00641039125     HEPARIN SODIUM                         SOLN         1000UNIT/ML   T1

   00641040025     HEPARIN SODIUM                         SOLN         5000UNIT/ML   T1

   63323091501     HEPARIN SODIUM DCU                     SOLN         20000UNIT/ML T1

   08290042005     HEPARIN SODIUM LOCK FLUSH              KIT          100UNIT/ML;   T1
                                                                       0.9%
   00234057508     HIBICLENS                              LIQD         4%            T1

   50383071915     HYDRO EAR DROPS                        SOLN         1MG/ML;       T1
                                                                       10MG/ML;
                                                                       10MG/ML
   58177092607     HYDRO-TUSSIN DHC                       SYRP         2MG/5ML;      T1
                                                                       7.5MG/5ML;
                                                                       15MG/5ML
   58177090607     HYDRO-TUSSIN DM                        ELIX         20MG/5ML;     T1
                                                                       200MG/5ML


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 241 of 285
   58177092707     HYDRO-TUSSIN EXP                       SYRP         7.5MG/5ML;    T1
                                                                       100MG/5ML;
                                                                       15MG/5ML
   58177089007     HYDRO-TUSSIN HD                        SOLN         100MG/5ML;    T1
                                                                       2.5MG/5ML;
                                                                       30MG/5ML
   60432045516     HYDROCODONE /HOMATROPINE               SYRP         1.5MG/5ML;    T1
                                                                       5MG/5ML
   52152014002     HYDROCODONE BITARTRATE/HOMATROPINE TABS             1.5MG; 5MG    T1
                   METHYLBROMIDE
   00093516101     HYDROCODONE/IBUPROFEN                  TABS         7.5MG; 200MG T1

   00093916871     HYDROCORTISONE                         ENEM         100MG/60ML    T1

   59366270601     HYDROCORTISONE /IODOQUINOL             CREA         1%; 1%        T1

   59366278503     HYDROQUINONE                           CREA         4%            T1

   45802097564     HYDROQUINONE /SUNSCREENS               CREA         3%; 4%; 2%;   T1
                                                                       8%
   59366278903     HYDROQUINONE/SUNSCREENS                CREA         4%; 4%; 4%;   T1
                                                                       8%
   59366278303     HYDROQUINONE/SUNSCREENS                GEL          30MG/GM;      T1
                                                                       40MG/GM;
                                                                       50MG/GM
   00591288830     HYDROXOCOBALAMIN                       SOLN         1000MCG/ML    T1

   58980015020     HYPERCARE                              SOLN         20%           T1

   13533063106     HYPERRHO S/D                           INJ          50MCG         T1

   63044020361     IFEREX 150                             CAPS         150MG         T1

   60977011401     INFUMORPH 200                          SOLN         10MG/ML       T1

   00395277516     IODINE STRONG                          SOLN         5%; 10%       T1

   00603132958     IOPHEN C-NR                            LIQD         10MG/5ML;     T1
                                                                       100MG/5ML
   00998031105     ISOPTO HOMATROPINE                     SOLN         2%            T1

   00998031505     ISOPTO HOMATROPINE                     SOLN         5%            T1

   00781184001     ISOXSUPRINE HCL                        TABS         10MG          T1

   00781184201     ISOXSUPRINE HCL                        TABS         20MG          T1

   00555905058     KARIVA                                 TABS         0; 0          T1

   51991027141     KERATOL HC                             CREA         1%; 10%       T1

   17478071710     KETOTIFEN FUMARATE                     SOLN         0.025%        T1

   58980072211     KOVIA 6.5                              OINT         650000UNIT/G T1
                                                                       M; 10%


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   00338011404     LACTATED RINGER'S IRRIGATION           SOLN         3MEQ/L;      T1
                                                                       109MEQ/L;
                                                                       28MEQ/L;
                                                                       4MEQ/L;
                                                                       130MEQ/L
   00093068801     LAMOTRIGINE CHEWABLE DISPERSIBLE       TBDP         5MG          T1

   00093013201     LAMOTRIGINE CHEWABLE DISPERSIBLE       TBDP         25MG         T1

   58173003704     LARTUS                                 LIQD         2MG/5ML;     T1
                                                                       15MG/5ML;
                                                                       150MG/5ML;
                                                                       5MG/5ML
   00555048401     LEUCOVORIN CALCIUM                     TABS         5MG          T1

   00555048527     LEUCOVORIN CALCIUM                     TABS         25MG         T1

   00168020437     LIDOCAINE                              OINT         5%           T1

   60258004101     LIDOCAINE HCL/HYDROCORTISONE           CREA         0.5%; 3%     T1
                   ACETATE
   68032012420     LIDOCAINE HCL/HYDROCORTISONE           KIT          0.5%; 3%     T1
                   ACETATE
   60258004206     LIDOCAINE HCL/HYDROCORTISONE           LOTN         0.5%; 3%     T1
                   ACETATE
   68032012820     LIDOCAINE HCL/HYDROCORTISONE           KIT          1%; 3%       T1
                   ACETATE
   68032019320     LIDOCAINE HCL/HYDROCORTISONE           KIT          2.5%; 3%     T1
                   ACETATE
   68032011101     LIDOCAINE HCL/HYDROCORTISONE           CREA         0.5%; 3%     T1
                   ACETATE
   49326043990     LIPOCHOL PLUS                          TABS         334MG;       T1
                                                                       500MCG;
                                                                       334MG; 100MG
   64543013001     LIQUIBID                               TABS         400MG        T1

   00409198530     LORAZEPAM                              SOLN         2MG/ML       T1

   63304077405     LORAZEPAM                              TABS         2MG          T1

   10019010201     LORAZEPAM                              SOLN         2MG/ML       T1

   63304077305     LORAZEPAM                              TABS         1MG          T1

   63304077205     LORAZEPAM                              TABS         0.5MG        T1

   52083084030     LYSIPLEX                               TABS         200MG;       T1
                                                                       50MCG;
                                                                       500MCG;
                                                                       200MG; 20MG;
                                                                       4MG; 6MG;
                                                                       20MG;
                                                                       40UNIT; 30MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com             Page 243 of 285
   60258017101     MAGNESIUM OXIDE                        TABS         400MG        T1

   63323006410     MAGNESIUM SULFATE                      SOLN         50%          T1

   00703681121     MEDROXYPROGESTERONE ACETATE            SUSP         150MG/ML     T1   QL (1.00 per 90 days)


   00378108901     MELOXICAM                              TABS         15MG         T1

   58980047310     MELPAQUE HP                            CREA         4%           T1

   10019016001     MEPERIDINE HCL                         SOLN         50MG/ML      T1

   10019015868     MEPERIDINE HCL                         SOLN         100MG/ML     T1

   00603442421     MEPROZINE                              CAPS         50MG; 25MG   T1

   60432062216     METOCLOPRAMIDE HCL                     SOLN         5MG/5ML      T1

   63304020518     MIDAZOLAM HCL                          SYRP         2MG/ML       T1

   55390013705     MIDAZOLAM HCL                          SOLN         1MG/ML       T1

   00225036035     MOBISYL                                CREA         10%          T1

   17474012505     MONOJECT PREFILL HEPARIN SODIUM LOCK SOLN           100UNIT/ML   T1
                   FLUSH
   17474300205     MONOJECT PREFILL SODIUM CHLORIDE       SOLN         0.9%         T1

   00409126130     MORPHINE SULFATE                       SOLN         10MG/ML      T1

   00409113403     MORPHINE SULFATE                       SOLN         50MG/ML      T1

   63824000810     MUCINEX                                TB12         600MG        T1

   52152015002     MULTI VITA-BETS/FLUORIDE               CHEW         60MG;        T1
                                                                       4.5MCG;
                                                                       0.25MG;
                                                                       0.3MG;
                                                                       13.5MG;
                                                                       1.05MG;
                                                                       1.2MG;
                                                                       1.05MG;
                                                                       15UNIT;
                                                                       2500UNIT;
                                                                       400UNIT
   00603471421     MULTI-VITAMIN/FLUORIDE                 CHEW         400UNIT;     T1
                                                                       4.5MCG;
                                                                       0.3MG;
                                                                       13.5MG;
                                                                       1.05MG;
                                                                       1.2MG; 60MG;
                                                                       0.5MG;
                                                                       1.05MG;
                                                                       2500UNIT;
                                                                       15UNIT




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                     Page 244 of 285
   51991012611     MULTIFOL                               TABS         60MG; 125MG; T1
                                                                       5MCG; 65MG;
                                                                       1MG; 15MG;
                                                                       2.5MG; 1.8MG;
                                                                       1.1MG;
                                                                       6000UNIT;
                                                                       400UNIT;
                                                                       30UNIT
   52152004814     MULTIRET FOLIC-500                     TBCR         500MG;       T1
                                                                       25MCG;
                                                                       525MG;
                                                                       0.8MG; 30MG;
                                                                       10MG; 5MG;
                                                                       6MG; 6MG
   24208027715     MURO 128                               SOLN         5%           T1

   00781312646     NAFCILLIN SODIUM                       SOLR         10GM         T1

   00555090201     NALTREXONE HCL                         TABS         50MG         T1

   24208078055     NEOMYCIN /BACITRACIN /POLYMYXIN        OINT         400UNIT/GM; T1
                                                                       5MG/GM;
                                                                       10000UNIT/GM
   24208079062     NEOMYCIN /POLYMYXIN /GRAMICIDIN        SOLN         0.025MG/ML; T1
                                                                       2.5MG/ML;
                                                                       10000UNIT/ML
   61314064175     NEOMYCIN /POLYMYXIN /HYDROCORTISONE SUSP            1%;          T1
                                                                       3.5MG/ML;
                                                                       10000UNIT/ML
   61314064511     NEOMYCIN /POLYMYXIN /HYDROCORTISONE SUSP            1%;          T1
                                                                       3.5MG/ML;
                                                                       10000UNIT/ML
   59528031701     NEPHPLEX RX                            TABS         60MG;         T1
                                                                       300MCG; 6MG;
                                                                       1MG; 20MG;
                                                                       10MG; 10MG;
                                                                       1.7MG; 1.5MG;
                                                                       12.5MG
   00536730001     NEPHRO-VITE                            TABS         60MG;        T1
                                                                       300MCG;
                                                                       6MCG;
                                                                       800MCG;
                                                                       20MG; 10MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG
   59528445601     NEPHRON FA                             TABS         40MG;        T1
                                                                       300MCG;
                                                                       6MCG; 75MG;
                                                                       200MG; 1MG;
                                                                       20MG; 10MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 245 of 285
   49326032560     NERVIDOX-6 NR                          TABS         200MCG;      T1               AL (max: 35y)
                                                                       1000MCG;
                                                                       0.5MG;
                                                                       200MG; 150MG
   49326044090     NERVO B-12 SL                          LOZG         200MCG;                  T1
                                                                       1000MCG;
                                                                       500MCG;
                                                                       2000MCG;
                                                                       1500MCG
   60258015816     NEUTRAL SODIUM FLUORIDE                SOLN         0.2%                     T1

   00536407401     NICOTINIC ACID SR                      CPCR         250MG                    T1

   24839022204     NOVASUS                                SUSP         4MG/5ML;                 T1
                                                                       5MG/5ML
   00703331104     OCTREOTIDE ACETATE                     SOLN         100MCG/ML                T1

   00703330104     OCTREOTIDE ACETATE                     SOLN         50MCG/ML                 T1

   55111015330     ONDANSETRON HCL                        TABS         4MG                      T1   QL (15.00 per 30 days)


   50111094543     ONDANSETRON ODT                        TBDP         4MG                      T1   QL (15.00 per 30 days)


   50111094643     ONDANSETRON ODT                        TBDP         8MG                      T1   QL (15.00 per 30 days)


   54859050401     ORASEP                                 SOLN         600MG/30ML;              T1
                                                                       30MG/30ML;
                                                                       30MG/30ML;
                                                                       300MG/30ML
   54859050301     ORASEP                                 SOLN         600MG/30ML;              T1
                                                                       30MG/30ML;
                                                                       30MG/30ML;
                                                                       300MG/30ML
   00603723873     OTICAINE OTIC                          SOLN         20%                      T1

   00228206710     OXAZEPAM                               CAPS         10MG                     T1

   00228206910     OXAZEPAM                               CAPS         15MG                     T1

   00228207310     OXAZEPAM                               CAPS         30MG                     T1

   00472080216     PAREGORIC                              TINC         2MG/5ML                  T1

   51927333800     PCCA LIPODERM BASE                     CREA         0;   0;   0;   0;   0;   T1
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0;
                                                                       0;   0;   0;   0;   0
   00093117201     PENICILLIN V POTASSIUM                 TABS         250MG                    T1

   00093412574     PENICILLIN V POTASSIUM                 SOLR         125MG/5ML                T1

   00093412774     PENICILLIN V POTASSIUM                 SOLR         250MG/5ML                T1

   00093511601     PENTOXIFYLLINE ER                      TBCR         400MG                    T1




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   43900037120     PEPTINEX 1.0                           LIQD         40MG/237ML; T1
                                                                       0;
                                                                       80MCG/237ML;
                                                                       237MG/237ML;
                                                                       2.6MG/237ML;
                                                                       190MG/237ML;
                                                                       95UNIT/237ML
                                                                       ;
                                                                       54.5MG/237ML
                                                                       ;
                                                                       23.7MCG/237M
                                                                       L;
                                                                       0.31MG/237ML
                                                                       ;
                                                                       1.9MCG/237ML
                                                                       ;
                                                                       2.8MG/237ML;
                                                                       142MCG/237M
                                                                       L;
                                                                       23.7MG/237ML
                                                                       ; 64MG/237ML;
                                                                       0.4MG/237ML;
                                                                       5.5MG/237ML;
                                                                       237MG/237ML;
                                                                       12.6MCG/237M
                                                                       L;
                                                                       360MG/237ML;
                                                                       23.7MCG/237M
                                                                       L;
                                                                       0.95MG/237ML
                                                                       ;
                                                                       0.45MG/237ML
                                                                       ;
                                                                       250MG/237ML;
                                                                       15.4MCG/237M
                                                                       L;
                                                                       14.5MCG/237M
                                                                       L; 0;
                                                                       47.4MG/237ML
                                                                       ;
                                                                       0.4MG/237ML;
                                                                       20UNIT/237ML
                                                                       ;
                                                                       790UNIT/237M
                                                                       L;
                                                                       3.1MG/237ML
   66813081001     PERLOXX                                TABS         300MG; 10MG   T1

   00603514121     PHENAZOPYRIDINE HCL                    TABS         100MG         T1

   00603514221     PHENAZOPYRIDINE HCL                    TABS         200MG         T1

   64376053716     PHENCARB GG                            SYRP         20MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       10MG/5ML



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   00143144510     PHENOBARBITAL                          TABS         15MG          T1

   00143145510     PHENOBARBITAL                          TABS         60MG          T1

   00603516532     PHENOBARBITAL                          TABS         16.2MG        T1

   00603516632     PHENOBARBITAL                          TABS         32.4MG        T1

   00603516721     PHENOBARBITAL                          TABS         64.8MG        T1

   00603150858     PHENOBARBITAL                          ELIX         20MG/5ML      T1

   00143145010     PHENOBARBITAL                          TABS         30MG          T1

   00603516821     PHENOBARBITAL                          TABS         97.2MG        T1

   64125090301     PHENOBARBITAL                          TABS         100MG         T1

   52152015902     PHENTERMINE HCL                        TABS         37.5MG        T1

   00185500001     PHENTERMINE HCL                        CAPS         30MG          T1

   00409131701     PHENYTOIN SODIUM                       SOLN         50MG/ML       T1

   60258000601     PHOS-NAK POWDER CONCENTRATE            PACK         250MG;       T1
                                                                       278MG; 164MG
   00574060115     PODOCON 25 IN BENZOIN TINCTURE         SOLN         25%           T1

   50383064150     POLY-VITAMIN                           SOLN         35MG/ML;      T1
                                                                       400UNIT/ML;
                                                                       2MCG/ML;
                                                                       0.5MG/ML;
                                                                       8MG/ML;
                                                                       0.4MG/ML;
                                                                       0.6MG/ML;
                                                                       0.5MG/ML;
                                                                       5UNIT/ML;
                                                                       1500UNIT/ML
   50383063450     POLY-VITAMIN /IRON /FLUORIDE           SOLN         35MG/ML;      T1
                                                                       400UNIT/ML;
                                                                       0.25MG/ML;
                                                                       10MG/ML;
                                                                       8MG/ML;
                                                                       0.4MG/ML;
                                                                       0.6MG/ML;
                                                                       0.5MG/ML;
                                                                       5UNIT/ML;
                                                                       1500UNIT/ML




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 248 of 285
   50383064250     POLY-VITAMIN/FLUORIDE                  SOLN         35MG/ML;     T1
                                                                       50MCG/ML;
                                                                       2MCG/ML;
                                                                       0.25MG/ML;
                                                                       8MG/ML;
                                                                       3MG/ML;
                                                                       0.4MG/ML;
                                                                       0.6MG/ML;
                                                                       0.5MG/ML;
                                                                       1500UNIT/ML;
                                                                       400UNIT/ML;
                                                                       5UNIT/ML
   61314062810     POLYMYXIN B SULFATE/TRIMETHOPRIM       SOLN         10000UNIT/ML T1
                   SULFATE                                             ; 0.1%
   10592000101     PONARIS                                SOLN         0; 0; 0; 0; 0; 0 T1

   64980013701     POTASSIUM CITRATE EXTENDED-RELEASE     TBCR         540MG           T1

   66993090445     PRASCION RA WITH SUNSCREENS            CREA         10%; 5%         T1

   00378828077     PRAVASTATIN SODIUM                     TABS         80MG            T1

   24208071502     PREDNISOLONE SODIUM PHOSPHATE          SOLN         1%              T1

   00603536121     PRENATAL PLUS                          TABS         120MG;       T1       GL (f); AL (max: 35y)
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       65MG; 1MG;
                                                                       20MG; 10MG;
                                                                       3MG; 1.84MG;
                                                                       22MG;
                                                                       4000UNIT;
                                                                       25MG
   55056040601     PROCHIEVE                              GEL          4%              T1

   00603813611     PROCTOSERT HC                          SUPP         30MG            T1

   00591312879     PROGESTERONE                           OIL          50MG/ML         T1

   00603158758     PROMETHAZINE VC PLAIN                  SYRP         5MG/5ML;        T1
                                                                       6.25MG/5ML
   00603158858     PROMETHAZINE VC/CODEINE                SYRP         10MG/5ML;       T1
                                                                       5MG/5ML;
                                                                       6.25MG/5ML
   00603158658     PROMETHAZINE-DM                        SYRP         15MG/5ML;       T1
                                                                       6.25MG/5ML
   00472162716     PROMETHAZINE/CODEINE                   SYRP         10MG/5ML;       T1
                                                                       6.25MG/5ML
   61314001601     PROPARACAINE HCL                       SOLN         0.5%            T1

   50111079001     PROPOXYPHENE-N /ACETAMINOPHEN          TABS         500MG; 100MG T1

   10892012710     PROTID                                 TBCR         500MG; 8MG;     T1
                                                                       40MG

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   64376073340     PSEUDO COUGH                           LIQD         15MG/5ML;        T1
                                                                       175MG/5ML;
                                                                       32MG/5ML
   60258031404     PULMARI                                SUSP         4MG/5ML;         T1
                                                                       30MG/5ML;
                                                                       7.5MG/5ML
   63323018001     PYRIDOXINE HCL                         SOLN         100MG/ML         T1

   50383080916     QUAD-TUSS TANNATE PEDIATRIC            SUSP         30MG/5ML;        T1
                                                                       4MG/5ML;
                                                                       5MG/5ML;
                                                                       5MG/5ML
   53303002130     RADIGEL                                GEL          0; 0; 0; 0; 0;   T1
                                                                       0; 0; 0
   60258023201     RALIX                                  TB12         8MG; 2.5MG;      T1
                                                                       40MG
   68032010006     RE 10 WASH                             LIQD         10%              T1

   68032014714     RE SA 6%                               LOTN         6%               T1

   58394000502     REFACTO                                KIT          1000UNIT         T1

   58394000602     REFACTO                                KIT          500UNIT          T1

   60258042316     RELACON-DM NR                          LIQD         15MG/5ML;        T1
                                                                       200MG/5ML;
                                                                       32MG/5ML
   51674013005     RELAGARD                               GEL          0.9%; 0.025% T1

   60258016101     RENA-VITE RX                           TABS         60MG;        T1
                                                                       300MCG;
                                                                       6MCG; 1MG;
                                                                       20MG; 10MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG
   60258016201     RENAL                                  CAPS         100MG;       T1
                                                                       150MCG;
                                                                       6MCG; 1MG;
                                                                       20MG; 5MG;
                                                                       10MG; 1.7MG;
                                                                       1.5MG
   15370000710     RHINOFLEX                              TABS         500MG; 50MG      T1

   59243000616     RU-TUSS DM                             SYRP         15MG/5ML;        T1
                                                                       100MG/5ML;
                                                                       45MG/5ML
   68032011001     SCALP TREATMENT                        KIT          10%; 10%         T1

   59366340002     SEB-PREV                               CREA         10%              T1

   59366350001     SEB-PREV                               GEL          10%              T1

   59366360001     SEB-PREV WASH                          LIQD         10%              T1



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   68032012718     SELENIUM SULFIDE                       SHAM         0; 2.25%; 0   T1

   00904545209     SENNA                                  SYRP         8.8MG/5ML     T1

   00182111301     SENNA S                                TABS         50MG; 8.6MG   T1

   59762494001     SERTRALINE HCL                         CONC         20MG/ML       T1

   00591081055     SILVER SULFADIAZINE                    CREA         1%            T1

   65162044310     SIMETHICONE                            CHEW         80MG          T1

   60258042616     SIMUC-DM                               SOLN         25MG/5ML;     T1
                                                                       225MG/5ML
   00677013110     SODIUM BICARBONATE                     TABS         650MG         T1

   00338004804     SODIUM CHLORIDE 0.9%                   SOLN         0.9%          T1

   00409488810     SODIUM CHLORIDE 0.9%                   SOLN         0.9%          T1

   00574016816     SORBITOL                               SOLN         70%           T1

   00245000331     SSKI                                   SOLN         1GM/ML        T1

   00409488710     STERILE WATER FOR INJECTION            SOLN         0             T1

   00338000404     STERILE WATER IRRIGATION PLASTIC       SOLN         0             T1
                   BOTTLE
   60258024516     SU-TUSS DM                             ELIX         20MG/5ML;     T1
                                                                       200MG/5ML
   00168038204     SULFACETAMIDE SODIUM                   SUSP         10%           T1

   51991017245     SULFATOL                               GEL          10%; 5%;      T1
                                                                       10%
   00093078256     TAMOXIFEN CITRATE                      TABS         20MG          T1

   50383086316     TANNATE 12 S                           SUSP         30MG/5ML;     T1
                                                                       4MG/5ML
   50383086604     TANNATE DMP-DEX                        SUSP         2.5MG/5ML;    T1
                                                                       25MG/5ML;
                                                                       75MG/5ML
   50383085616     TANNATE-V-DM                           SUSP         25MG/5ML;     T1
                                                                       12.5MG/5ML;
                                                                       30MG/5ML
   00378401001     TEMAZEPAM                              CAPS         15MG          T1

   00378505001     TEMAZEPAM                              CAPS         30MG          T1

   24208092064     TETRACAINE HCL                         SOLN         0.5%          T1

   00536468001     THIAMINE HCL                           TABS         100MG         T1

   63323001302     THIAMINE HCL                           SOLN         100MG/ML      T1

   52604710502     THROMBIN-JMI W/DIL SPRAY PUMP          KIT          20000UNIT     T1
                   ACTUATOR

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   58869040601     TOURO ALLERGY                          TB12         6MG; 45MG       T1

   49884003201     TRANYLCYPROMINE SULFATE                TABS         10MG            T1

   45802036342     TRETINOIN                              GEL          0.025%          T1   AL (max: 35y)


   45802036242     TRETINOIN                              GEL          0.01%           T1   AL (max: 35y)


   66530024740     TRETINOIN EMOLLIENT                    CREA         0.05%           T1   AL (max: 35y)


   50383081904     TRI-HIST PEDIATRIC                     SUSP         2MG/5ML;        T1
                                                                       5MG/5ML;
                                                                       12.5MG/5ML
   58177092507     TRI-VENT DM                            SYRP         15MG/5ML;       T1
                                                                       100MG/5ML;
                                                                       40MG/5ML
   58177092307     TRI-VENT DPC                           SYRP         2MG/5ML;        T1
                                                                       15MG/5ML;
                                                                       6MG/5ML
   50383063750     TRI-VITAMIN/FLUORIDE                   SOLN         35MG/ML;     T1
                                                                       0.25MG/ML;
                                                                       1500UNIT/ML;
                                                                       400UNIT/ML
   59762371804     TRIAZOLAM                              TABS         0.25MG          T1

   59762371704     TRIAZOLAM                              TABS         0.125MG         T1

   51991013116     TRITAL DM                              LIQD         4MG/5ML;        T1
                                                                       15MG/5ML;
                                                                       10MG/5ML
   51552092106     TROCHIBASE S                           FLAK         0; 0; 0; 0; 0   T1

   24208059064     TROPICAMIDE                            SOLN         0.5%            T1

   61314035501     TROPICAMIDE                            SOLN         1%              T1

   60258043116     TUSDEC-DM                              LIQD         2MG/5ML;        T1
                                                                       15MG/5ML;
                                                                       7.5MG/5ML
   52083023616     TUSSI PRES-B                           LIQD         2MG/5ML;        T1
                                                                       15MG/5ML;
                                                                       200MG/5ML
   00406886701     TUSSIZONE-12 RF                        TABS         60MG; 5MG       T1

   45802017156     UREA                                   GEL          40%             T1

   50383073145     UREALAC                                OINT         50%             T1

   12830030101     UROBLUE                                TABS         0.12MG;         T1
                                                                       81.6MG;
                                                                       10.8MG;
                                                                       36.2MG;
                                                                       40.8MG
   00409653301     VANCOMYCIN HCL                         SOLR         1000MG          T1


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   00555905167     VELIVET                                TABS         0; 0          T1

   00409114402     VERAPAMIL HCL                          SOLN         2.5MG/ML      T1

   00172428660     VERAPAMIL HCL ER                       TBCR         180MG         T1

   49326031090     VERTIN-32                              TABS         32MG          T1

   62559574200     VIRATAN-DM                             CHEW         25MG; 25MG;   T1
                                                                       30MG
   52152007802     VITA CON FORTE                         CAPS         150MG; 10MG; T1    AL (max: 35y)
                                                                       10MCG; 1MG;
                                                                       70MG; 4MG;
                                                                       25MG; 2MG;
                                                                       5MG; 10MG;
                                                                       8000UNIT;
                                                                       50UNIT; 80MG
   53879020060     VITACEL                                TABS         500MG;       T1
                                                                       125MG;
                                                                       300MCG;
                                                                       25MG; 10MG;
                                                                       1MG; 33MG;
                                                                       50MG; 25MG;
                                                                       25MG; 50MCG;
                                                                       25MG;
                                                                       5000UNIT;
                                                                       200UNIT;
                                                                       100UNIT;
                                                                       80MG
   00642007416     VITAFOL                                SYRP         8.34MCG/5ML; T1
                                                                       100MG/5ML;
                                                                       0.25MG/5ML;
                                                                       13.3MG/5ML;
                                                                       2MG/5ML
   54022111201     VITAMIN B-12                           SUBL         2500MCG       T1

   50111099001     VITAMIN D                              CAPS         50000UNIT     T1

   52152007602     VITAPLEX                               TABS         500MG; 18MG; T1    AL (max: 35y)
                                                                       5MCG; 0.5MG;
                                                                       100MG; 4MG;
                                                                       15MG; 15MG
   63717055106     XIRATUSS                               TABS         60MG; 5MG;    T1
                                                                       10MG
   68047021001     Y-COF DM                               TB12         6MG; 30MG;    T1
                                                                       20MG
   13811000130     Z-DEX                                  LIQD         3MG/ML;       T1
                                                                       35MG/ML;
                                                                       2.5MG/ML
   13811000216     Z-DEX                                  SYRP         20MG/5ML;     T1
                                                                       100MG/5ML;
                                                                       10MG/5ML




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                              Page 253 of 285
   59630017010     ZEBUTAL                                CAPS         500MG; 50MG; T1
                                                                       40MG
   63304092060     ZIDOVUDINE                             TABS         300MG       T1

   00245008011     ZINC SULFATE                           CAPS         220MG       T1

   58980077611     ZIOX 405                               OINT         0.5%;        T1
                                                                       405900UNIT/G
                                                                       M; 10%
   00603749539     ZOLENE HC                              SOLN         1MG/ML;     T1
                                                                       10MG/ML;
                                                                       10MG/ML
   49884065701     ZORPRIN                                TBCR         800MG       T1

   00603749639     ZOTANE HC                              SOLN         1MG/ML;     T1
                                                                       10MG/ML;
                                                                       10MG/ML


   Tier: T2
   NDC             Product Name                           Form         Strength    Pref   Cost   Coverage Details          Comment

   17204042750     A/G PRO                                TABS         100MG; 1MG; T2
                                                                       75MG;
                                                                       0.15MG;
                                                                       10MG; 300MG;
                                                                       20MG; 2MG;
                                                                       20MG;
                                                                       3.25GM; 2MG;
                                                                       2MG
   50924088401     ACCU-CHEK COMPACT TEST DRUM            STRP         0           T2            QL (204.00 per 30 days)


   00064100134     ACCUZYME SE                            EMUL         830000UNIT/G T2
                                                                       M; 10%
   68712000301     ACLARO                                 EMUL         4%          T2

   68712001502     ACLARO PD                              EMUL         4%          T2

   63004773101     ACTHAR HP                              GEL          80UNIT/ML   T2

   00149047501     ACTONEL WITH CALCIUM                   TABS         1250MG; 35MG T2

   58914001006     ADEKS                                  CHEW         60MG; 3MG;   T2
                                                                       50MCG;
                                                                       400UNIT;
                                                                       12MCG;
                                                                       0.2MG; 10MG;
                                                                       10MG;
                                                                       150MCG;
                                                                       1500MCG;
                                                                       1300MCG;
                                                                       1200MCG;
                                                                       4000UNIT;
                                                                       150UNIT;
                                                                       7.5MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 254 of 285
   10337081506     ADOXA                                  CAPS         150MG            T2

   00944294110     ADVATE                                 SOLR         250UNIT          T2

   00944294210     ADVATE                                 SOLR         500UNIT          T2

   00944294310     ADVATE                                 SOLR         1000UNIT         T2

   00944294410     ADVATE                                 SOLR         1500UNIT         T2

   00944294510     ADVATE                                 SOLR         2000UNIT         T2

   00944294610     ADVATE                                 SOLR         3000UNIT         T2

   00074307290     ADVICOR                                TB24         20MG; 750MG      T2

   38739011003     AEROKID                                SYRP         4MG/5ML;         T2
                                                                       1.25MG/5ML;
                                                                       10MG/5ML
   59196001704     AH-CHEW D                              SUSP         10MG/5ML         T2

   13548003025     AKNE-MYCIN                             OINT         2%               T2

   68040070513     ALCORTIN A                             GEL          1%; 2%; 1%       T2

   29336061012     ALDARA                                 CREA         5%               T2

   67546011112     ALINIA                                 TABS         500MG            T2

   66869040710     ALLERDUR                               SUSP         3MG/5ML;         T2
                                                                       50MG/5ML
   54799053466     ALODOX CONVENIENCE KIT                 KIT          20MG             T2

   68516460002     ALPHANATE                              SOLR         1000-1500        T2
                                                                       UNIT
   00054306844     ALPRAZOLAM INTENSOL                    CONC         1MG/ML           T2

   00469002103     AMEVIVE                                SOLR         15MG             T2

   64764024060     AMITIZA                                CAPS         24MCG            T2

   00245002216     AMLACTIN XL                            LOTN         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0
   63459070060     AMRIX                                  CP24         15MG             T2

   68220005510     ANADROL-50                             TABS         50MG             T2

   49326034650     ANANA FORTE                            TABS         133333UNIT       T2

   50419048303     ANGELIQ                                TABS         0.5MG; 1MG       T2

   67404010005     APHTHASOL                              PSTE         5%               T2

   64029452501     APLISOL                                SOLN         5UNIT/0.1ML      T2

   00193362721     ASCENSIA AUTODISC BLOOD GLUCOSE TEST STRP           0                T2   QL (204.00 per 30 days)
                   STRIPS

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   41167005703     ASPERCREME/ALOE                        CREA         10%              T2

   16881030015     AURALGAN                               SOLN         0.01%; 5.4%;     T2
                                                                       1.4%; 0.01%
   00225052547     AYR SALINE NASAL                       GEL          0                T2

   00072420008     BALNETAR LIQUIM                        EMUL         2.5%             T2

   08290320109     BD ULTRAFINE III SHORT PEN NEEDLES/31G MISC                          T2   QL (200.00 per 30 days)
                   X 5/16"
   64193024402     BEBULIN VH                             SOLR         200-1200 UNIT T2

   58394000106     BENEFIX                                SOLR         1000UNIT         T2

   58394000301     BENEFIX                                SOLR         250UNIT          T2

   58394000206     BENEFIX                                SOLR         500UNIT          T2

   58394000802     BENEFIX                                SOLR         2000UNIT         T2

   00187038034     BENOQUIN                               CREA         20%              T2

   63801010709     BENSAL HP                              OINT         6%; 3%           T2

   66992012016     BETAVENT                               LIQD         20MG/5ML;        T2
                                                                       100MG/5ML
   00062020502     BIAFINE                                EMUL         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0
   60793060210     BICILLIN C-R                           SUSP         900000UNIT/M T2
                                                                       L;
                                                                       300000UNIT/M
                                                                       L
   60793060110     BICILLIN C-R                           SUSP         300000UNIT/M T2
                                                                       L;
                                                                       300000UNIT/M
                                                                       L
   68712000901     BIONECT                                SOLN         0.2%             T2

   68712000702     BIONECT                                CREA         0.2%             T2

   68712000802     BIONECT                                GEL          0.2%             T2

   11026268106     BRONCOTRON-D                           SUSP         40MG/10ML;       T2
                                                                       400MG/10ML;
                                                                       10MG/10ML
   49963081304     BRONTUSS SF                            SYRP         15MG/5ML;        T2
                                                                       350MG/5ML;
                                                                       10MG/5ML
   58552010301     BUCALSEP                               SOLN         600MG/30ML;      T2
                                                                       30MG/30ML;
                                                                       45MG/30ML;
                                                                       30MG/30ML




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                           Page 256 of 285
   58552010401     BUCALSEP                               LIQD         600MG/30ML;   T2
                                                                       30MG/30ML;
                                                                       45MG/30ML;
                                                                       30MG/30ML
   00037011360     BUTISOL SODIUM                         TABS         30MG          T2

   00037011016     BUTISOL SODIUM                         ELIX         30MG/5ML      T2

   00037011460     BUTISOL SODIUM                         TABS         50MG          T2

   68220009990     CALAFOL RX                             TABS         600MG;       T2
                                                                       400UNIT;
                                                                       1.6MG;
                                                                       425MCG; 5MG;
                                                                       25MG
   00642006630     CALCIFOL                               WAFR         1MG; 1342MG; T2
                                                                       200UNIT;
                                                                       25MCG;
                                                                       1.6MG; 50MG;
                                                                       10MG
   00642006860     CALCIFOLIC-D                           WAFR         250MCG;      T2
                                                                       1342MG;
                                                                       300UNIT;
                                                                       125MCG; 1MG;
                                                                       50MG; 10MG
   08489800001     CAPHOSOL                               SOLN         0.052%;       T2
                                                                       0.569%;
                                                                       0.032%;
                                                                       0.009%
   58552011716     CARBAPHEN 12                           SUSP         60MG/5ML;     T2
                                                                       8MG/5ML;
                                                                       20MG/5ML
   58552011802     CARBAPHEN 12 PED                       SUSP         15MG/ML;      T2
                                                                       2MG/ML;
                                                                       2.5MG/ML
   12539086560     CARDIOVID PLUS                         CAPS         500MCG;       T2
                                                                       240MG;
                                                                       360MG;
                                                                       1000MG;
                                                                       800MCG;
                                                                       600MG; 20MG
   58177061866     CARENATAL DHA                          MISC         120MG;       T2    GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       0; 0; 1MG;
                                                                       29MG; 0;
                                                                       25MG; 20MG;
                                                                       250MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       30MG; 25MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 257 of 285
   00597003234     CATAPRES-TTS-2                         PTWK         0.2MG/24HR            T2

   45809080160     CEDAX                                  SUSR         90MG/5ML              T2

   00004026129     CELLCEPT                               SUSR         200MG/ML              T2

   00004025901     CELLCEPT                               CAPS         250MG                 T2

   00004026001     CELLCEPT                               TABS         500MG                 T2

   00004029809     CELLCEPT INTRAVENOUS                   SOLR         500MG                 T2

   00525050390     CEREFOLIN                              TABS         1MG;                  T2
                                                                       5.635MG;
                                                                       50MG; 5MG
   00525051090     CEREFOLIN NAC                          TABS         600MG;                T2
                                                                       5.6MG; 2MG
   64543018090     CERTUSS                                TB12         60MG; 1200MG T2

   44087120301     CETROTIDE                              KIT          3MG                   T2

   44087122501     CETROTIDE                              KIT          0.25MG                T2

   00069046997     CHANTIX                                TABS         1MG                   T2

   67386020111     CHEMET                                 CAPS         100MG                 T2

   64011019826     CHROMAGEN                              TABS         150MG; 2MG; T2
                                                                       10MCG; 50MG;
                                                                       70MG; 75MG
   64011019926     CHROMAGEN FA                           TABS         150MG; 2MG; T2
                                                                       10MCG; 70MG;
                                                                       1MG; 75MG
   64011019726     CHROMAGEN FORTE                        TABS         60MG; 0.8MG; T2
                                                                       10MCG; 50MG;
                                                                       101MG; 1MG;
                                                                       50MG
   16781015460     CLARIFOAM EF                           FOAM         10%; 5%               T2

   00145251605     CLARIPEL                               CREA         3%; 4%;               T2
                                                                       7.5%; 6%
   14168261002     CLEERAVUE-M                            KIT          0;   0;   0;   0; 0;   T2
                                                                       0;   0;   0;   50MG;
                                                                       0;   0;   0;   0; 0;
                                                                       0;   0;   0;   0; 0; 0
   65880050302     CLINDAREACH                            KIT          1%                    T2

   38779061005     COAL TAR                               SOLN         20%                   T2

   16110005260     CORDRAN                                LOTN         0.05%                 T2

   16110003530     CORDRAN SP                             CREA         0.05%                 T2

   55515001480     CORDRAN TAPE                           TAPE         4MCG/SQCM             T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                       Page 258 of 285
   51674011702     CORTANE-B                              LOTN         1MG/ML;       T2
                                                                       10MG/ML;
                                                                       10MG/ML
   00091069520     CORTIFOAM                              FOAM         90MG          T2

   61570003150     CORTISPORIN                            OINT         400UNIT/GM;   T2
                                                                       1%; 0.5%;
                                                                       5000UNIT/GM
   61570003275     CORTISPORIN                            CREA         0.5%; 0.5%;  T2
                                                                       10000UNIT/GM
   61570009010     CORTISPORIN-TC                         SUSP         3MG/ML;       T2
                                                                       10MG/ML;
                                                                       3.3MG/ML;
                                                                       0.5MG/ML
   00548590000     CORTROSYN                              SOLR         0.25MG        T2

   10952003513     CRESYLATE                              SOLN         25%           T2

   55056081802     CRINONE                                GEL          8%            T2

   25010070515     CUPRIMINE                              CAPS         250MG         T2

   00462033330     CUTIVATE                               OINT         0.005%        T2

   00462033230     CUTIVATE                               CREA         0.05%         T2

   00462043404     CUTIVATE                               LOTN         0.05%         T2

   00065039705     CYCLOGYL                               SOLN         2%            T2

   00065039515     CYCLOGYL                               SOLN         0.5%          T2

   16477012030     DALLERGY                               LIQD         1MG/ML;       T2
                                                                       2MG/ML
   62942010102     DEBACTEROL                             SOLN         50%; 30%      T2

   42023011001     DELESTROGEN                            OIL          10MG/ML       T2

   42023011101     DELESTROGEN                            OIL          20MG/ML       T2

   58238021604     DELTUSS DMX                            LIQD         1MG/5ML;      T2
                                                                       20MG/5ML;
                                                                       30MG/5ML
   00409125301     DEMEROL                                SOLN         50MG/ML       T2

   00409125502     DEMEROL                                SOLN         50MG/ML       T2

   00409117630     DEMEROL                                SOLN         25MG/ML       T2

   00409118069     DEMEROL                                SOLN         100MG/ML      T2

   00409117830     DEMEROL                                SOLN         50MG/ML       T2

   00409118130     DEMEROL                                SOLN         50MG/ML       T2

   00409117930     DEMEROL                                SOLN         75MG/ML       T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 259 of 285
   00409120301     DEMEROL                                SOLN         50MG/ML       T2

   25010030515     DEMSER                                 CAPS         250MG         T2

   00525041030     DEPLIN                                 TABS         7.5MG         T2

   11584104506     DESPEC DM                              SYRP         15MG/5ML;     T2
                                                                       100MG/5ML;
                                                                       5MG/5ML
   11584104801     DESPEC DROPS                           LIQD         4MG/ML;       T2
                                                                       20MG/ML;
                                                                       10MG/ML
   10542001409     DIALYVITE 3000                         TABS         100MG;       T2
                                                                       300MCG;
                                                                       10MG;
                                                                       30UNIT; 3MG;
                                                                       1MG; 20MG;
                                                                       25MG; 1.7MG;
                                                                       70MCG;
                                                                       1.5MG; 15MG
   00187065920     DIASTAT ACUDIAL                        GEL          20MG          T2

   00187065820     DIASTAT ACUDIAL                        GEL          10MG          T2

   66490065020     DIASTAT PEDIATRIC                      GEL          2.5MG         T2

   00193280250     DIASTIX                                STRP         0             T2   QL (204.00 per 30 days)


   00525428190     DIATX ZN                               TABS         60MG;         T2
                                                                       300MCG;
                                                                       1.5MG; 2MG;
                                                                       5MG; 20MG;
                                                                       10MG; 50MG;
                                                                       1.5MG; 1.5MG;
                                                                       25MG
   00054318863     DIAZEPAM                               SOLN         1MG/ML        T2

   00054318544     DIAZEPAM INTENSOL                      CONC         5MG/ML        T2

   00074245531     DILAUDID-HP                            SOLR         250MG         T2

   50474060001     DIPENTUM                               CAPS         250MG         T2

   65649031112     DIURIL                                 SUSP         250MG/5ML     T2

   66813007316     DOLGIC LQ                              ELIX         325MG/15ML;   T2
                                                                       50MG/15ML;
                                                                       40MG/15ML
   68453007410     DOLGIC PLUS                            TABS         750MG; 50MG; T2
                                                                       40MG
   16477010630     DONATUSSIN                             LIQD         20MG/ML;      T2
                                                                       1.5MG/ML
   16477013001     DONATUSSIN DM                          SUSP         2MG/5ML;      T2
                                                                       30MG/5ML;
                                                                       20MG/5ML


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                        Page 260 of 285
   16477081130     DONATUSSIN DM                          LIQD         1MG/ML;       T2
                                                                       3MG/ML;
                                                                       1.5MG/ML
   63004773401     DORAL                                  TABS         15MG          T2

   66479084801     DUET                                   TABS         120MG;        T2   GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       0; 1MG; 29MG;
                                                                       0; 25MG;
                                                                       20MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       30MG; 25MG
   66479083090     DUET                                   CHEW         120MG;       T2    GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       1MG; 29MG;
                                                                       25MG; 20MG;
                                                                       25MG; 4MG;
                                                                       1.8MG; 30MG;
                                                                       25MG
   66479085530     DUET DHA                               MISC         120MG;        T2   GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       275MG; 0;
                                                                       1MG; 29MG; 0;
                                                                       25MG; 20MG;
                                                                       400MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       30MG; 25MG
   66479086130     DUET DHA EC                            MISC         120MG;        T2   GL (f); AL (max: 35y)
                                                                       3000UNIT;
                                                                       200MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       275MG; 0;
                                                                       1MG; 29MG; 0;
                                                                       25MG; 20MG;
                                                                       400MG; 25MG;
                                                                       4MG; 1.8MG;
                                                                       3MG; 25MG
   66869082610     DURABAC                                CAPS         325MG; 50MG; T2
                                                                       20MG; 250MG
   66869082710     DURABAC FORTE                          TABS         500MG; 50MG; T2
                                                                       500MG; 20MG
   68453055010     DURATUSS CS                            TB12         60MG; 900MG   T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 261 of 285
   68453068016     DURATUSS DM 12                         SUSP         15MG/5ML;        T2
                                                                       225MG/5ML
   63717059004     DYTAN-AT                               SUSP         30MG/5ML;        T2
                                                                       25MG/5ML
   00485005916     ED-BRON G                              SYRP         100MG/15ML;      T2
                                                                       300MG/15ML
   25010020515     EDECRIN                                TABS         25MG             T2

   00496059801     ELETONE                                CREA         0; 0; 0; 0; 0; 0 T2

   58406045504     ENBREL                                 SOLN         25MG/0.5ML       T2   PA; MN; QL (28.00 days supply per dispensing)


   64011016636     ENCORA                                 MISC         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 10MG;
                                                                       100MG;
                                                                       650MG; 0;
                                                                       50UNIT
   55566650003     ENDOMETRIN                             INST         100MG            T2

   66813055516     ENTEX                                  SUSP         22.5MG/5ML       T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                 Page 262 of 285
   49735012666     EO28 SPLASH                            LIQD         7.4MG/237ML; T2
                                                                       4.7MCG/237ML
                                                                       ;
                                                                       147MG/237ML;
                                                                       0.57MG/237ML
                                                                       ; 83MG/237ML;
                                                                       43.4MG/237ML
                                                                       ;
                                                                       7.1MCG/237ML
                                                                       ;
                                                                       240MCG/237M
                                                                       L;
                                                                       0.17MCG/237M
                                                                       L;
                                                                       73.5UNIT/237
                                                                       ML;
                                                                       1.8MG/237ML;
                                                                       14.2MCG/237M
                                                                       L;
                                                                       4.3MG/237ML;
                                                                       21.3MG/237ML
                                                                       ;
                                                                       0.24MG/237ML
                                                                       ;
                                                                       2.1MG/237ML;
                                                                       147MG/237ML;
                                                                       220MG/237ML;
                                                                       14.2MCG/237M
                                                                       L;
                                                                       0.19MG/237ML
                                                                       ;
                                                                       0.15MG/237ML
                                                                       ;
                                                                       3.7MCG/237ML
                                                                       ;
                                                                       47.4MG/237ML
                                                                       ;
                                                                       8.3MCG/237ML
                                                                       ;
                                                                       0.13MG/237ML
                                                                       ;
                                                                       277UNIT/237M
                                                                       L;
                                                                       1.9UNIT/237M
                                                                       L;
                                                                       3.6MCG/237ML
                                                                       ; 1.8MG/237ML
   00091074010     EPIFOAM                                FOAM         1%; 1%      T2

   67402001030     EPIQUIN MICRO                          CREA         4%          T2

   10551009110     EQUAGESIC                              TABS         325MG; 200MG T2

   15456032556     ESTRASORB                              EMUL         4.35MG/1.74G T2
                                                                       M



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com             Page 263 of 285
   14629011416     EXTENDRYL                              SOLN         1MG/5ML;      T2
                                                                       1.25MG/5ML;
                                                                       10MG/5ML
   14629020201     EXTENDRYL DM                           TB12         8MG; 30MG;    T2
                                                                       2.5MG
   64193022204     FEIBA VH IMMUNO                        SOLR         0             T2

   64193022205     FEIBA VH IMMUNO                        SOLR         0             T2

   00430054414     FEMHRT 1/5                             TABS         5MCG; 1MG     T2

   68453095010     FEXMID                                 TABS         7.5MG         T2

   65628005001     FIRST-MOUTHWASH BLM                    SUSP         3.15GM/237ML T2
                                                                       ;
                                                                       0.2GM/237ML;
                                                                       1.6GM/237ML;
                                                                       3.15GM/237ML
                                                                       ;
                                                                       0.315GM/237M
                                                                       L
   65628006201     FIRST-PROGESTERONE VGS 100             SUPP         100MG         T2
                   COMPOUNDING KIT
   65628006301     FIRST-PROGESTERONE VGS 200             SUPP         200MG         T2
                   COMPOUNDING KIT
   65628006001     FIRST-PROGESTERONE VGS 25              SUPP         25MG          T2
                   COMPOUNDING KIT
   65628006101     FIRST-PROGESTERONE VGS 50              SUPP         50MG          T2
                   COMPOUNDING KIT
   00482400030     FLORA-Q                                CAPS         0; 0; 0; 0    T2

   00173071820     FLOVENT HFA                            AERO         44MCG/ACT     T2   QL (2.00 per 30 days)


   00245015560     FOLGARD OS                             TABS         500MG;        T2
                                                                       300UNIT;
                                                                       250MCG;
                                                                       1.1MG;
                                                                       100MG;
                                                                       12.5MG;
                                                                       1.5MG
   00245019111     FOLGARD RX                             TABS         1MG; 2.2MG;   T2
                                                                       25MG
   00052030902     FOLLISTIM AQ                           SOLN         150UNIT/0.5M T2    PA; QL (3600.00 per dispensing)
                                                                       L
   00052031301     FOLLISTIM AQ                           SOLN         300UNT/0.36M T2    PA; QL (3600.00 per dispensing)
                                                                       L
   00052030802     FOLLISTIM AQ                           SOLN         75UNIT/0.5ML T2    PA; QL (3600.00 per dispensing)


   00052032601     FOLLISTIM AQ                           SOLN         900UNT/1.08M T2    PA; QL (3600.00 per dispensing)
                                                                       L
   00052031601     FOLLISTIM AQ                           SOLN         600UNT/0.72M T2    PA; QL (3600.00 per dispensing)
                                                                       L


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                Page 264 of 285
   23594010010     FOLMOR                                 TABS         0; 2MG;          T2
                                                                       2.5MG; 0;
                                                                       25MG; 0
   68220001890     FOLPACE RX                             TABS         100UNIT;         T2
                                                                       2.05MG;
                                                                       425MCG;
                                                                       100MG; 25MG
   66869012210     FOLTRATE                               TABS         500MCG; 1MG      T2

   68040060316     FOSTEUM                                CAPS         200UNIT;         T2
                                                                       27MG; 20MG
   15821010115     FRESHKOTE                              SOLN         0; 2.7%; 2%      T2

   57844021552     GALZIN                                 CAPS         25MG             T2

   57844020852     GALZIN                                 CAPS         50MG             T2

   00052030151     GANIRELIX ACETATE                      SOLN         250MCG/0.5ML T2

   24477001015     GELCLAIR                               GEL          0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0
   00009032301     GELFOAM SPONGE                         MISC         0                T2

   58552010808     GILTUSS                                LIQD         15MG/5ML;        T2
                                                                       300MG/5ML;
                                                                       10MG/5ML
   58552011602     GILTUSS PED-C                          LIQD         3MG/ML;          T2
                                                                       50MG/ML;
                                                                       2.5MG/ML
   58552010702     GILTUSS PEDIATRIC                      LIQD         5MG/ML;          T2
                                                                       50MG/ML;
                                                                       2.5MG/ML
   58552030301     GILTUSS TR                             TB12         30MG; 600MG; T2
                                                                       20MG
   00078040134     GLEEVEC                                TABS         100MG            T2   QL (30.00 days supply per dispensing)


   00482015706     GLUTOFAC-MX                            TABS         100MG;       T2
                                                                       300MCG;
                                                                       150MCG;
                                                                       425MG;
                                                                       130MG;
                                                                       200MCG; 5MG;
                                                                       10MCG; 10MG;
                                                                       0.8MG; 15MG;
                                                                       415MG; 5MG;
                                                                       5MCG; 25MG;
                                                                       80MG;
                                                                       150MCG;
                                                                       100MCG;
                                                                       75MCG;
                                                                       10MCG;
                                                                       10MCG; 35MG



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                         Page 265 of 285
   00482015906     GLUTOFAC-ZX                            TABS         200MG;       T2
                                                                       200MCG;
                                                                       10MG;
                                                                       400UNIT;
                                                                       200MCG;
                                                                       2.5MG;
                                                                       2500MCG;
                                                                       100UNIT;
                                                                       2800MCG;
                                                                       500MCG;
                                                                       500MCG;
                                                                       100MG;
                                                                       2.5MG;
                                                                       100MG; 25MG;
                                                                       20MG;
                                                                       100MCG;
                                                                       20MG;
                                                                       5000UNIT;
                                                                       15MG
   00187042146     GLYQUIN XM                             CREA         3%; 4%; 8%;   T2
                                                                       4%
   44087907001     GONAL-F                                SOLR         1050UNIT      T2   PA; QL (3600.00 per dispensing)


   44087903001     GONAL-F                                SOLR         450UNIT       T2   PA; QL (3600.00 per dispensing)


   44087900506     GONAL-F RFF                            SOLR         75UNIT        T2   PA; QL (3600.00 per dispensing)


   44087111201     GONAL-F RFF PEN                        SOLN         450UNT/0.75M T2    PA; QL (3600.00 per dispensing)
                                                                       L
   44087111301     GONAL-F RFF PEN                        SOLN         300UNIT/0.5M T2    PA; QL (3600.00 per dispensing)
                                                                       L
   44087111401     GONAL-F RFF PEN                        SOLN         900UNIT/1.5M T2    PA; QL (3600.00 per dispensing)
                                                                       L
   66500015801     GYNODIOL                               TABS         1.5MG         T2

   00062318012     GYNOL II                               GEL          2%            T2

   52268052001     HALFLYTELY BOWEL PREP/FLAVOR PACKS     KIT          5MG; 210GM;   T2
                                                                       0.74GM;
                                                                       2.86GM;
                                                                       5.6GM
   51724000120     HALOTIN                                CREA         1%            T2

   00016031055     HEALON                                 SOLN         10MG/ML       T2

   65483049514     HELIDAC                                MISC         0; 0; 0       T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                Page 266 of 285
   11026274608     HEMATRON                               LIQD         25MCG/5ML;    T2
                                                                       50MG/5ML;
                                                                       1MG/5ML;
                                                                       150MG/5ML;
                                                                       10MG/5ML;
                                                                       5MG/5ML;
                                                                       2MG/5ML;
                                                                       2MG/5ML;
                                                                       10MG/5ML
   11026275509     HEMATRON-AF                            TBCR         500MG;       T2
                                                                       150MCG;
                                                                       5MCG; 3MG;
                                                                       60MCG; 50MG;
                                                                       1MG; 75MG;
                                                                       150MG;
                                                                       150MCG;
                                                                       30UNIT
   52747080060     HEMOCYTE PLUS                          CAPS         10MG; 0.8MG; T2
                                                                       15MCG;
                                                                       324MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG; 5MG;
                                                                       6MG; 200MG;
                                                                       10MG; 18.2MG
   00944293503     HEMOFIL M                              SOLR         801-1700 UNIT T2

   00409140231     HEPARIN SODIUM                         SOLN         5000UNIT/ML   T2

   23589000110     HISTEX SR                              CP12         10MG; 120MG   T2

   00053761505     HUMATE-P                               SOLR         250UNIT;      T2
                                                                       600UNIT
   00053761520     HUMATE-P                               SOLR         1000UNIT;     T2
                                                                       2400UNIT
   00053761510     HUMATE-P                               SOLR         500UNIT;      T2
                                                                       1200UNIT
   00053762010     HUMATE-P                               SOLR         1000UNIT      T2

   23710004075     HYDRO 40 FOAM                          FOAM         40%           T2

   83490010760     HYPER-SAL                              NEBU         7%            T2

   63717011201     ICAR-C PLUS SR                         CPCR         320MG;        T2
                                                                       25MCG; 1MG;
                                                                       100MG
   52544093102     INFED                                  SOLN         50MG/ML       T2

   00187200702     INFERGEN                               INJ          9MCG/0.3ML    T2

   00187200601     INFERGEN                               INJ          15MCG/0.5ML   T2

   17205062601     INVERSINE                              TABS         2.5MG         T2

   52041004515     IROFOL                                 TABS         1MG; 150MG    T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 267 of 285
   52041004533     IROFOL                                 LIQD         1MG/5ML;      T2
                                                                       100MG/5ML
   00998033105     ISOPTO HYOSCINE                        SOLN         0.25%         T2

   64661003230     J-TAN D PD                             LIQD         1MG/ML;       T2
                                                                       7.5MG/ML
   64661003130     J-TAN PD                               LIQD         1MG/ML        T2

   00006057561     JANUMET                                TABS         500MG; 50MG   T2

   50474059640     KEPPRA                                 TABS         750MG         T2

   10337064810     KERALAC NAILSTIK                       SOLN         50%           T2

   11086003040     KERALYT                                GEL          6%            T2

   10337064510     KEROL                                  SUSP         0; 0; 50%     T2

   00193288250     KETO-DIASTIX                           STRP         0             T2   QL (204.00 per 30 days)


   00193288050     KETOSTIX                               STRP         0             T2   QL (204.00 per 30 days)


   55513017728     KINERET                                SOLN         100MG/0.67ML T2    PA; MN; QL (28.00 per 28 days)


   68135030002     KUVAN                                  TBSO         100MG         T2

   00023031204     LACRI-LUBE S.O.P.                      OINT         0.5%; 2%;     T2
                                                                       42.5%; 55%
   25010080568     LACRISERT                              INST         5MG           T2

   66993091498     LAVOCLEN-8 ACNE WASH KIT               KIT          8%            T2

   00054449710     LEUCOVORIN CALCIUM                     TABS         10MG          T2

   66992016050     LEVACET                                TABS         250MG;        T2
                                                                       500MG;
                                                                       32.5MG;
                                                                       150MG
   00187410010     LIBRAX                                 CAPS         5MG; 2.5MG    T2

   68040060216     LIMBREL                                CAPS         500MG         T2

   68040060116     LIMBREL                                CAPS         250MG         T2

   58281056102     LIORESAL INTRATHECAL                   KIT          10MG/5ML      T2

   64543024090     LIQUIBID-D 1200                        TB12         1200MG; 40MG T2

   64543024690     LIQUIBID-PD                            TB12         315MG; 20MG   T2

   00054353244     LORAZEPAM INTENSOL                     CONC         2MG/ML        T2

   51672132703     LUSTRA-AF                              CREA         0; 4%; 0      T2

   51672132802     LUSTRA-ULTRA                           CREA         4%            T2

   44087137501     LUVERIS                                SOLR         75UNIT        T2


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                               Page 268 of 285
   12830081016     M-END DM                               SYRP         2MG/5ML;         T2
                                                                       15MG/5ML;
                                                                       15MG/5ML
   09198013303     MAGINEX                                TBEC         615MG            T2

   59528041605     MAGNEBIND 400                          TABS         200MG; 1MG;      T2
                                                                       400MG
   00682250001     MARNATAL-F PLUS DUO PACK               MISC         100MG;       T2       GL (f); AL (max: 35y)
                                                                       250MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       100MG;
                                                                       150MG;
                                                                       500MG; 1MG;
                                                                       25MG; 20MG;
                                                                       250MG; 60MG;
                                                                       200MCG; 5MG;
                                                                       3.4MG; 3MG;
                                                                       30UNIT;
                                                                       2000UNIT;
                                                                       25MG
   30698003201     MARPLAN                                TABS         10MG             T2

   00006026612     MAXALT                                 TABS         5MG              T2   QL (12.00 per 30 days)


   67386080102     MEBARAL                                TABS         32MG             T2

   67386080202     MEBARAL                                TABS         50MG             T2

   67386080302     MEBARAL                                TABS         100MG            T2

   00259030350     MEDERMA                                GEL          0; 0; 0; 0; 0;   T2
                                                                       0; 0
   55566750102     MENOPUR                                SOLR         75UNIT           T2   PA; QL (3600.00 per dispensing)


   25010040515     MEPHYTON                               TABS         5MG              T2

   00074245712     MERIDIA                                CAPS         10MG             T2

   00074245812     MERIDIA                                CAPS         15MG             T2

   67108356509     MESNEX                                 TABS         400MG            T2

   00525801990     METANX                                 TABS         2.8MG; 2MG;      T2
                                                                       25MG
   00078005405     METHERGINE                             TABS         0.2MG            T2

   00299382004     METROGEL 1% KIT                        KIT          1%               T2

   00145420002     MIMYX                                  CREA         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0
   00430350011     MOISTUREL                              CREA         10%;    10%;     T2
                                                                       10%;    10%;
                                                                       10%;    10%;
                                                                       10%;    10%;
                                                                       10%

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                   Page 269 of 285
   00187050002     MOTOFEN                                TABS         0.025MG; 1MG T2

   50580019815     MOTRIN INFANTS                         SUSP         40MG/ML       T2

   65649020175     MOVIPREP                               SOLR         4.7GM;        T2
                                                                       100GM;
                                                                       1.015GM;
                                                                       5.9GM;
                                                                       2.691GM;
                                                                       7.5GM
   00193216121     MULTISTIX 10 SG STRIPS                 STRP         0             T2   QL (204.00 per 30 days)


   00078038566     MYFORTIC                               TBEC         180MG         T2

   00078038666     MYFORTIC                               TBEC         360MG         T2

   67871773305     NASCOBAL                               SOLN         500MCG/0.1ML T2

   00085128801     NASONEX                                SUSP         50MCG/ACT     T2   QL (2.00 per 30 days)


   16477062030     NEO DM                                 LIQD         0.75MG/ML;    T2
                                                                       2.75MG/ML;
                                                                       1.75MG/ML
   16477056001     NEO DM                                 SUSP         10MG/5ML;     T2
                                                                       30MG/5ML;
                                                                       25MG/5ML
   16477062501     NEO HC                                 SYRP         3MG/5ML;      T2
                                                                       5MG/5ML;
                                                                       7.5MG/5ML
   67402002206     NEOBENZ MICRO SD                       CREA         8.5%          T2

   67402002006     NEOBENZ MICRO SD                       CREA         3.5%          T2

   12539088816     NEOTUSS-D                              LIQD         4MG/10ML;     T2
                                                                       60MG/10ML;
                                                                       400MG/10ML;
                                                                       60MG/10ML
   58394000401     NEUMEGA                                SOLR         5MG           T2

   53879020210     NEURIN-SL                              SUBL         600MCG;       T2
                                                                       600MCG
   00074307490     NIASPAN                                TBCR         500MG         T2

   00074307990     NIASPAN                                TBCR         750MG         T2

   00074308090     NIASPAN                                TBCR         1000MG        T2

   65880079260     NICOMIDE                               TABS         1.5MG;        T2
                                                                       500MCG;
                                                                       750MG; 25MG
   00009540001     NICOTROL INHALER                       INHA         10MG          T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                        Page 270 of 285
   64011016226     NIFEREX GOLD                           TABS         60MG; 0.8MG; T2
                                                                       25MCG; 50MG;
                                                                       50MG; 1MG;
                                                                       150MG; 50MG;
                                                                       10MG
   64011016326     NIFEREX-150                            CAPS         50MG; 0;         T2
                                                                       150MG; 0;
                                                                       50MG; 0
   64011016426     NIFEREX-150 FORTE                      CAPS         60MG; 0.8MG; T2
                                                                       25MCG; 50MG;
                                                                       1MG; 100MG;
                                                                       50MG
   00091332201     NIRAVAM                                TBDP         0.5MG            T2

   00091332101     NIRAVAM                                TBDP         0.25MG           T2

   00091332401     NIRAVAM                                TBDP         2MG              T2

   00091332301     NIRAVAM                                TBDP         1MG              T2

   00169770511     NORDITROPIN NORDIFLEX PEN              SOLN         10MG/1.5ML       T2   PA


   51724022004     NORTUSS-EX                             LIQD         20MG/5ML;        T2
                                                                       200MG/5ML
   24839022816     NOTUSS-FORTE                           SYRP         4MG/5ML;         T2
                                                                       5MG/5ML;
                                                                       40MG/5ML
   68040070426     NOVACORT                               GEL          1%; 2%; 1%       T2

   00169706201     NOVOSEVEN                              SOLR         4800MCG          T2

   00169706001     NOVOSEVEN                              SOLR         1200MCG          T2

   00169706101     NOVOSEVEN                              SOLR         2400MCG          T2

   61570001860     NUCOFED                                CAPS         20MG; 60MG       T2

   08514021001     NUMOISYN                               LOZG         0; 0; 0; 0; 0; T2
                                                                       0; 0; 0; 0.3GM
   08514011002     NUMOISYN                               LIQD         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0
   00067581296     NUPERCAINAL                            OINT         1%               T2

   66992018043     NUZON                                  GEL          0; 2%            T2

   00813931601     O-CAL FA                               TABS         90MG; 200MG; T2       GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       27MG; 1MG;
                                                                       100MG; 20MG;
                                                                       150MCG; 4MG;
                                                                       3MG; 0.5MG;
                                                                       3MG;
                                                                       2500UNIT;
                                                                       30UNIT; 15MG


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                         Page 271 of 285
   68025001010     OB COMPLETE                            TABS         120MG;         T2   GL (f); AL (max: 35y)
                                                                       2100UNIT;
                                                                       315UNIT;
                                                                       1MG; 15MCG;
                                                                       20UNIT;
                                                                       1.25MG;
                                                                       50MG; 15MG;
                                                                       10MG; 10MG;
                                                                       3.4MG; 2MG;
                                                                       10MG
   68025002260     OB COMPLETE WITH DHA                   CAPS         120MG;       T2     GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       1MG; 15MCG;
                                                                       200MG; 28MG;
                                                                       1.25MG;
                                                                       10MG; 3.4MG;
                                                                       2MG; 30UNIT;
                                                                       25MG
   53885024510     ONETOUCH ULTRA TEST STRIPS             STRP         0              T2

   16781011695     OPTASE                                 GEL          788MG/GM;      T2
                                                                       87MG/GM;
                                                                       0.12MG/GM
   59630041230     OPTINATE                               MISC         120MG;       T2
                                                                       30MCG;
                                                                       200MG; 6MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       250MG; 50MG;
                                                                       400MCG;
                                                                       90MG;
                                                                       600MCG;
                                                                       30MG; 20MG;
                                                                       20MG; 3.4MG;
                                                                       3MG; 10UNIT;
                                                                       15MG
   38779074308     ORA PLUS                               LIQD         0; 0; 0; 0     T2

   67204021016     ORATUSS                                LIQD         20MG/5ML;      T2
                                                                       75MG/5ML
   65649070141     OSMOPREP                               TABS         0.398GM;       T2
                                                                       1.102GM
   59630041360     OSTIVA                                 TABS         500MG;         T2
                                                                       200UNIT;
                                                                       0.25MG;
                                                                       0.565MG;
                                                                       50MG; 1.2MG
   49326050915     OTILAM                                 LIQD         5%; 0.5%; 0;   T2
                                                                       10%
   49326090115     OTOSPORIN                              SOLN         0; 0; 0; 0     T2

   23589002201     OVACE                                  FOAM         10%            T2



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                       Page 272 of 285
   44087115001     OVIDREL                                INJ          250MCG/0.5ML T2

   00064341030     PANAFIL                                OINT         0.5%;        T2
                                                                       405900UNIT/G
                                                                       M; 10%
   00064351034     PANAFIL SE                             EMUL         0.5%;        T2
                                                                       405900UNIT/G
                                                                       M; 10%
   11026267504     PANATUSS DXP                           LIQD         1MG/5ML;         T2
                                                                       15MG/5ML;
                                                                       100MG/5ML;
                                                                       5MG/5ML
   11026266202     PANATUSS DXP PEDIATRIC                 LIQD         0.5MG/ML;        T2
                                                                       5MG/ML;
                                                                       50MG/ML;
                                                                       2MG/ML
   00462015315     PANDEL                                 CREA         0.1%             T2

   62856060122     PANRETIN                               GEL          0.1%             T2   QL (60.00 per 30 days)


   51927333700     PCCA COSMETIC HRT BASE                 CREA         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0; 0;
                                                                       0; 0; 0; 0




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                          Page 273 of 285
   70074050653     PEDIASURE WITH FIBER                   LIQD         24MG/240ML; T2
                                                                       76MCG/240ML;
                                                                       230MG/240ML;
                                                                       240MG/240ML;
                                                                       71MG/240ML;
                                                                       7.1MCG/240ML
                                                                       ;
                                                                       0.24MG/240ML
                                                                       ;
                                                                       1.4MCG/240ML
                                                                       ;
                                                                       88MCG/240ML;
                                                                       19MG/240ML;
                                                                       23MCG/240ML;
                                                                       3.3MG/240ML;
                                                                       47MG/240ML;
                                                                       0.59MG/240ML
                                                                       ;
                                                                       8.5MCG/240ML
                                                                       ; 4MG/240ML;
                                                                       2.4MG/240ML;
                                                                       190MG/240ML;
                                                                       310MG/240ML;
                                                                       0.62MG/240ML
                                                                       ;
                                                                       0.5MG/240ML;
                                                                       5.4MCG/240ML
                                                                       ; 90MG/240ML;
                                                                       0.64MG/240ML
                                                                       ;
                                                                       610UNIT/240M
                                                                       L;
                                                                       120UNIT/240M
                                                                       L;
                                                                       5.4UNIT/240M
                                                                       L;
                                                                       9MCG/240ML;
                                                                       2.8MG/240ML
   65649021124     PEPCID                                 SUSR         40MG/5ML         T2

   00482480124     PERANEX HC                             KIT          2%; 2%           T2

   58552030601     PHENABID DM                            TB12         8MG; 30MG;       T2
                                                                       20MG
   49452522002     PHENOL                                 LIQD         0                T2

   00847035501     PHENYLADE PHEBLOC                      TABS         0; 0; 0; 0; 0;   T2
                                                                       0; 0; 0; 0
   00024153506     PHISOHEX                               LIQD         3%               T2

   00187084401     PHRENILIN FORTE                        CAPS         650MG; 50MG      T2

   51285076993     PLAN B                                 TABS         0.75MG           T2   GL (f); AL (min: 17y)


   00006494300     PNEUMOVAX 23/1 DOSE                    INJ          25MCG/0.5ML      T2



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   00409186602     PONTOCAINE                             SOLN         2%            T2

   00516005125     POTABA                                 CAPS         500MG         T2

   00516005401     POTABA                                 TABS         500MG         T2

   00496071604     PRAMOSONE                              CREA         1%; 1%        T2

   00496071704     PRAMOSONE                              CREA         2.5%; 1%      T2

   00496076304     PRAMOSONE                              OINT         1%; 1%        T2

   00496077704     PRAMOSONE                              OINT         2.5%; 1%      T2

   00496072604     PRAMOSONE                              LOTN         2.5%; 1%      T2

   00496072904     PRAMOSONE                              LOTN         1%; 1%        T2

   51285006390     PREFEST                                TABS         0; 0          T2

   64011001919     PREMESIS RX                            TABS         200MG;        T2   GL (f); AL (max: 35y)
                                                                       12MCG; 1MG;
                                                                       75MG
   59630041435     PRENATE DHA                            CAPS         85MG; 150MG; T2    GL (f); AL (max: 35y)
                                                                       200UNIT;
                                                                       12MCG;
                                                                       300MG; 50MG;
                                                                       27MG;
                                                                       400MCG;
                                                                       600MCG;
                                                                       50MG; 25MG;
                                                                       10UNIT
   00300154630     PREVACID NAPRAPAC                      KIT          15MG; 500MG   T2

   00126007534     PREVIDENT 5000 BOOSTER                 PSTE         1.1%          T2

   00126007061     PREVIDENT 5000 SENSITIVE               PSTE         5%; 1.1%      T2

   64011020428     PRIMACARE                              MISC         100MG;       T2    GL (f); AL (max: 35y)
                                                                       35MCG; 0;
                                                                       400MG; 0;
                                                                       400UNIT;
                                                                       45MCG;
                                                                       1.3MG;
                                                                       12MCG; 50MG;
                                                                       30MG; 1MG;
                                                                       30MG; 30MG;
                                                                       50MCG; 20MG;
                                                                       300MG; 7MG;
                                                                       50MG; 3.4MG;
                                                                       75MCG; 35MG;
                                                                       3MG; 30UNIT;
                                                                       90MCG; 11MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 275 of 285
   64011020019     PRIMACARE ONE                          CAPS         150MG; 25MG; T2     GL (f); AL (max: 35y)
                                                                       170UNIT;
                                                                       1MG; 27MG;
                                                                       30MG; 30MG;
                                                                       300MG; 25MG;
                                                                       30UNIT
   10631040601     PROCTO-KIT                             CREA         2.5%           T2

   00091475020     PROCTOFOAM                             FOAM         1%             T2

   67181021690     PROFERRIN-FORTE                        TABS         1MG; 12MG      T2

   00469061773     PROGRAF                                CAPS         1MG            T2

   00469060773     PROGRAF                                CAPS         0.5MG          T2

   00469065773     PROGRAF                                CAPS         5MG            T2

   66869080110     PROHIST DM                             LIQD         1MG/ML;        T2
                                                                       5MG/ML;
                                                                       12MG/ML
   51674001907     PROLEX DM                              LIQD         15MG/5ML;      T2
                                                                       300MG/5ML
   00032171101     PROMETRIUM                             CAPS         200MG          T2

   00032170801     PROMETRIUM                             CAPS         100MG          T2

   00006007131     PROPECIA                               TABS         1MG            T2

   15456080503     PROSED /DS                             TABS         9MG; 0.12MG; T2
                                                                       81.6MG;
                                                                       10.8MG;
                                                                       36.2MG
   00009316906     PROSTIN VR PEDIATRIC                   SOLN         500MCG/ML      T2

   64281010006     PROVOCHOLINE                           SOLR         20MG/ML        T2

   50242010040     PULMOZYME                              SOLN         1MG/ML         T2

   58914060021     PYLERA                                 CAPS         140MG;       T2
                                                                       125MG; 125MG
   66813016116     PYRLEX                                 SUSP         12MG/5ML       T2

   66813016216     PYRLEX CB                              SUSP         22.5MG/5ML;    T2
                                                                       12MG/5ML
   00008103006     RAPAMUNE                               SOLN         1MG/ML         T2

   00008104205     RAPAMUNE                               TABS         2MG            T2

   00008104105     RAPAMUNE                               TABS         1MG            T2

   00944293801     RECOMBINATE                            SOLR         220-400 UNIT   T2

   00944293803     RECOMBINATE                            SOLR         801-1240 UNIT T2




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   00944293802     RECOMBINATE                            SOLR         401-800 UNIT   T2

   58394001102     REFACTO                                KIT          2000UNIT       T2

   23594020010     RELAMINE                               TABS         0; 300MG;      T2
                                                                       400MG; 0; 0
   60336003530     REMERGENT HQ                           CREA         4%             T2

   00327001105     RENACIDIN                              SOLN         6.602GM/100M T2
                                                                       L;
                                                                       0.198GM/100M
                                                                       L;
                                                                       3.177GM/100M
                                                                       L
   00062018702     RENOVA                                 CREA         0.02%          T2   AL (max: 35y)


   64011020734     REPLIVA 21/7                           TABS         140MG; 60MG; T2
                                                                       0.8MG;
                                                                       10MCG; 70MG;
                                                                       81MG; 1MG;
                                                                       150MG
   11528041001     REPREXAIN                              TABS         5MG; 200MG     T2

   55566718502     REPRONEX                               SOLR         75UNIT         T2   PA; QL (3600.00 per dispensing)


   60575007819     RESPA DM                               TB12         28MG; 600MG    T2

   60575017719     RESPA-A.R.                             TB12         0.24MG; 8MG; T2
                                                                       90MG
   00406991501     RESTORIL                               CAPS         7.5MG          T2

   00406991403     RESTORIL                               CAPS         22.5MG         T2

   00562780501     RHOGAM ULTRA-FILTERED PLUS             INJ          300MCG         T2

   67457017750     RIMSO-50                               SOLN         50%            T2

   60977015071     ROBAXIN                                SOLN         100MG/ML       T2

   10337066212     ROSULA                                 EMUL         10%; 5%; 0     T2

   10337066716     ROSULA CLARIFYING WASH                 EMUL         10%; 4%;       T2
                                                                       10%
   00037071203     RYNATAN PEDIATRIC                      CHEW         4.5MG; 5MG     T2

   00037071792     RYNATUSS                               TABS         60MG; 5MG;     T2
                                                                       10MG; 10MG
   13548001013     SALEX                                  CREA         6%             T2

   13548001206     SALEX                                  SHAM         6%             T2

   53303001108     SALICEPT                               SUSR         0              T2

   00064501030     SANTYL                                 OINT         250UNIT/GM     T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                 Page 277 of 285
   63304067901     SECONAL                                CAPS         100MG        T2

   00642007790     SELECT-OB                              CHEW         60MG; 0;      T2   GL (f); AL (max: 35y)
                                                                       400UNIT;
                                                                       5MCG; 1MG;
                                                                       25MG; 15MG;
                                                                       29MG; 2.5MG;
                                                                       1.8MG; 1.6MG;
                                                                       30UNIT;
                                                                       1700UNIT;
                                                                       15MG
   12539001308     SIDEROL                                LIQD         75MCG/15ML; T2
                                                                       514MG/15ML;
                                                                       0.825MG/15ML
                                                                       ; 300MG/15ML;
                                                                       30.6MG/15ML;
                                                                       30MG/15ML;
                                                                       15MG/15ML;
                                                                       6MG/15ML;
                                                                       6MG/15ML;
                                                                       30MG/15ML;
                                                                       6.9MG/15ML
   12539036060     SIDEROL                                TABS         250MG; 8MG; T2
                                                                       60MCG;
                                                                       100MG;
                                                                       150MG;
                                                                       400MCG; 3MG;
                                                                       20MG; 25MG;
                                                                       15MG; 15MG;
                                                                       50MG
   49502064015     SODIUM CHLORIDE DEY-PAK                NEBU         3%           T2

   49502064115     SODIUM CHLORIDE DEY-PAK                NEBU         10%          T2

   13478000101     SOLAGE                                 SOLN         2%; 0.01%    T2

   63717028004     SOLOTUSS                               SUSP         30MG/5ML     T2

   51507001316     SORBUTUSS                              LIQD         10MG/5ML;    T2
                                                                       100MG/5ML;
                                                                       85MG/5ML
   00145430001     SORIATANE CK                           KIT          25MG; 0; 0   T2

   00145380001     SORIATANE CK                           KIT          10MG; 0; 0   T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 278 of 285
   00642020810     STROVITE ADVANCE                       TABS         0; 300MG; 0; T2    GL (f); AL (max: 35y)
                                                                       100MCG;
                                                                       15MG;
                                                                       3000UNIT;
                                                                       50MCG; 0;
                                                                       1.5MG;
                                                                       50MCG; 1MG;
                                                                       15MG; 5MG;
                                                                       50MG; 1.5MG;
                                                                       25MG; 25MG;
                                                                       5MG; 100MCG;
                                                                       30MG;
                                                                       400UNIT;
                                                                       100UNIT; 0;
                                                                       25MG
   67871001104     SUCRAID                                SOLN         8500UNIT/ML   T2

   51079062381     SULFAMYLON                             CREA         85MG/GM       T2

   11026284108     SUPERVITE                              LIQD         25MCG/15ML; T2
                                                                       20MG/15ML;
                                                                       1MG/15ML;
                                                                       1000MG/15ML;
                                                                       100MG/15ML;
                                                                       2MG/15ML;
                                                                       10MG/15ML;
                                                                       10MG/15ML;
                                                                       75MG/15ML
   27437020603     SUPRAX                                 SUSR         200MG/5ML     T2

   66780012102     SYMLINPEN 120                          SOLN         1000MCG/ML    T2   PA


   66780011502     SYMLINPEN 60                           SOLN         1000MCG/ML    T2   PA


   10551041910     SYNALGOS-DC                            CAPS         356.4MG;      T2
                                                                       30MG; 16MG
   25010071015     SYPRINE                                CAPS         250MG         T2

   52747090090     TANDEM                                 CAPS         162MG;        T2
                                                                       115.2MG
   52747090460     TANDEM DHA                             CAPS         215.12MG;     T2   AL (max: 35y)
                                                                       53.46MG;
                                                                       15MG; 1MG;
                                                                       310.1MG;
                                                                       15MG; 25MG;
                                                                       20MG
   52747090160     TANDEM F                               CAPS         162MG; 1MG;   T2
                                                                       115.2MG




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                      Page 279 of 285
   52747090360     TANDEM OB                              CAPS         10MG; 0.8MG; T2       GL (f); AL (max: 35y)
                                                                       15MCG;
                                                                       162MG; 1MG;
                                                                       6.9MG; 1.3MG;
                                                                       30MG;
                                                                       115.2MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG;
                                                                       18.2MG
   52747090260     TANDEM PLUS                            CAPS         10MG; 0.8MG; T2
                                                                       15MCG;
                                                                       162MG; 1MG;
                                                                       1.3MG; 30MG;
                                                                       115.2MG;
                                                                       5MG; 6MG;
                                                                       200MG; 10MG;
                                                                       18.2MG
   00187093901     TASMAR                                 TABS         200MG            T2

   54799091817     TEARS AGAIN HYDRATE                    CAPS         40MG; 500MG; T2
                                                                       1000MG
   00078049471     TOBI                                   NEBU         300MG/5ML        T2

   67386040401     TRANXENE-SD                            TB24         11.25MG          T2

   67386040501     TRANXENE-SD                            TB24         22.5MG           T2

   14290035097     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2   AL (max: 35y)
                                                                       0.1%
   14290035197     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2   AL (max: 35y)
                                                                       0.05%
   14290035297     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2   AL (max: 35y)
                                                                       0.025%
   14290035497     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2   AL (max: 35y)
                                                                       0.01%
   14290035397     TRETIN-X                               KIT          0; 0; 0; 0; 0;   T2   AL (max: 35y)
                                                                       0.025%
   00299595030     TRI-LUMA                               CREA         0.01%; 4%;       T2
                                                                       0.05%
   60575045719     TRIKOF-D                               TB12         28MG; 600MG; T2
                                                                       58MG
   58238021104     TRISPEC DMX                            LIQD         15MG/5ML;        T2
                                                                       25MG/5ML
   58238021201     TRISPEC DMX PEDIATRIC                  LIQD         15MG/5ML;        T2
                                                                       25MG/5ML
   58238021304     TRISPEC PSE                            LIQD         15MG/5ML;        T2
                                                                       25MG/5ML;
                                                                       30MG/5ML
   58238021401     TRISPEC PSE PEDIATRIC                  LIQD         15MG/5ML;        T2
                                                                       25MG/5ML;
                                                                       30MG/5ML


4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                         Page 280 of 285
   58238021504     TRISPEC SFX                            LIQD         1MG/5ML;      T2
                                                                       15MG/5ML;
                                                                       25MG/5ML
   00642070016     TRITUSS                                SYRP         25MG/5ML;     T2
                                                                       175MG/5ML;
                                                                       12.5MG/5ML
   54859050206     TUSNEL                                 LIQD         15MG/5ML;     T2
                                                                       200MG/5ML;
                                                                       30MG/5ML
   54859080160     TUSNEL                                 CAPS         2MG; 15MG;    T2
                                                                       200MG
   54859055704     TUSNEL PED-C                           SYRP         5MG/5ML;      T2
                                                                       50MG/5ML;
                                                                       15MG/5ML
   54859054404     TUSNEL PEDIATRIC                       LIQD         5MG/5ML;      T2
                                                                       50MG/5ML;
                                                                       15MG/5ML
   54859060302     TUSNEL-DM PEDIATRIC                    LIQD         5MG/ML;       T2
                                                                       25MG/ML;
                                                                       5MG/ML
   53879010304     TUSSAFED EX                            LIQD         30MG/5ML;     T2
                                                                       200MG/5ML;
                                                                       10MG/5ML
   00642047016     TUSSALL                                SYRP         2MG/5ML;      T2
                                                                       20MG/5ML;
                                                                       10MG/5ML
   00037069210     TUSSI-12D                              TABS         60MG; 10MG;   T2
                                                                       40MG
   68453071416     TUSSI-ORGANIDIN DM NR                  LIQD         10MG/5ML;     T2
                                                                       300MG/5ML
   52083023304     TUSSI-PRES                             LIQD         15MG/5ML;     T2
                                                                       200MG/5ML;
                                                                       5MG/5ML
   52083023204     TUSSI-PRES PEDIATRIC                   LIQD         5MG/5ML;      T2
                                                                       75MG/5ML;
                                                                       2.5MG/5ML
   51674033004     TUSSINAL 12                            SUSP         2MG/5ML;      T2
                                                                       6MG/5ML;
                                                                       10MG/5ML
   53014054867     TUSSIONEX PENNKINETIC EXTENDED         LQCR         8MG/5ML;      T2
                   RELEASE                                             10MG/5ML
   13436070002     TWINJECT                               DEVI         0.3MG/DOSE    T2

   13436070102     TWINJECT                               DEVI         0.15MG/DOSE   T2

   00078053815     TYZEKA                                 TABS         600MG         T2

   00482476015     TYZINE                                 SOLN         0.1%          T2




4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com              Page 281 of 285
   66869082010     UDAMIN SP                              TABS         250MCG; 1MG; T2
                                                                       2.5MG;
                                                                       12.5MG;
                                                                       100MCG;
                                                                       320MG;
                                                                       12.5MG;
                                                                       4.5MG;
                                                                       75UNIT;
                                                                       7.5MG
   13613073035     ULTRALYTIC 2                           FOAM         12%; 20%           T2

   13613023004     ULTRALYTIC 2                           CREA         12%; 20%           T2

   54859070760     UROSEX                                 TABS         9MG; 500MCG; T2
                                                                       75MG; 2MG;
                                                                       2MG; 100MCG;
                                                                       5MG; 15UNIT;
                                                                       75MG; 100MG
   67402004030     VANIQA                                 CREA         13.9%              T2

   66992023004     VAZOBID                                SUSP         6MG/5ML;           T2
                                                                       10MG/5ML
   66992022004     VAZOTAN                                SUSP         6MG/5ML;           T2
                                                                       25MG/5ML;
                                                                       10MG/5ML
   10148010230     VENTAVIS                               SOLN         10MCG/ML           T2

   10148010130     VENTAVIS                               SOLN         10MCG/ML           T2

   65649060141     VISICOL                                TABS         0.398GM;           T2
                                                                       1.102GM
   00642007630     VITAFOL-OB+DHA                         MISC         70MG;         T2        AL (max: 35y)
                                                                       2700UNIT;
                                                                       100MG;
                                                                       400UNIT;
                                                                       2MG; 12MCG;
                                                                       250MG; 65MG;
                                                                       1MG; 25MG;
                                                                       18MG; 2.5MG;
                                                                       1.8MG; 1.6MG;
                                                                       30UNIT; 25MG
   51285059402     VIVACTIL                               TABS         10MG               T2

   51285059502     VIVACTIL                               TABS         5MG                T2

   54482093001     VSL#3 DS                               PACK         0; 0; 0; 0; 0;     T2
                                                                       0; 0; 0
   08514001001     XCLAIR                                 CREA         0;   0; 0; 0; 0;   T2
                                                                       0;   0; 0; 0; 0;
                                                                       0;   0; 0; 0; 0;
                                                                       0;   0
   00064390060     XENADERM                               OINT         788MG/GM;          T2
                                                                       87MG/GM;
                                                                       90UNIT/GM

4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                   Page 282 of 285
   00004025652     XENICAL                                CAPS         120MG         T2

   00096070960     XERAC AC                               SOLN         6.25%         T2

   67425000450     XIBROM                                 SOLN         0.09%         T2

   13478000304     XOLEGEL DUO                            KIT          2%; 1%        T2

   63402051530     XOPENEX CONCENTRATE                    NEBU         1.25MG/0.5ML T2             QL (120.00 per 30 days)


   63717024001     XPECT-AT                               TB12         60MG; 600MG   T2

   63717070501     XPECT-HC                               TB12         600MG; 5MG    T2

   00024580090     XYZAL                                  TABS         5MG           T2

   50419040203     YASMIN 28                              TABS         3MG; 0.03MG   T2

   50419040503     YAZ                                    TABS         3MG; 0.02MG   T2

   51724043204     YODEFAN                                LIQD         600MG/15ML    T2

   51724030004     YODEFAN-NF                             LIQD         300MG/5ML     T2

   24338071115     ZINOTIC                                LIQD         1MG/ML;       T2
                                                                       5MG/ML;
                                                                       1MG/ML
   14629047401     ZINX ALLERGY                           KIT          8MG; 0;       T2
                                                                       120MG
   10337075410     ZODERM                                 PADS         8.5%; 10%     T2

   00310020920     ZOMIG ZMT                              TBDP         2.5MG         T2            QL (12.00 per 30 days)


   10337080403     ZONALON                                CREA         5%            T2

   00006496300     ZOSTAVAX                               SOLR         19400UNT/0.6 T2
                                                                       5ML
   00206885216     ZOSYN                                  SOLR         2GM; 0.25GM   T2

   68025000510     ZOTEX -GP                              TABS         550MG; 8.5MG T2

   68025002416     ZOTEX-12                               SUSP         25MG/5ML;     T2
                                                                       15.5MG/5ML;
                                                                       15.5MG/5ML
   67204034016     ZYMINE DXR                             SUSP         45MG/5ML;     T2
                                                                       2.5MG/5ML
   67204032516     ZYMINE XR                              SUSP         2.5MG/5ML     T2


   Tier: T3
   NDC             Product Name                           Form         Strength      Pref   Cost   Coverage Details                          Comment

   55566850506     BRAVELLE                               SOLR         75UNIT        T3            PA; GL (m); QL (3600.00 per dispensing)


   67286081203     CARDENE I.V.                           SOLN         2.5MG/ML      T3



4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com                                                                           Page 283 of 285
   67286081404     CARDENE SR                             CP12         30MG          T3   MN


   67286081504     CARDENE SR                             CP12         60MG          T3   MN


   67286081304     CARDENE SR                             CP12         45MG          T3   MN


   60598012030     CARDIZEM LA                            TB24         120MG         T3   MN


   60598012330     CARDIZEM LA                            TB24         300MG         T3   MN


   00085132201     CLARINEX-D 12 HOUR                     TB12         2.5MG; 120MG T3    MN


   00062165003     ERTACZO                                CREA         2%            T3   MN


   16252053901     ISRADIPINE                             CAPS         2.5MG         T3   MN


   16252054001     ISRADIPINE                             CAPS         5MG           T3   MN


   00430053014     LOESTRIN 24 FE                         TABS         20MCG; 75MG; T3    MN
                                                                       1MG
   62175017137     MOEXIPRIL HCL                          TABS         7.5MG         T3

   62175017737     MOEXIPRIL HCL                          TABS         15MG          T3

   00186404001     NEXIUM                                 PACK         40MG          T3

   00093079401     NICARDIPINE HCL                        CAPS         30MG          T3   MN


   00378102077     NICARDIPINE HCL                        CAPS         20MG          T3

   00093079301     NICARDIPINE HCL                        CAPS         20MG          T3   MN


   00378143077     NICARDIPINE HCL                        CAPS         30MG          T3

   00062065730     ULTRAM ER                              TB24         300MG         T3   MN; QL (30.00 per 30 days)


   00062065330     ULTRAM ER                              TB24         100MG         T3   MN; QL (30.00 per 30 days)


   00062065530     ULTRAM ER                              TB24         200MG         T3   MN; QL (30.00 per 30 days)


   00091371501     UNIVASC                                TABS         15MG          T3   MN


   00091370701     UNIVASC                                TABS         7.5MG         T3   MN


   13478000204     VUSION                                 OINT         0.25%;        T3   MN
                                                                       81.35%; 15%
   68012010430     ZEGERID                                CAPS         40MG; 1100MG T3    PA; MN; ST(#2:PPI)


   68012005230     ZEGERID                                PACK         20MG; 1680MG T3    PA; MN; ST(#2:PPI)


   68012005430     ZEGERID                                PACK         40MG; 1680MG T3    PA; MN; ST(#2:PPI)


   68012010230     ZEGERID                                CAPS         20MG; 1100MG T3    PA; MN; ST(#2:PPI)




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4/14/2008 8:37:50 AM - NDC Tiered Formulary Report - Created by Zynchros.com   Page 285 of 285

				
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