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Home , Acetarsol, Benactyzine, Caesium bromide, Chloroxine, Chrysin, Clemizole

Magellan Complete Care of Virginia – MCC VA

We cover both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name . Generic drugs usually cost less than brand name drugs and are rated by the and Drug Administration (FDA) to be as safe and effective as brand name drugs.

What is a Preferred Drug List? A Preferred Drug List is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our Preferred Drug List as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

How to Search For Drugs  Use the alphabetical list to search by the first letter of your .  Search by typing part of the generic (chemical) and brand (trade) names.

How to Request an Exception You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:  You can ask us to cover your drug even if it is not on our Preferred Drug List.  You can ask us to waive coverage restrictions or limits on your drug.

You should contact us to ask us for an initial coverage decision for a Preferred Drug List or utilization restriction exception. When you are requesting a Preferred Drug List or utilization restriction exception you should submit a statement from your physician supporting your request.

TIER DESCRIPTION

T0 Covered OTC

T1 Preferred Drugs

T2 Non-Preferred Drugs

TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.

This may only be covered if you meet the AL Age Limit minimum or maximum age limit.

Specialty drugs are high-cost drugs used to treat complex or rare conditions. Some examples of the diseases include; S Specialty Drug multiple sclerosis, rheumatoid arthritis, C, and hemophilia.

DC Drug Class.

PS Preferred Specialty Preferred Specialty.

Your provider is required to get prior authorization before you fill your prescription, which ensures appropriate use of the PA PA Applies selected drug. Without prior approval, we may not cover this drug.

QPD Quantity Per Day Quantity Per Day.

IPC IPC - SPECIALTY PROGRAM IPC- Specialty Program.

PAGE 2 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTI-INFLAMMATORY DRUGS

ADDED STRENGTH HEADACHE T1 ADULT LOW DOSE EC T0 ADVIL JUNIOR STRENGTH T0 ALL DAY PAIN RELIEF (CVS PAIN RLF 220 MG TB, GNP PAIN RLF 220 MG TB, PAIN RELIEF 220 MG TAB, PAIN RLF 220 T1 MG CAPLET, SM RELIEF 220 MG CAPLT, SM RELIEF 220 MG TAB) ALL DAY RELIEF T1 ANAPROX DS T2 PA ARTHROTEC 50 T2 PA ARTHROTEC 75 T2 PA ASPIR 81 T1 ASPIR-LOW T1 ASPIR-TRIN T1 aspirin (300 mg supp.rect, 600 mg supp.rect) T1 aspirin (81 mg tab chew, 81 mg tablet dr, 325 mg tablet, T1 325 mg tablet dr) aspirin (bayer 325 mg caplet, bayer 325 mg tablet, 500 mg tablet dr, bayer 500 mg caplet, bayer 500 mg tablet, T0 650 mg tablet dr) aspirin/ carbonate/ T1 BAYER ADVANCED T0 BAYER CHEWABLE ASPIRIN T0 BAYER T1

PAGE 3 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CALDOLOR 800 MG/8 ML VIAL T2 PA QL 1 / day CAMBIA T2 PA QL 2 / day CELEBREX (50 MG , 200 MG CAPSULE) T2 PA QL 3 / day CELEBREX 100 MG CAPSULE T2 PA QL 1 / day CELEBREX 400 MG CAPSULE T2 PA celecoxib 100 mg capsule T1 QL 3 / day celecoxib 200 mg capsule T1 QL 2 / day QL 1 / day celecoxib 400 mg capsule T2 PA QL 2 / day celecoxib 50 mg capsule T2 PA CHILDREN'S MOTRIN T1 CHILDREN'S PROFEN IB T1 CHILDREN'S PROFENIB T1 salicyl/mag salicylate 500 mg/5ml T2 PA DAYPRO T2 PA diclofenac potassium T2 PA diclofenac sodium 100 mg tab er 24h T2 PA diclofenac sodium (50 mg tablet dr, 75 mg tablet dr) T1 diclofenac sodium 25 mg tablet dr T1 diclofenac sodium/misoprostol (sodium/misoprostol 50 T2 PA tab ir dr, sodium/misoprostol 75 tab ir dr)

PAGE 4 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diflunisal 500 mg tablet T1 QL 3 / day DUEXIS T2 PA EC-NAPROSYN T2 PA ECOTRIN T0 ECPIRIN T1 etodolac (400 mg tab er 24h, 500 mg tab er 24h, 600 mg T2 PA tab er 24h) etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, T1 500 mg tablet) EXTRA PAIN RELIEF T1 EXTRAPRIN T1 FELDENE T2 PA fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 T2 PA mg tablet) FENORTHO T2 PA FLANAX 220 MG TABLET T1 flurbiprofen (50 mg tablet, 100 mg tablet) T1 GOODY'S EXTRA STRENGTH T2 PA HEADACHE RELIEF T1 I-PRIN T1 IBU T1 IBU-200 T1 IBUPAK T2 PA

PAGE 5 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (50 mg/1.25 drops susp, 100 mg tablet, 100 mg/5ml oral susp, 200 mg capsule, 200 mg tablet, 400 mg T1 tablet, 600 mg tablet, 800 mg tablet) ibuprofen 100 mg tab chew T1 ibuprofen /pf T2 PA QL 6 / day INDOCIN 25 MG/5 ML SUSPENSION T2 PA QL 4 / day INDOCIN 50 MG T2 PA indomethacin (25 mg capsule, 50 mg capsule) T1 indomethacin 75 mg capsule er T2 PA indomethacin sodium T2 PA indomethacin, submicronized T2 PA INFANT'S MOTRIN T1 INFANTS PROFENIB T1 INFANTS' ADVIL T1 INFANTS' MOTRIN T1 ketoprofen (50 mg capsule, 75 mg capsule, 200 mg T2 PA cap24h pel) tromethamine 15.75 mg spray T2 PA ketorolac tromethamine 10 mg tablet T1 QL 21 / fill ketorolac tromethamine (15 mg/ml cartridge, 15 mg/ml QL 40 / 23 days T2 vial) PA ketorolac tromethamine (30 mg/ml cartridge, 30 mg/ml QL 0.667 / DAY vial, 60 mg/2 ml cartridge, 60 mg/2 ml syringe, 60 mg/2 T2 ml vial) PA

PAGE 6 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ketorolac tromethamine (30 mg/ml syringe, 30mg/ml(1) QL 0.87 / DAY T2 vial) PA LODINE T2 PA meclofenamate sodium (50 mg capsule, 100 mg capsule) T2 PA MEDIPROXEN T1 QL 5 / day mefenamic 250 mg capsule T2 PA meloxicam (7.5 mg tablet, 15 mg tablet) T1 QL 1 / day MIDOL 220 MG CAPLET T1 MIGRAINE FORMULA T1 MIGRAINE RELIEF T1 QL 1 / day MOBIC T2 PA MOTRIN IB 200 MG CAPLET T1 nabumetone (500 mg tablet, 750 mg tablet) T2 PA NALFON (400 MG CAPSULE, 600 MG TABLET) T2 PA NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) T2 PA QL 1 / day NAPRELAN CR 750 MG TABLET T2 PA NAPROSYN (125 MG/5 ML SUSPEN, 500 MG TABLET) T2 PA naproxen 125 mg/5ml oral susp T2 PA naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet T1 dr, 500 mg tablet, 500 mg tablet dr) naproxen sodium (220 mg capsule, 220 mg tablet) T1 naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 T2 PA mg tbmp 24hr, 550 mg tablet)

PAGE 7 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day naproxen/esomeprazole magnesium T2 PA NEOPROFEN T2 PA oxaprozin 600 mg tablet T2 PA PAIN RELIEVER (RA RELIEVER TABLET, RELIEVER TABLET, T1 RELIEVR 250-250-65MG CPLT) PAIN RELIEVER PLUS T1 PAIN-OFF T1 AL Up to 75 yrs old piroxicam (10 mg capsule, 20 mg capsule) T2 PA PROFENO T2 PA

PROVIL T1 AL At least 17 yrs old salsalate (500 mg tablet, 750 mg tablet) T2 PA SPRIX T2 PA ST. JOSEPH ASPIRIN T0 ST. JOSEPH ASPIRIN EC T0 sulindac (150 mg tablet, 200 mg tablet) T1 TIVORBEX T2 PA tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mg T2 PA tablet) TRI-BUFFERED ASPIRIN 325 MG T1 QL 2 / day VIMOVO T2 PA QL 1 / day VIVLODEX T2 AL At least 18 yrs old PA

PAGE 8 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VOLTAREN-XR T2 PA WAL-PROFEN (200 MG CAPLET, 200 MG CAPSULE, 200 T1 MG SOFTGEL, 200 MG TABLET) WAL-PROXEN T1 QL 4 / day ZIPSOR T2 PA QL 3 / day ZORVOLEX T2 PA ANALGESICS, LONG-ACTING

QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG T2 DC LONG ACTING CAPSULE) PA QL 6 / day DOLOPHINE HCL T2 DC LONG ACTING OPIOIDS PA QL 0.334 / day DURAGESIC T2 DC LONG ACTING OPIOIDS PA QL 0.334 / day (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr T1 DC LONG ACTING OPIOIDS patch td72) PA hydrocodone bitartrate (10 mg cap er 12h, 15 mg cap er DC LONG ACTING 12h, 20 mg cap er 12h, 30 mg cap er 12h, 40 mg cap er T2 OPIOIDS 12h, 50 mg cap er 12h) PA QL 2 / day KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 50 T2 DC LONG ACTING MG CAPSULE, ER 100 MG CAPSULE) OPIOIDS PA

PAGE 9 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day KADIAN (ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 60 T2 DC LONG ACTING MG CAPSULE, ER 80 MG CAPSULE, ER 200 MG CAPSULE) OPIOIDS PA QL 6 / day hcl (5 mg tablet, 10 mg tablet) T2 DC LONG ACTING OPIOIDS PA QL 2 / day (10 mg cap er pel, 20 mg cap er pel, 50 T2 DC LONG ACTING mg cap er pel, 100 mg cap er pel) OPIOIDS PA QL 1 / day morphine sulfate (30 mg cap er pel, 60 mg cap er pel, 80 T2 DC LONG ACTING mg cap er pel) OPIOIDS PA morphine sulfate (30 mg cpmp 24hr, 40 mg cap er pel, 45 DC LONG ACTING mg cpmp 24hr, 60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 T2 OPIOIDS mg cpmp 24hr, 120 mg cpmp 24hr) PA QL 4 / day morphine sulfate 15 mg tablet er T1 DC LONG ACTING OPIOIDS PA QL 3 / day morphine sulfate 30 mg tablet er T1 DC LONG ACTING OPIOIDS PA QL 2 / day morphine sulfate 60 mg tablet er T1 DC LONG ACTING OPIOIDS PA

PAGE 10 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day MS CONTIN ER 15 MG TABLET T2 DC LONG ACTING OPIOIDS PA QL 3 / day MS CONTIN ER 30 MG TABLET T2 DC LONG ACTING OPIOIDS PA QL 2 / day MS CONTIN ER 60 MG TABLET T2 DC LONG ACTING OPIOIDS PA hcl (100 mg cpbp 25-75, 100 mg tab er 24h, 100 QL 1 / day mg tbmp 24hr, 200 mg cpbp 25-75, 200 mg tab er 24h, T2 DC LONG ACTING 200 mg tbmp 24hr, 300 mg cpbp 17-83, 300 mg tab er OPIOIDS 24h, 300 mg tbmp 24hr) PA

DC LONG ACTING tramadol hcl 150 mg cpbp 25-75 T2 OPIOIDS PA QL 2 / day ZOHYDRO ER T2 DC LONG ACTING OPIOIDS PA OPIOID ANALGESICS, SHORT-ACTING

QL 4 / day ABSTRAL T2 DC SHORT ACTING OPIOIDS PA QL 139 / day AL At least 12 yrs acetaminophen with 120-12mg/5 T1 old DC SHORT ACTING OPIOIDS

PAGE 11 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 125 / day AL At least 12 yrs acetaminophen with codeine 300mg/12.5 solution T1 old DC SHORT ACTING OPIOIDS QL 10 / day acetaminophen with codeine (300mg-15mg At least 12 yrs T1 AL tablet, 300mg-30mg tablet, 300mg-60mg tablet) old DC SHORT ACTING OPIOIDS QL 10 / day acetaminophen/caff/dihydrocod 320.5-30mg capsule T2 DC SHORT ACTING OPIOIDS PA QL 4 / day ACTIQ T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING OPIOIDS alfentanil hcl 500 mcg/ml ampul T2 PA IPC IPC - SPECIALTY PROGRAM QL 6 / day ASCOMP WITH CODEINE T2 DC SHORT ACTING OPIOIDS PA QL 2 / day BENZEFOAM T1 DC SHORT ACTING OPIOIDS

AL At least 12 yrs old /acetaminophen//codeine phosphate T2 DC SHORT ACTING OPIOIDS PA

PAGE 12 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.3 / day AL At least 18 yrs old tartrate 10 mg/ml spray T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING OPIOIDS butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial) T2 PA IPC IPC - SPECIALTY PROGRAM QL 21 / day /aspirin/codeine phosphate T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING codeine phosphate/butalbital/aspirin/caffeine T2 OPIOIDS PA QL 6 / day codeine sulfate T2 DC SHORT ACTING OPIOIDS PA DEMEROL (25 MG/0.5 ML AMPUL, 25 MG/ML DC SHORT ACTING CARPUJECT, 50 MG/ML AMPUL, 50 MG/ML CARPUJECT, OPIOIDS 50 MG/ML VIAL, 75 MG/1.5 ML AMPUL, 75 MG/ML T2 PA CARPUJECT, 100 MG/2 ML AMPUL, 100 MG/ML AMPUL, IPC IPC - SPECIALTY 100 MG/ML CARPUJECT, 100 MG/ML VIAL) PROGRAM QL 9 / day DEMEROL 100 MG TABLET T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING DILAUDID (0.5 MG/0.5 ML SYRINGE, 1 MG/ML SYRINGE, 2 OPIOIDS MG/ML SYRINGE, 4 MG/ML SYRINGE, 5 MG/5 ML ORAL T2 PA LIQUID, 8 MG TABLET) IPC IPC - SPECIALTY PROGRAM

PAGE 13 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DC SHORT ACTING DILAUDID (2 MG TABLET, 4 MG TABLET) T2 OPIOIDS PA

DC SHORT ACTING OPIOIDS DURAMORPH T2 PA IPC IPC - SPECIALTY PROGRAM QL 6 / day DC SHORT ACTING OPIOIDS ENDOCET 10-325 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM QL 12 / day DC SHORT ACTING ENDOCET 2.5-325 MG TABLET T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 12 / day DC SHORT ACTING OPIOIDS ENDOCET 5-325 TABLET T2 PA IPC IPC - SPECIALTY PROGRAM QL 8 / day DC SHORT ACTING OPIOIDS ENDOCET 7.5-325 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 14 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day fentanyl citrate (100 mcg tablet eff, 200 mcg lozenge hd, 200 mcg tablet eff, 400 mcg lozenge hd, 400 mcg tablet AL At least 18 yrs old eff, 600 mcg lozenge hd, 600 mcg tablet eff, 800 mcg T2 lozenge hd, 800 mcg tablet eff, 1200 mcg lozenge hd, DC SHORT ACTING OPIOIDS 1600 mcg lozenge hd) PA fentanyl citrate in 0.9 % /pf (% nacl/pf 5 mcg/ml plast. bag, % nacl/pf 10 mcg/ml plast. bag, % nacl/pf 10 mcg/ml pump resvr, % nacl/pf 10 mcg/ml DC SHORT ACTING OPIOIDS syringe, % nacl/pf 20 mcg/ml plast. bag, % nacl/pf 100 T2 PA mcg/10 syringe, % nacl/pf 300mcg/30 pca syring, % nacl/pf 500 mcg/50 pca syring, % nacl/pf 600mcg/30 pca IPC IPC - SPECIALTY syring, % nacl/pf 600mcg/30 pca vial, % nacl/pf PROGRAM 1375mcg/55 pca syring)

DC SHORT ACTING OPIOIDS fentanyl citrat/dextrose 5%/pf 100 mcg/10 pca syring T2 PA IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING fentanyl//ns/pf 2-1250mcg pump resvr T2 OPIOIDS PA fentanyl citrate/bupivacaine hcl in 0.9 % sodium chloride/pf (fentanyl/bupivacaine/ns/pf 2-1250mcg plast. DC SHORT ACTING bag, fentanyl/bupivacaine/ns/pf 2-625mcg/1 plast. bag, OPIOIDS fentanyl/bupivacaine/ns/pf 2-625mcg/1 pump resvr, T2 PA fentanyl/bupivacaine/ns/pf 2mcg/ml-.1 plast. bag, IPC IPC - SPECIALTY fentanyl/bupivacaine/ns/pf 2mcg/ml-.1 pump resvr, PROGRAM fentanyl/bupivacaine/ns/pf 10mcg/1-.2 syringe) fentanyl/bupivacaine/ns/pf 2-1250mcg syringe T2 PA

PAGE 15 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fentanyl citrate/pf (citrate/pf 50 mcg/ml ampul, citrate/pf 50 mcg/ml plast. bag, citrate/pf 50 mcg/ml vial, citrate/pf DC SHORT ACTING OPIOIDS 100mcg/2ml cartridge, citrate/pf 100mcg/2ml syringe, T2 PA citrate/pf 250mcg/5ml syringe, citrate/pf 1500mcg/30 pca syring, citrate/pf 2500mcg/50 pca syring, citrate/pf IPC IPC - SPECIALTY 2750mcg/55 pca syring) PROGRAM

DC SHORT ACTING fentanyl citrate/pf 50 mcg/ml syringe T2 OPIOIDS PA

DC SHORT ACTING fentanyl//ns/pf 2mcg/ml-.2 plast. bag T2 OPIOIDS PA fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf DC SHORT ACTING OPIOIDS (fentanyl/ropivacaine/ns/pf 2-1500mcg pump resvr, T2 PA fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 plast. bag, fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 pump resvr) IPC IPC - SPECIALTY PROGRAM fentanyl/ropivacaine/ns/pf 2mcg/ml-.2 pump resvr T2 PA QL 4 / day FENTORA T2 DC SHORT ACTING OPIOIDS PA QL 6 / day DC SHORT ACTING OPIOIDS FIORICET WITH CODEINE T2 PA IPC IPC - SPECIALTY PROGRAM QL 6 / day DC SHORT ACTING OPIOIDS FIORINAL WITH CODEINE #3 T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 16 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DC SHORT ACTING HISTEX-AC T2 OPIOIDS PA hydrocodone bitartrate/acetaminophen QL 140 / day (hydrocodone/acetaminophen 5-217mg/10 solution, T1 DC SHORT ACTING hydrocodone/acetaminophen 7.5-325/15 solution) OPIOIDS QL 12 / Day hydrocodone/acetaminophen 10-325/15 solution T1 DC SHORT ACTING OPIOIDS QL 120 / day hydrocodone/acetaminophen 2.5-108/5 solution T1 DC SHORT ACTING OPIOIDS hydrocodone bitartrate/acetaminophen QL 9 / day (hydrocodone/acetaminophen 10mg-300mg tablet, T1 DC SHORT ACTING hydrocodone/acetaminophen 10mg-325mg tablet) OPIOIDS hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-325 mg tablet, hydrocodone/acetaminophen 5 mg-300mg tablet, QL 12 / day T1 hydrocodone/acetaminophen 5 mg-325mg tablet, DC SHORT ACTING hydrocodone/acetaminophen 7.5-300 mg tablet, OPIOIDS hydrocodone/acetaminophen 7.5-325 mg tablet) QL 5 / day hydrocodone/ibuprofen T1 DC SHORT ACTING OPIOIDS QL 13 / day DC SHORT ACTING OPIOIDS hydromorphone hcl 1 mg/ml liquid T2 PA IPC IPC - SPECIALTY PROGRAM QL 4 / day hydromorphone hcl 3 mg supp.rect T2 DC SHORT ACTING OPIOIDS PA

PAGE 17 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydromorphone hcl (0.5mg/.5ml syringe, 1 mg/ml ampul, DC SHORT ACTING OPIOIDS 1 mg/ml cartridge, 1 mg/ml syringe, 2 mg/ml ampul, 2 T2 PA mg/ml cartridge, 2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml ampul, 4 mg/ml cartridge, 60 mg/30ml pca syring) IPC IPC - SPECIALTY PROGRAM QL 11.2 / Day hydromorphone hcl 2 mg tablet T1 DC SHORT ACTING OPIOIDS QL 5.6 / Day hydromorphone hcl 4 mg tablet T1 DC SHORT ACTING OPIOIDS QL 2.8 / Day hydromorphone hcl 8 mg tablet T1 DC SHORT ACTING OPIOIDS hydromorphone hcl in 0.9 % sodium chloride (in 0.2 mg/ml plast. bag, in 0.5mg/50ml plast. bag, in 1 mg/50 DC SHORT ACTING OPIOIDS ml plast. bag, in 2 mg/50 ml plast. bag, in 2 mg/ml plast. T2 PA bag, in 6mg/30ml pca syring, in 10 mg/50ml pump resvr, in 15 mg/30ml pca syring, in 15 mg/30ml pca vial, in 55 IPC IPC - SPECIALTY mg/55ml pca syring, in 100mg/50ml pump resvr) PROGRAM hydromorphone hcl/0.9% nacl/pf 5mg/25ml pca syring T2 PA

PAGE 18 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 0.2 mg/ml plast. bag, hcl/0.9% nacl/pf 0.5 mg/ml plast. bag, hcl/0.9% nacl/pf 1 mg/ml plast. bag, hcl/0.9% nacl/pf 10 mg/50ml pca syring, hcl/0.9% nacl/pf 10 mg/50ml pump resvr, hcl/0.9% nacl/pf 15 mg/30ml pca DC SHORT ACTING OPIOIDS syring, hcl/0.9% nacl/pf 20mg/100ml pump resvr, T2 PA hcl/0.9% nacl/pf 30 mg/30ml pca syring, hcl/0.9% nacl/pf 30 mg/30ml pca vial, hcl/0.9% nacl/pf 50 mg/50ml pca IPC IPC - SPECIALTY syring, hcl/0.9% nacl/pf 50 mg/50ml pump resvr, hcl/0.9% PROGRAM nacl/pf 55 mg/55ml pca syring, hcl/0.9% nacl/pf 6mg/30ml pca syring, hcl/0.9% nacl/pf 6mg/30ml pca vial)

DC SHORT ACTING OPIOIDS hydromorphone hcl in d5w/pf 0.5 mg/5ml syringe T2 PA IPC IPC - SPECIALTY PROGRAM hydromorphone hcl/bupivacaine hcl in 0.9% sodium chloride/pf (hydromorphone/bupiv/0.9nacl/pf 10mcg- DC SHORT ACTING OPIOIDS 0.1% pump resvr, hydromorphone/bupiv/0.9nacl/pf 20- T2 PA 0.125 pump resvr, hydromorphone/bupiv/0.9nacl/pf 20mcg-0.1% pump resvr, IPC IPC - SPECIALTY hydromorphone/bupiv/0.9nacl/pf 5mcg/ml-.1 plast. bag) PROGRAM

DC SHORT ACTING OPIOIDS hydromorphone hcl/pf (hcl/pf 2 mg/ml ampul, hcl/pf 2 T2 PA mg/ml vial, hcl/pf 10 mg/ml ampul, hcl/pf 10 mg/ml vial) IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING OPIOIDS hydromorphone hcl/ropivacaine in 0.9 % sodium T2 PA chloride/pf IPC IPC - SPECIALTY PROGRAM QL 5 / day DC SHORT ACTING OPIOIDS IBUDONE T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 19 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day ibuprofen/oxycodone hcl T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING OPIOIDS INFUMORPH T2 PA IPC IPC - SPECIALTY PROGRAM QL 4 / day LAZANDA T2 DC SHORT ACTING OPIOIDS PA QL 12 / day DC SHORT ACTING LORCET T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 9 / day DC SHORT ACTING LORCET HD T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 12 / day DC SHORT ACTING LORCET PLUS T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 90 / day DC SHORT ACTING OPIOIDS LORTAB T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 20 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DC SHORT ACTING OPIOIDS meperidine hcl 10 mg/ml cartridge T2 PA IPC IPC - SPECIALTY PROGRAM QL 90 / Day AL At least 18 yrs old meperidine hcl 50 mg/5 ml solution T2 DC SHORT ACTING OPIOIDS PA IPC IPC - SPECIALTY PROGRAM QL 9 / day AL At least 18 yrs old meperidine hcl 100 mg tablet T2 DC SHORT ACTING OPIOIDS PA QL 18 / day AL At least 18 yrs old meperidine hcl 50 mg tablet T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING meperidine hcl in 0.9 % sodium chloride/pf (in nacl/pf OPIOIDS 300mg/30ml pca syring, in nacl/pf 550mg/55ml pca T2 PA syring) IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING OPIOIDS meperidine hcl/pf T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 21 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DC SHORT ACTING OPIOIDS methadone in 0.9 % sod.chlorid 1 mg/ml(1) syringe T2 PA IPC IPC - SPECIALTY PROGRAM QL 45 / Day DC SHORT ACTING morphine sulfate 10 mg/5 ml solution T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 4.5 / Day DC SHORT ACTING morphine sulfate 100 mg/5ml solution T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 22.5 / Day DC SHORT ACTING morphine sulfate 20 mg/5 ml solution T1 OPIOIDS IPC IPC - SPECIALTY PROGRAM QL 9 / Day morphine sulfate 10 mg supp.rect T2 DC SHORT ACTING OPIOIDS PA QL 6 / Day morphine sulfate 20 mg supp.rect T2 DC SHORT ACTING OPIOIDS PA QL 3 / Day morphine sulfate 30 mg supp.rect T2 DC SHORT ACTING OPIOIDS PA QL 18 / Day morphine sulfate 5 mg supp.rect T2 DC SHORT ACTING OPIOIDS PA

PAGE 22 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 6 / day morphine sulfate 15 mg tablet T1 DC SHORT ACTING OPIOIDS QL 3 / day morphine sulfate 30 mg tablet T1 DC SHORT ACTING OPIOIDS morphine sulfate (2 mg/ml cartridge, 2 mg/ml syringe, 4 mg/ml cartridge, 4 mg/ml syringe, 4 mg/ml vial, 5 mg/ml DC SHORT ACTING OPIOIDS syringe, 8 mg/ml cartridge, 8 mg/ml syringe, 8 mg/ml T2 PA vial, 10 mg/ml cartridge, 10 mg/ml syringe, 10 mg/ml vial, 10mg/0.7ml pen injctr, 15 mg/ml vial, 25 mg/ml vial, IPC IPC - SPECIALTY 30 mg/30ml pca syring, 50 mg/ml vial) PROGRAM morphine sulfate in 0.9 % sodium chloride (in 0.9 % 0.5 mg/ml syringe, in 0.9 % 1 mg/ml plast. bag, in 0.9 % 1 mg/ml(1) syringe, in 0.9 % 10 mg/10ml syringe, in 0.9 % 2 DC SHORT ACTING mg/2 ml syringe, in 0.9 % 250mg/50ml pump resvr, in 0.9 OPIOIDS % 275mg/55ml pca syring, in 0.9 % 30 mg/30ml pca T2 PA syring, in 0.9 % 30 mg/30ml pca vial, in 0.9 % IPC IPC - SPECIALTY 300mg/30ml pca syring, in 0.9 % 5 mg/ml plast. bag, in PROGRAM 0.9 % 50 mg/50ml pca syring, in 0.9 % 50 mg/50ml pump resvr, in 0.9 % 500mg/0.1l pump resvr) morphine sulfate in 0.9 % sodium chloride/pf (sulfate/0.9% nacl/pf 0.5 mg/ml syringe, sulfate/0.9% DC SHORT ACTING nacl/pf 1 mg/ml plast. bag, sulfate/0.9% nacl/pf 1 mg/ml OPIOIDS syringe, sulfate/0.9% nacl/pf 2 mg/2 ml syringe, T2 PA sulfate/0.9% nacl/pf 30 mg/30ml pca syring, sulfate/0.9% IPC IPC - SPECIALTY nacl/pf 5 mg/ml plast. bag, sulfate/0.9% nacl/pf 50 PROGRAM mg/50ml pca syring)

DC SHORT ACTING morphine sulfate/pf (sulfate/pf 0.5 mg/ml vial, sulfate/pf OPIOIDS 1 mg/2 ml syringe, sulfate/pf 1 mg/ml vial, sulfate/pf 30 T2 PA mg/30ml pca vial, sulfate/pf 150mg/30ml pca vial) IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING OPIOIDS hcl (10 mg/ml ampul, 10 mg/ml vial, 20 T2 PA mg/ml ampul, 20 mg/ml vial) IPC IPC - SPECIALTY PROGRAM

PAGE 23 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 12 / day NORCO (5-325 TABLET, 7.5-325 TABLET) T2 DC SHORT ACTING OPIOIDS PA QL 9 / day DC SHORT ACTING OPIOIDS NORCO 10-325 TABLET T2 PA IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING NUCYNTA T2 OPIOIDS PA QL 12 / day DC SHORT ACTING OPIOIDS OPANA T2 PA IPC IPC - SPECIALTY PROGRAM QL 1 / day DC SHORT ACTING OPIOIDS /belladonna 30-16.2 mg supp.rect T2 PA IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING OPIOIDS opium/belladonna alkaloids 60-16.2 mg supp.rect T2 PA IPC IPC - SPECIALTY PROGRAM QL 8 / day OXAYDO T2 DC SHORT ACTING OPIOIDS PA

PAGE 24 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 12 / day oxycodone hcl (5 mg capsule, 5 mg tablet) T1 DC SHORT ACTING OPIOIDS QL 3 / day oxycodone hcl 20 mg/ml oral conc T2 DC SHORT ACTING OPIOIDS PA QL 60 / day oxycodone hcl 5 mg/5 ml solution T1 DC SHORT ACTING OPIOIDS QL 6 / day oxycodone hcl 10 mg tablet T1 DC SHORT ACTING OPIOIDS QL 4 / day oxycodone hcl 15 mg tablet T1 DC SHORT ACTING OPIOIDS QL 3 / day oxycodone hcl 20 mg tablet T1 DC SHORT ACTING OPIOIDS QL 2 / day oxycodone hcl 30 mg tablet T1 DC SHORT ACTING OPIOIDS oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5- QL 12 / day T1 325 mg tablet, hcl/acetaminophen 5 mg-325mg tablet) DC SHORT ACTING OPIOIDS QL 6 / day oxycodone hcl/acetaminophen 10mg-325mg tablet T1 DC SHORT ACTING OPIOIDS QL 8 / day oxycodone hcl/acetaminophen 7.5-325 mg tablet T1 DC SHORT ACTING OPIOIDS QL 7 / day oxycodone hcl/aspirin T2 DC SHORT ACTING OPIOIDS PA

PAGE 25 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day oxymorphone hcl 10 mg tablet T2 DC SHORT ACTING OPIOIDS PA QL 3 / day oxymorphone hcl 5 mg tablet T2 DC SHORT ACTING OPIOIDS PA QL 12 / day hcl/ hcl T2 DC SHORT ACTING OPIOIDS PA QL 12 / day DC SHORT ACTING OPIOIDS PERCOCET (2.5-325 MG TABLET, 5-325 MG TABLET) T2 PA IPC IPC - SPECIALTY PROGRAM QL 6 / day DC SHORT ACTING OPIOIDS PERCOCET 10-325 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM QL 8 / day DC SHORT ACTING OPIOIDS PERCOCET 7.5-325 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM QL 3 / day PRIMLEV 10-300 MG TABLET T2 DC SHORT ACTING OPIOIDS PA

PAGE 26 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 7 / day PRIMLEV 5-300 MG TABLET T2 DC SHORT ACTING OPIOIDS PA QL 4 / day PRIMLEV 7.5-300 MG TABLET T2 DC SHORT ACTING OPIOIDS PA QL 6 / day PROLATE 10-300 MG TABLET T2 DC SHORT ACTING OPIOIDS PA QL 12 / day PROLATE 5-300 MG TABLET T2 DC SHORT ACTING OPIOIDS PA QL 8 / day PROLATE 7.5-300 MG TABLET T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING OPIOIDS remifentanil hcl T2 PA IPC IPC - SPECIALTY PROGRAM QL 4 / day DC SHORT ACTING OPIOIDS ROXICODONE 15 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM QL 2 / day DC SHORT ACTING OPIOIDS ROXICODONE 30 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 27 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 12 / day DC SHORT ACTING OPIOIDS ROXICODONE 5 MG TABLET T2 PA IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING ROXYBOND 5 MG TABLET T2 OPIOIDS PA QL 12 / day SUBSYS T2 DC SHORT ACTING OPIOIDS PA

DC SHORT ACTING OPIOIDS sufentanil citrate (50 mcg/ml ampul, 50 mcg/ml vial) T2 PA IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING OPIOIDS TALWIN T2 PA IPC IPC - SPECIALTY PROGRAM QL 8 / day AL At least 12 yrs tramadol hcl 50 mg tablet T1 old DC SHORT ACTING OPIOIDS QL 8 / day AL At least 12 yrs tramadol hcl/acetaminophen T1 old DC SHORT ACTING OPIOIDS

PAGE 28 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DC SHORT ACTING TREZIX T2 OPIOIDS PA QL 10 / day DC SHORT ACTING OPIOIDS -CODEINE NO.3 T2 PA IPC IPC - SPECIALTY PROGRAM QL 10 / day DC SHORT ACTING OPIOIDS TYLENOL-CODEINE NO.4 T2 PA IPC IPC - SPECIALTY PROGRAM

DC SHORT ACTING OPIOIDS ULTIVA T2 PA IPC IPC - SPECIALTY PROGRAM QL 8 / day ULTRACET T2 DC SHORT ACTING OPIOIDS PA QL 8 / day ULTRAM T2 DC SHORT ACTING OPIOIDS PA QL 12 / day DC SHORT ACTING OPIOIDS VICODIN T2 PA IPC IPC - SPECIALTY PROGRAM

PAGE 29 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 9 / day DC SHORT ACTING OPIOIDS VICODIN HP T2 PA IPC IPC - SPECIALTY PROGRAM Opioid Analgesics, Long-acting

DC LONG ACTING BELBUCA T2 OPIOIDS PA QL 0.142 / day (15 mcg/hr patch tdwk, 20 mcg/hr patch T1 DC LONG ACTING tdwk) OPIOIDS PA QL 0.286 / day buprenorphine (5 mcg/hr patch tdwk, 7.5 mcg/hr patch T1 DC LONG ACTING tdwk, 10 mcg/hr patch tdwk) OPIOIDS PA QL 0.142 / day BUTRANS (15 MCG/HR PATCH, 20 MCG/HR PATCH) T1 DC LONG ACTING OPIOIDS PA QL 0.286 / day BUTRANS (5 MCG/HR PATCH, 7.5 MCG/HR PATCH, 10 T1 DC LONG ACTING MCG/HR PATCH) OPIOIDS PA QL 3 / day DISKETS T2 DC LONG ACTING OPIOIDS PA QL 2 / day EMBEDA T2 DC LONG ACTING OPIOIDS PA

PAGE 30 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day EXALGO T2 DC LONG ACTING OPIOIDS PA QL 0.5 / day fentanyl (62.5mcg/hr patch td72, 87.5mcg/hr patch td72) T2 DC LONG ACTING OPIOIDS PA QL 0.334 / Day fentanyl 37.5mcg/hr patch td72 T2 DC LONG ACTING OPIOIDS PA QL 1 / day hydromorphone hcl (8 mg tab er 24h, 16 mg tab er 24h, T2 DC LONG ACTING 32 mg tab er 24h) OPIOIDS PA QL 2 / Day hydromorphone hcl 12 mg tab er 24h T2 DC LONG ACTING OPIOIDS PA QL 1 / day HYSINGLA ER T2 DC LONG ACTING OPIOIDS PA QL 4 / day DC LONG ACTING OPIOIDS tartrate 2 mg tablet T2 PA IPC IPC - SPECIALTY PROGRAM QL 4 / day methadone hcl 10 mg/ml oral conc T2 DC LONG ACTING OPIOIDS PA

PAGE 31 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 15 / day methadone hcl 10 mg/5 ml solution T2 DC LONG ACTING OPIOIDS PA QL 40/ day methadone hcl 5 mg/5 ml solution T2 DC LONG ACTING OPIOIDS PA QL 3 / day methadone hcl 40 mg tablet sol T2 DC LONG ACTING OPIOIDS PA

DC LONG ACTING methadone hcl (10 mg/ml syringe, 10 mg/ml vial) T2 OPIOIDS PA QL 4 / day METHADONE INTENSOL T2 DC LONG ACTING OPIOIDS PA QL 4 / day METHADOSE 10 MG/ML ORAL CONC T2 DC LONG ACTING OPIOIDS PA QL 3 / day METHADOSE 40 MG TABLET DISPR T2 DC LONG ACTING OPIOIDS PA QL 1 / day morphine sulfate (100 mg tablet er, 200 mg tablet er) T1 DC LONG ACTING OPIOIDS PA

PAGE 32 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day MS CONTIN (ER 100 MG TABLET, ER 200 MG TABLET) T2 DC LONG ACTING OPIOIDS PA

DC LONG ACTING NUCYNTA ER T2 OPIOIDS PA QL 3 / day oxycodone hcl (10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h, 60 mg T2 DC LONG ACTING OPIOIDS tab er 12h, 80 mg tab er 12h) PA QL 3 / day OXYCONTIN T2 DC LONG ACTING OPIOIDS PA oxymorphone hcl (5 mg tab er 12h, 10 mg tab er 12h, 20 DC LONG ACTING T2 OPIOIDS mg tab er 12h, 40 mg tab er 12h) PA QL 2 / day oxymorphone hcl (7.5 mg tab er 12h, 15 mg tab er 12h, 30 T2 DC LONG ACTING mg tab er 12h) OPIOIDS PA QL 2 / day XTAMPZA ER T2 DC LONG ACTING OPIOIDS PA LOCAL ANESTHETICS AMIDATE (20 MG/10 ML AMPUL, 20 MG/10 ML VIAL, 40 T2 PA MG/20 ML ABBOJECT, 40 MG/20 ML VIAL)

PAGE 33 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANASTIA T2 PA hcl/epinephrine bitartrate T2 PA bupivacaine hcl in 0.9 % sodium chloride/pf (hcl/0.9 % nacl/pf 0.125 % bulkbaginj, hcl/0.9 % nacl/pf 0.125 % T2 PA plast. bag) bupivacaine hcl/0.9 % nacl/pf 0.125 % pump resvr T1 bupivacaine hcl in dextrose/pf T2 PA bupivacaine hcl/epinephrine T1 bupivacaine hcl/epinephrine bitartrate T2 PA bupivacaine hcl/epinephrine/pf 0.25-.0005 vial T2 PA bupivacaine hcl/epinephrine/pf 0.5-1:200k vial T1 bupivacaine hcl/pf (hcl/pf 2.5 mg/ml ampul, hcl/pf 2.5 mg/ml vial, hcl/pf 5 mg/ml ampul, hcl/pf 5 mg/ml vial, T2 PA hcl/pf 7.5 mg/ml ampul, hcl/pf 7.5 mg/ml vial) CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL) T2 PA hcl/pf T2 PA T2 PA DIPRIVAN T2 PA T2 PA EXPAREL T2 PA FORANE T2 PA T2 PA KETALAR T2 PA hcl (10 mg/ml vial, 50 mg/ml vial, 100 mg/2ml T2 PA syringe, 100 mg/ml vial)

PAGE 34 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ketamine hcl in 0.9 % sodium chloride (in 0.9 % 20 mg/2 T2 PA ml syringe, in 0.9 % 50 mg/5 ml syringe) hcl (10 mg/ml syringe, 100 mg/5ml syringe) T1 lidocaine hcl (0.5 mg pen injctr, 5 mg/ml vial, 10 mg/ml vial, 20 mg/ml vial, 30 mg/3 ml syringe, 100mg/10ml T2 PA syringe) lidocaine hcl buffered with 8.4 % sodium bicarbonate (0.9 %(1ml) syringe, 0.9 %(3ml) syringe, 0.9 %(5ml) syringe, T2 PA 0.9%(.5ml) syringe, 0.9%(10ml) syringe) lidocaine hcl in 0.9 % sodium chloride T2 PA lidocaine hcl in 0.9 % nacl/pf 100mg/10ml syringe T2 PA lidocaine hcl in dextrose 5% in /pf (hcl/dextrose 5 T2 PA %/pf 4 mg/ml iv soln, hcl/dextrose 5 %/pf 8 mg/ml iv soln) lidocaine hcl in dextrose 7.5 % in water/pf T2 PA lidocaine hcl in sodium chloride, iso-osmotic/pf T2 PA lidocaine hcl/epinephrine (hcl/epinephrine 0.5-1:200k vial, T2 PA hcl/epinephrine 1%-1:100k vial) lidocaine hcl/epinephrine 2 %-1:100k vial T1 lidocaine hcl/epinephrine bitartrate T2 PA lidocaine hcl/epinephrine/pf (hcl/epinephrine/pf 1.5- 1:200k ampul, hcl/epinephrine/pf 1.5-1:200k vial, T2 PA hcl/epinephrine/pf 2%-1:200k vial) lidocaine hcl/pf (hcl/pf 10 mg/ml ampul, hcl/pf 10 mg/ml syringe, hcl/pf 10 mg/ml vial, hcl/pf 15 mg/ml ampul, hcl/pf 20 mg/ml ampul, hcl/pf 40 mg/ml ampul, hcl/pf 50 T2 PA mg/5 ml syringe, hcl/pf 100 mg/5ml syringe, hcl/pf 200mg/10ml syringe, hcl/pf 200mg/20ml syringe) lidocaine hcl/pf 20 mg/ml vial T2 PA lidocaine hcl/pf 5 mg/ml vial T1

PAGE 35 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LIDOTRAL T2 PA LIDOTREX 2% WOUND T2 PA MARCAINE (0.25% VIAL, 0.5% VIAL, 0.75% VIAL) T2 PA MARCAINE SPINAL T2 PA MARCAINE-EPINEPHRINE (0.25%-EPI, 0.5%-EPI VL) T2 PA hcl/pf T2 PA NAROPIN (0.2% 20 MG/10 ML AMP, 0.2% 20 MG/10 ML VIAL, 0.2% 200 MG/100 ML BAG, 0.2% 200 MG/100 ML BTL, 0.2% 40 MG/20 ML AMP, 0.2% 40 MG/20 ML VIAL, 0.2% 400 MG/200 ML BAG, 0.2% 400 MG/200 ML BTL, 0.5% 1,000 MG/200 ML, 0.5% 100 MG/20 ML AMP, 0.5% T2 PA 100 MG/20 ML VIAL, 0.5% 150 MG/30 ML VIAL, 0.5% 500 MG/100 ML BTL, 0.75% 150 MG/20 ML AMP, 0.75% 150 MG/20 ML VL, 1% 100 MG/10 ML AMPULE, 1% 100 MG/10 ML VIAL, 1% 200 MG/20 ML AMPULE, 1% 200 MG/20 ML VIAL) NESACAINE T2 PA NESACAINE-MPF T2 PA NUMBONEX T2 PA ORABLOC T2 PA POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) T2 PA POLOCAINE-MPF T2 PA 10 mg/ml vial T2 PA REGENECARE T2 PA ropivacaine hcl in 0.9 % sodium chloride/pf (in chl/pf 0.1% 400ml els pmp hr, in chl/pf 0.2% 400ml els pmp hr, in T2 PA chl/pf 0.2% 550ml els pmp hr)

PAGE 36 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ropivacaine hcl/pf (hcl/pf 2 mg/ml infus. btl, hcl/pf 2 mg/ml plast. bag, hcl/pf 2 mg/ml vial, hcl/pf 5 mg/ml vial, T2 PA hcl/pf 7.5 mg/ml vial, hcl/pf 10 mg/ml vial) SCANDONEST PLAIN T2 PA SENSORCAINE T2 PA SENSORCAINE WITH DEXTROSE T2 PA SENSORCAINE-EPINEPHRINE T2 PA SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% T2 PA AMPUL, 0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) SENSORC-MPF 0.25%-EPI 1:200000 T1 SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.75%- T2 PA EPI, SENSORCN-MPF 0.5%-EPI) SEPTOCAINE 4%-EPI 1:100,000 T2 PA T2 PA SUPRANE T2 PA TERRELL T2 PA hcl/pf (hcl/pf 10 mg/ml ampul, hcl/pf 20 mg/2 T2 PA ml vial) ULTANE T2 PA XYLOCAINE T2 PA XYLOCAINE 2%-EPI 1:50,000 CART T2 PA XYLOCAINE IV T2 PA XYLOCAINE WITH EPINEPHRINE (0.5%-EPI 1:200,000, 1%- T2 PA EPI 1:100,000, 2%-EPI 1:100,000, 2%-EPI 1:200,000) XYLOCAINE-MPF (0.5% VIAL, 1% AMPUL, 1% VIAL, 1.5% T2 PA AMPUL, 2% AMPUL, 2% VIAL)

PAGE 37 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XYLOCAINE-MPF WITH EPINEPHRINE T2 PA ZINGO T2 PA ANTI-/SUBSTANCE ABUSE TREATMENT AGENTS DETERRENTS/ANTI-CRAVING calcium T1 ANTABUSE T2 PA (250 mg tablet, 500 mg tablet) T1 hcl 50 mg tablet T1 S VIVITROL 380 MG VIAL T1 PS

AL At least 16 yrs old VIVITROL 380 MG VIAL + DILUENT T1 S PS OPIOID DEPENDENCE TREATMENTS

QL 1 / day BUNAVAIL 2.1-0.3 MG FILM T2 AL At least 16 yrs old PA QL 2 / day BUNAVAIL 4.2-0.7 MG FILM T2 AL At least 16 yrs old PA QL 3 / DAY BUNAVAIL 6.3-1 MG FILM T2 AL At least 16 yrs old PA

PAGE 38 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BUPRENEX T2 PA QL 3 / day buprenorphine hcl 2 mg tab subl T1 AL At least 16 yrs old PA QL 2 / day buprenorphine hcl 8 mg tab subl T1 AL At least 16 yrs old PA buprenorphine hcl (0.3 mg/ml cartridge, 0.3 mg/ml vial) T2 PA QL 2 / DAY buprenorphine hcl/naloxone hcl 12 mg-3 mg film T2 AL At least 16 yrs old PA QL 1 / day buprenorphine hcl/naloxone hcl 4mg-1mg film T2 AL At least 16 yrs old PA QL 3 / DAY buprenorphine hcl/naloxone hcl 8 mg-2 mg film T2 AL At least 16 yrs old PA QL 3 / day buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg film, /naloxone 2 mg-0.5mg tab subl, /naloxone 8 mg-2 T2 AL At least 16 yrs old mg tab subl) PA PROBUPHINE T2 PA QL 3 / DAY SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) T1 AL At least 16 yrs old PA

PAGE 39 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / DAY SUBOXONE 12 MG-3 MG SL FILM T1 AL At least 16 yrs old PA QL 1 / DAY SUBOXONE 4 MG-1 MG SL FILM T1 AL At least 16 yrs old PA QL 2 / day ZUBSOLV (1.4-0.36 MG TABLET, 2.9-0.71 MG TABLET, 5.7- T2 AL At least 16 yrs 1.4 MG TABLET, 8.6-2.1 MG TABLET, 11.4-2.9 MG TABLET) old PA OPIOID REVERSAL AGENTS

EVZIO T2 PA naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1 T1 mg/ml syringe) NARCAN T1 CESSATION AGENTS

ACID CONTROLLER 20 MG TABLET T1 CHANTIX STARTING MONTH BOX T1 CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 T1 QL 2 / day MG TABLET) 20 mg tablet T1 NICODERM CQ 21 MG/24HR PATCH T1 QL 1 / day NICORELIEF T1 QL 24 / day (2 MG MINI LOZENGE, 4 MG MINI LOZENGE) T0 QL 24 / day (7mg/24hr patch td24, 14mg/24hr patch td24, 21 T1 QL 1 / day mg/24hr patch td24, 21-14-7mg patch dysq)

PAGE 40 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nicotine polacrilex (2 mg gum, 2 mg lozenge, 2 mg lozng T1 QL 24 / day mini, 4 mg gum, 4 mg lozenge, 4 mg lozng mini) QL 16 / day NICOTROL T2 PA QL 20 / day NICOTROL NS T2 PA QUIT 2 MG CHEWING GUM T1 QL 24 / day QUIT 2 MG LOZENGE T0 QL 24 / day QUIT 4 MG CHEWING GUM T1 QL 24 / day QUIT 4 MG LOZENGE T0 QL 24 / day SELSUN BLUE 1% T1 STOP SMOKING AID T1 QL 24 / day QL 2 / day ZYBAN T2 PA ANTIBACTERIALS sulfate T2 PA sulfate (20 mg/2 ml vial, 40 mg/ml vial) T2 PA gentamicin sulfate in sodium chloride, iso-osmotic T2 PA gentamicin sulfate/pf (sulfate/pf 20 mg/2 ml vial, T2 PA sulfate/pf 60 mg/6 ml vial port) gentamicin sulfate/pf 100mg/10ml vial port T1 sulfate 500 mg tablet T1 sulfate 250 mg capsule T2 PA sulfate 1 g vial T2 PA

PAGE 41 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml T2 PA vial) tobramycin sulfate/sodium chloride T2 PA ANTIBACTERIALS, OTHER 0.25 % irrig soln T1 AVYCAZ T2 PA BACIIM T2 PA bacitracin 50000 unit vial T2 PA BACTROBAN NASAL T1 sod succinate T2 PA CLEOCIN 2% VAGINAL CREAM T2 PA CLEOCIN 100 MG VAGINAL OVULE T1 QL 4 / day CLEOCIN HCL T2 PA QL 70 / day CLEOCIN PEDIATRIC T2 PA CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 150 MG/ML VIAL, 300 MG/2 ML VIAL, 300 MG/2ML ADDVAN, 600 MG/4 ML T2 PA VIAL, 600 MG/4ML ADDVAN, 900 MG/6 ML VIAL, 900 MG/6ML ADDVAN) CLINDACIN ETZ KIT T2 PA CLINDACIN PAC T2 PA hcl (75 mg capsule, 150 mg capsule, 300 mg T1 QL 4 / day capsule) clindamycin palmitate hcl T1 QL 70 / day

PAGE 42 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clindamycin phosphate (2 % cream/appl, 150 mg/ml vial, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml T2 PA vial port) clindamycin phosphate in 0.9 % sodium chloride T2 PA clindamycin phosphate/dextrose 5 % in water T2 PA CLINDESSE T1 (colistimethate na) 150 mg vial T2 PA COLY-MYCIN M PARENTERAL T2 PA CUBICIN T2 PA CUBICIN RF T2 PA CYSTEX PLUS T2 PA daptomycin 500 mg vial T2 PA FLAGYL (250 MG TABLET, 375 CAPSULE, 500 MG TABLET) T2 PA FURADANTIN T2 PA HIPREX T2 PA HYOPHEN T2 PA LINCOCIN T2 PA QL 10 / day hcl T2 PA QL 900 / rx 100 mg/5ml susp recon T2 PA linezolid 600 mg tablet T1 QL 2 / day linezolid in 0.9 % sodium chloride T2 PA linezolid in dextrose 5 % in water T2 PA

PAGE 43 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MACROBID T2 PA MACRODANTIN T2 PA methenamine hippurate T1 methenamine mandelate (1 g tablet, 500 mg tablet) T2 PA methenamine/sod phosph,monobasic/ T2 PA blue/ METRO IV T2 PA METROGEL-VAGINAL T2 PA 375 mg capsule T2 PA metronidazole (0.75 % gel w/appl, 250 mg tablet, 500 mg T1 tablet) metronidazole in sodium chloride T2 PA MONUROL T2 PA neomycin sulfate/ sulfate (/polymyxin 40- T2 PA 200k/ml ampul, /polymyxin 40-200k/ml vial) nitrofurantoin 25 mg/5 ml oral susp T2 PA nitrofurantoin macrocrystal (25 mg capsule, 50 mg T1 capsule, 100 mg capsule) nitrofurantoin monohydrate/macrocrystals T1 NUVESSA T1 PHOSPHASAL T2 PA polymyxin b sulfate T2 PA PRIMSOL T2 PA QL 0.2 / DAY SIVEXTRO (200 MG TABLET, 200 MG VIAL) T2 PA

PAGE 44 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SULFAMYLON 8.5% CREAM T2 PA SYNERCID T2 PA T2 PA TINDAMAX T2 PA (250 mg tablet, 500 mg tablet) T2 PA trimethoprim 100 mg tablet T1 TRIMPEX T2 PA TYGACIL T2 PA URELLE T2 PA URETRON D-S T2 PA QL 4 / day URIBEL T2 PA URIMAR-T T2 PA URIN D.S. T2 PA URO-458 T2 PA UROGESIC-BLUE T2 PA URYL T2 PA USTELL T2 PA UTA T2 PA UTIRA-C T2 PA VANCOCIN HCL T2 PA hcl (125 mg capsule, 250 mg capsule) T1

PAGE 45 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial, 100 g bulkbaginj, 125mg/2.5 syringe, 500 mg vial, 500 mg T2 PA vial port, 750 mg vial, 750 mg vial port) vancomycin hcl in water for injection (peg-400, nada) (vancomycin/water inj 1g/200ml piggyback, T2 PA vancomycin/water inj 500mg/0.1l piggyback) vancomycin in 0.9 % sodium chloride (vancomycin/0.9 % 1 g/100 ml plast. bag, vancomycin/0.9 % 1.25 g/150 plast. bag, vancomycin/0.9 % 1.25 g/250 plast. bag, vancomycin/0.9 % 1.5g/150ml plast. bag, vancomycin/0.9 % 1.5g/250ml plast. bag, vancomycin/0.9 % 1.5g/500ml plast. bag, vancomycin/0.9 % 1.75 g/500 plast. bag, T2 PA vancomycin/0.9 % 1.75g/250 plast. bag, vancomycin/0.9 % 1g/200ml froz.piggy, vancomycin/0.9 % 1g/250ml plast. bag, vancomycin/0.9 % 2 g/250 ml plast. bag, vancomycin/0.9 % 2 g/500 ml plast. bag, vancomycin/0.9 % 500mg/0.1l froz.piggy, vancomycin/0.9 % 750 mg/250 plast. bag, vancomycin/0.9 % 750mg/.15l froz.piggy) vancomycin/0.9 % sod chloride 750mg/.15l plast. bag T1 vancomycin in 5 % dextrose in water (in 5 % 1 g/100 ml plast. bag, in 5 % 1.25 g/250 plast. bag, in 5 % 1.5g/250ml plast. bag, in 5 % 1g/200ml froz.piggy, in 5 % 1g/250ml T2 PA plast. bag, in 5 % 500mg/0.1l froz.piggy, in 5 % 750mg/.15l froz.piggy) VANDAZOLE T1 VIBATIV T2 PA XIFAXAN T2 PA ZYVOX (200 MG/100, 600 MG/300) T2 PA QL 900 / rx ZYVOX 100 MG/5 ML SUSPENSION T2 PA QL 2 / day ZYVOX 600 MG TABLET T2 PA

PAGE 46 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BETA-LACTAM, CEPHALOSPORINS cefaclor (250 mg capsule, 500 mg capsule) T1 cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, T2 PA 375 mg/5ml susp recon) QL 0.667 / DAY cefaclor 500 mg tab er 12h T2 PA cefadroxil (1 g tablet, 500 mg capsule, 500 mg/5ml susp T1 recon) cefadroxil 250 mg/5ml susp recon T2 PA cefazolin sodium (1 g vial, 1 g vial port, 10 g vial, 20 g vial, T2 PA 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial) cefazolin sodium in 0.9 % sodium chloride (in 0.9 % 1 g/10 ml syringe, in 0.9 % 2 g/10 ml syringe, in 0.9 % 2 g/100 ml T2 PA plast. bag, in 0.9 % 2 g/50 ml piggyback, in 0.9 % 3 g/100 ml piggyback) cefazolin sodium/dextrose 5 % in water (sodium/d5w 2 T2 PA g/100 ml plast. bag, sodium/d5w 2 g/50 ml piggyback) cefazolin sodium/dextrose, iso-osmotic (sodium/dextrose,iso 1 g/50 ml froz.piggy, sodium/dextrose,iso 1 g/50 ml piggyback, T2 PA sodium/dextrose,iso 2 g/100 ml froz.piggy, sodium/dextrose,iso 2 g/50 ml piggyback) cefazolin sodium/water for injection,sterile T2 PA cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, T1 300 mg capsule) cefditoren pivoxil T1 cefepime hcl (1 g vial, 2 g vial) T2 PA cefepime hcl in dextrose 5 % in water T2 PA

PAGE 47 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cefepime hcl in iso-osmotic dextrose T2 PA cefixime 400 mg capsule T2 PA cefixime (100 mg/5ml susp recon, 200 mg/5ml susp QL 13.337 / DAY T2 recon) PA CEFOTAN T2 PA cefotaxime sodium T2 PA cefotetan disodium T2 PA cefotetan disodium in iso-osmotic dextrose T2 PA cefoxitin sodium T2 PA cefoxitin sodium/dextrose, iso-osmotic T2 PA cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg T2 PA tablet, 100 mg/5ml susp recon, 200 mg tablet) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 T1 mg/5ml susp recon, 500 mg tablet) ceftazidime (1 g vial, 2 g vial, 6 g vial) T2 PA ceftazidime in dextrose 5% and water T2 PA ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial T2 PA port, 10 g vial, 100 g bulkbaginj, 250 mg vial, 500 mg vial) ceftriaxone sodium in iso-osmotic dextrose (in 1 g/50 ml froz.piggy, in 1 g/50 ml piggyback, in 2 g/50 ml froz.piggy, T2 PA in 2 g/50 ml piggyback) cefuroxime axetil T1 cefuroxime sodium T2 PA cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 T1 mg tablet, 750 mg capsule)

PAGE 48 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLAFORAN (1 GM ADD-VANTAGE VL, 1 GM VIAL, 2 GM T2 PA ADD-VANTAGE VL, 2 GM VIAL, 10 GM VIAL) FORTAZ (1 VIAL, 2 VIAL) T2 PA KEFLEX T2 PA MAXIPIME (1 GM ADD-VANTAGE VL, 1 GRAM VIAL, 2 GM T2 PA ADD-VANTAGE VL, 2 GRAM VIAL) SPECTRACEF T2 PA SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML T2 PA SUSPENSION)

QL 13.337 / DAY SUPRAX 100 MG/5 ML SUSPENSION T2 PA QL 1200 / 90 days SUPRAX 200 MG/5 ML SUSPENSION T2 PA TAZICEF (1 GM ADD-VANTAGE VIAL, 1 GRAM VIAL, 2 GM T2 PA ADD-VANTAGE VIAL, 2 GRAM VIAL, 6 GRAM VIAL) TEFLARO T2 PA BETA-LACTAM, OTHER

AZACTAM T2 PA AZACTAM-ISO-OSMOTIC DEXTROSE T2 PA aztreonam T2 PA doripenem T2 PA sodium T2 PA /cilastatin sodium T2 PA INVANZ T2 PA meropenem T2 PA

PAGE 49 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS meropenem in 0.9 % sodium chloride T2 PA MERREM T2 PA PRIMAXIN T2 PA BETA-LACTAM, amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab T1 chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) amoxicillin/potassium clav 1000-62.5 tab er 12h T2 PA amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, T1 amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet) ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial T2 PA port, 10 g vial, 125 mg vial, 250 mg vial, 500 mg vial) ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 g vial, sodium/sulbactam 1.5 g vial port, T2 PA sodium/sulbactam 3 g vial, sodium/sulbactam 3 g vial port, sodium/sulbactam 15 g vial) ampicillin trihydrate 250 mg capsule T1 ampicillin trihydrate 500 mg capsule T2 PA AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML, T2 PA 500-125 TABLET, 875-125 TABLET) AUGMENTIN ES-600 T2 PA AUGMENTIN XR T2 PA

PAGE 50 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BICILLIN C-R T2 PA BICILLIN L-A T2 PA sodium T1 MOXATAG T2 PA in dextrose, iso-osmotic T2 PA nafcillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial T2 PA port, 10 g vial) oxacillin sodium (1 g vial, 1 g vial port, 2 g vial, 2 g vial T2 PA port, 10 g vial) oxacillin sodium in iso-osmotic dextrose T2 PA g potassium T2 PA penicillin g potassium/dextrose-water T2 PA penicillin g T2 PA penicillin g sodium T2 PA penicillin v potassium (125 mg/5ml soln recon, 250 mg T1 tablet, 250 mg/5ml soln recon, 500 mg tablet) PFIZERPEN T2 PA piperacillin sodium/tazobactam sodium (sodium/tazobactam 2.25 g vial, sodium/tazobactam 2.25 g vial port, sodium/tazobactam 3.375 g vial, sodium/tazobactam 3.375 g vial port, T2 PA sodium/tazobactam 4.5 g vial, sodium/tazobactam 4.5 g vial port, sodium/tazobactam 13.5 g vial, sodium/tazobactam 40.5 g vial) UNASYN T2 PA

PAGE 51 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZOSYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM VIAL, 3.375 GM/50 ML GALAXY, 3.375 GRAM VIAL, 4.5 GM/100 T2 PA ML GALAXY BAG, 4.5 GRAM VIAL, 40.5 GRAM BULK VIAL) (1 g packet, 100 mg/5ml susp recon, 200 T1 mg/5ml susp recon, 500 mg tablet, 600 mg tablet) azithromycin 250 mg tablet T1 QL 6 / 5 DAYS azithromycin (500 mg vial, 500 mg vial port) T2 PA 500 mg tab er 24h T2 PA clarithromycin (125 mg/5ml susp recon, 250 mg tablet, T1 250 mg/5ml susp recon, 500 mg tablet) DIFICID 200 MG TABLET T2 PA E.E.S. 200 T1 E.E.S. 400 T2 PA ERY-TAB T2 PA ERYPED 200 T1 ERYPED 400 T2 PA ERYTHROCIN LACTOBIONATE (1 GM ADDVANT VIAL, 500 T2 PA MG ADDVAN VIAL, LACT 500 MG VIAL) ERYTHROCIN STEARATE T2 PA 250 mg capsule dr T1 erythromycin base (250 mg tablet, 250 mg tablet dr, 333 T2 PA mg tablet dr, 500 mg tablet, 500 mg tablet dr) erythromycin ethylsuccinate (400 mg tablet, 400 mg/5ml T2 PA susp recon) erythromycin ethylsuccinate 200 mg/5ml susp recon T1

PAGE 52 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 30 / fill ZITHROMAX 100 MG/5 ML SUSP T2 PA QL 60 / fill ZITHROMAX 200 MG/5 ML SUSP T2 PA ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAK T2 PA TABLET, I.V. 500 MG VIAL) QL 6 / 5 days ZITHROMAX 250 MG TABLET T2 PA QL 5 / fill ZITHROMAX 500 MG TABLET T2 PA ZITHROMAX TRI-PAK T2 PA QUINOLONES

QL 21 / fill AVELOX T2 PA AVELOX IV T2 PA QL 0.767 / day BESIVANCE T2 PA QL 0.567 / day CETRAXAL T2 PA QL 10 / day CIPRO 10% SUSPENSION T2 PA QL 7 / day CIPRO 5% SUSPENSION T2 PA QL 2 / day CIPRO (250 MG TABLET, 500 MG TABLET) T2 PA 250 mg/5ml sus mc rec T1 QL 7 / day

PAGE 53 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ciprofloxacin 500 mg/5ml sus mc rec T1 QL 10 / day QL 0.567 / day ciprofloxacin hcl 0.2 % droperette T2 PA ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 500 mg T1 QL 2 / day tablet, 750 mg tablet) ciprofloxacin lactate/dextrose 5 % in water T2 PA QL 14 / 1 RX ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr T2 PA QL 28 / fill ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr T2 PA QL 7 / day FACTIVE T2 PA QL 30 / fill LEVAQUIN T2 PA (25 mg/ml vial, 250mg/10ml solution) T2 PA levofloxacin (250 mg tablet, 500 mg tablet, 750 mg T1 QL 30 / fill tablet) levofloxacin/dextrose 5 % in water T2 PA QL 21 / fill moxifloxacin hcl 400 mg tablet T2 PA moxifloxacin hcl in sodium and sulfate,water,iso- T2 PA osm moxifloxacin hcl in sodium chloride, iso-osmotic T1 QL 56 / fill (300 mg tablet, 400 mg tablet) T2 PA OTIPRIO T2 PA

PAGE 54 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SULFONAMIDES

AVC T2 PA BACTRIM T2 PA BACTRIM DS T2 PA 500 mg tablet T2 PA sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg tablet, T1 sulfamethoxazole/trimethoprim 800-160 mg tablet, sulfamethoxazole/trimethoprim 800-160/20 oral susp) sulfamethoxazole/trimethoprim 80-16mg/ml vial T2 PA SULFATRIM T1

ACTICLATE T2 PA AVIDOXY T1 QL 1 / day COREMINO (ER 90 MG TABLET, ER 135 MG TABLET) T2 PA QL 3 / day COREMINO ER 45 MG TABLET T2 PA hcl T2 PA QL 7 / rx DORYX DR 200 MG TABLET T2 PA DORYX DR 50 MG TABLET T2 PA DORYX MPC T2 PA DOXY 100 T2 PA

PAGE 55 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hyclate (20 mg tablet, 50 mg capsule, 100 mg T1 capsule, 100 mg tablet) doxycycline hyclate (50 mg tablet, 50 mg tablet dr, 75 mg tablet, 75 mg tablet dr, 100 mg tablet dr, 100 mg vial, 150 T2 PA mg tablet, 150 mg tablet dr) QL 7 / rx doxycycline hyclate 200 mg tablet dr T2 PA QL 1 / day doxycycline monohydrate 40 mg cap ir dr T2 PA QL 30 / fill doxycycline monohydrate 150 mg capsule T2 PA doxycycline monohydrate (25 mg/5 ml susp recon, 75 mg T2 PA capsule, 75 mg tablet, 150 mg tablet) doxycycline monohydrate (50 mg capsule, 50 mg tablet, T1 100 mg capsule, 100 mg tablet) MINOCIN (50 MG PELLETIZED CAP, 100 MG VIAL) T2 PA hcl (75 mg capsule, 100 mg capsule) T1 QL 2 / day minocycline hcl 50 mg capsule T1 QL 4 / day minocycline hcl (55 mg tab er 24h, 65 mg tab er 24h, 80 QL 1 / day mg tab er 24h, 90 mg tab er 24h, 105 mg tab er 24h, T2 115mg tab er 24h, 135 mg tab er 24h) PA QL 3 / day minocycline hcl 45 mg tab er 24h T2 PA minocycline hcl (50 mg tablet, 75 mg tablet, 100 mg T2 PA tablet) MONDOXYNE NL T2 PA MONODOX T2 PA MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) T2 PA

PAGE 56 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OKEBO T2 PA QL 1 / day ORACEA T2 PA QL 1 / day SOLODYN T2 PA SOLOXIDE T2 PA TARGADOX T2 PA hcl (250 mg capsule, 500 mg capsule) T2 PA VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, T2 PA 100 MG CAPSULE) ANTICONVULSANTS, OTHER

QL 20 / day BRIVIACT (10 MG/ML ORAL SOLN, 50 MG/5 ML VIAL) T2 PA QL 4 / day BRIVIACT (10 MG TABLET, 50 MG TABLET) T2 PA QL 2 / day BRIVIACT 100 MG TABLET T2 PA QL 8 / day BRIVIACT 25 MG TABLET T2 PA QL 3 / day BRIVIACT 75 MG TABLET T2 PA QL 6 / day FYCOMPA 0.5 MG/ML ORAL SUSP T2 PA

FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 QL 1 / day T2 MG TABLET, 10 MG TABLET, 12 MG TABLET) PA

PAGE 57 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 500 MG/5 ML VIAL, 750 MG TABLET, 1,000 T2 PA MG TABLET) KEPPRA XR T2 PA 500 mg/5ml solution T1 QL 31.534 / DAY levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 750 mg T1 tablet, 1000 mg tablet) levetiracetam 500 mg/5ml vial T2 PA levetiracetam in sodium chloride, iso-osmotic T2 PA ROWEEPRA T1 ROWEEPRA XR T1 QL 3 / day SPRITAM T2 AL At least 4 yrs old PA MODIFYING AGENTS

CELONTIN T2 PA (250 mg capsule, 250 mg/5ml solution) T1 ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) T2 PA ZONEGRAN T2 PA (25 mg capsule, 50 mg capsule, 100 mg T1 capsule) GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

S 2.5 mg/ml oral susp T2 PS PA

PAGE 58 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clobazam (10 mg tablet, 20 mg tablet) T1 PA DEPACON T2 PA DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) T2 PA DEPAKOTE T2 PA DEPAKOTE ER T2 PA DEPAKOTE SPRINKLE T2 PA QL 0.07 / day DIASTAT T2 AL At least 2 yrs old PA QL 0.07 / day DIASTAT ACUDIAL T2 AL At least 2 yrs old PA (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) T1 QL 0.07 / day divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, T1 500 mg tablet dr) (100 mg capsule, 300 mg capsule, 400 mg T1 QL 9 / day capsule) gabapentin (250 mg/5ml solution, 300 mg/6ml solution) T1 QL 72 / day gabapentin 600 mg tablet T1 QL 6 / day gabapentin 800 mg tablet T1 QL 5 / day GABITRIL T1 QL 1 / day GRALISE ER 300 MG TABLET T2 PA QL 3 / day GRALISE ER 600 MG TABLET T2 PA

PAGE 59 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MYSOLINE T2 PA NEMBUTAL SODIUM T2 PA

NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 400 QL 9 / day T2 MG CAPSULE) PA

NEURONTIN (250 MG/5 ML SOLN, 250 MG/5 ML QL 72 / day T2 SOLUTION) PA QL 6 / day NEURONTIN 600 MG TABLET T2 PA QL 5 / day NEURONTIN 800 MG TABLET T2 PA

AL At least 2 yrs old ONFI 2.5 MG/ML SUSPENSION T2 S PS PA

AL At least 2 yrs ONFI (10 MG TABLET, 20 MG TABLET) T2 old PA sodium T2 PA (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg T1 tablet, 97.2mg tablet, 100 mg tablet) phenobarbital sodium (65 mg/ml vial, 130mg/ml vial) T2 PA (50 mg tablet, 250 mg tablet) T1 QL 6 / day SABRIL (500 MG POWDER PACKET, 500 MG TABLET) T2 PA hcl T1

PAGE 60 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valproic acid 250 mg capsule T1 valproic acid (as sodium ) ( sodium) (250 T1 mg/5ml solution, 500mg/10ml solution) valproic acid (as sodium salt) 500 mg/5ml vial T2 PA QL 6 / day S (500 mg powd pack, 500 mg tablet) T2 PS PA QL 6 / day VIGADRONE T2 PA GLUTAMATE REDUCING AGENTS (400 mg tablet, 600 mg tablet, 600 mg/5ml T2 PA oral susp) FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 T2 PA ML SUSP) LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG T2 PA TABLET) LAMICTAL (BLUE) T2 PA LAMICTAL (GREEN) T2 PA LAMICTAL (ORANGE) T2 PA LAMICTAL ODT T2 PA LAMICTAL ODT (BLUE) T2 PA LAMICTAL ODT (GREEN) T2 PA LAMICTAL ODT (ORANGE) T2 PA LAMICTAL XR T2 PA

PAGE 61 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LAMICTAL XR (BLUE) T2 PA LAMICTAL XR (GREEN) T2 PA LAMICTAL XR (ORANGE) T2 PA (25 mg tab rapdis, 25(21)-50 tb rd dspk, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 25-50-100 tb T2 PA rd dspk, 25mg (35) tab ds pk, 50 mg tab rapdis, 50(42)- 100 tb rd dspk, 100 mg tab rapdis, 200 mg tab rapdis) lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp, 50 mg tab er 24, 100 mg tab er T1 24, 100 mg tablet, 150 mg tablet, 200 mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24) QUDEXY XR T2 PA SUBVENITE T1 SUBVENITE (BLUE) T2 PA SUBVENITE (GREEN) T2 PA SUBVENITE (ORANGE) T2 PA TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG T2 PA TABLET) (25 mg cap spr 24, 50 mg cap spr 24, 100 mg T2 PA cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24) topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg T1 tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) TROKENDI XR T2 PA AGENTS

APTIOM T2 PA BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 T2 PA MG TABLET)

PAGE 62 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100 mg/5ml oral susp, 200 mg cpmp T1 12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h) CARBATROL T2 PA CEREBYX T2 PA DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG T2 PA CAPSULE) DILANTIN-125 T2 PA EPITOL T1 sodium T2 PA (150 mg tablet, 300 mg tablet, 300 T1 mg/5ml oral susp, 600 mg tablet) OXTELLAR XR T2 PA PEGANONE T2 PA PHENYTEK T2 PA (50 mg tab chew, 100 mg/4ml oral susp, 125 T1 mg/5ml oral susp) phenytoin sodium (50 mg/ml ampul, 50 mg/ml syringe, 50 T2 PA mg/ml vial) phenytoin sodium extended T1 TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) T2 PA TEGRETOL XR T2 PA TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 T2 PA ML SUSP, 600 MG TABLET) VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG T1 TABLET, 150 MG TABLET, 200 MG TABLET, STARTER KIT)

PAGE 63 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIMPAT 200 MG/20 ML VIAL T2 PA ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER mesylates 1 mg tablet T2 PA hcl (10 mg tablet, 20 mg tablet) T2 PA hcl 30 mg/ml vial T2 PA INHIBITORS

AL At least 40 yrs ARICEPT T2 old PA hcl 23 mg tablet T1 AL At least 40 yrs old donepezil hcl (5 mg tablet, 10 mg tab rapdis, 10 mg T1 tablet) donepezil hcl 5 mg tab rapdis T1 AL At least 40 yrs old EXELON T1 hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, T2 PA 24 mg cap24h pel) NAMZARIC (7 MG-10 MG CAPSULE, 21 MG-10 MG T2 PA CAPSULE, TITRATION PACK) RAZADYNE T2 PA RAZADYNE ER T2 PA T1

AL At least 40 yrs rivastigmine tartrate T2 old PA

PAGE 64 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS N-METHYL-D-ASPARTATE (NMDA) ANTAGONIST hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg T2 PA cap spr 24, 28 mg cap spr 24) QL 360 / 30 days memantine hcl 2 mg/ml solution T2 AL At least 40 yrs old PA

AL At least 40 yrs memantine hcl 5 mg-10 mg tab ds pk T2 old PA QL 2 / day memantine hcl 10 mg tablet T1 AL At least 40 yrs old QL 3 / day memantine hcl 5 mg tablet T1 AL At least 40 yrs old

NAMENDA (5 MG TABLET, 5-10 MG TITRATION PK, 10 MG AL At least 40 yrs T2 old TABLET) PA

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG AL At least 40 yrs T2 old CAPSULE, 28 MG CAPSULE, TITRATION PACK) PA ANTIDEPRESSANTS, OTHER hcl/ T2 PA QL 1 / day APLENZIN T2 PA hcl (150 mg tab er 12h, 150 mg tab sr 12h, 200 T1 QL 2 / day mg tab sr 12h)

PAGE 65 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bupropion hcl 150 mg tab er 24h T1 QL 3 / day bupropion hcl 300 mg tab er 24h T1 QL 1 / day QL 1 / day bupropion hcl 450 mg tab er 24h T2 PA bupropion hcl 100 mg tablet T1 QL 5 / day bupropion hcl 75 mg tablet T1 QL 6 / day bupropion hcl (100 mg tab er 12h, 100 mg tab sr 12h) T1 QL 4 / day QL 1 / day FORFIVO XL T2 PA (15 mg tab rapdis, 15 mg tablet, 30 mg tab T1 QL 1 / day rapdis, 30 mg tablet, 45 mg tab rapdis, 45 mg tablet) mirtazapine 7.5 mg tablet T1 QL 2 / day QL 1 / day / hcl T2 AL At least 18 yrs old PA /amitriptyline hcl T1 AL At least 18 yrs old REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MG QL 1 / day T2 SOLTAB, 30 MG TABLET, 45 MG SOLTAB) PA QL 1 / day SYMBYAX T2 AL At least 18 yrs old PA QL 2 / day WELLBUTRIN SR (SR 150 MG TABLET, SR 200 MG TABLET) T2 PA QL 4 / day WELLBUTRIN SR 100 MG TABLET T2 PA

PAGE 66 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day WELLBUTRIN XL 150 MG TABLET T2 PA QL 1 / day WELLBUTRIN XL 300 MG TABLET T2 PA MONOAMINE INHIBITORS

QL 1 / day EMSAM T2 PA QL 6 / day MARPLAN T2 PA QL 6 / day NARDIL T2 PA QL 6 / day PARNATE T2 PA sulfate 15 mg tablet T1 QL 6 / day QL 6 / day sulfate T2 PA SSRIS/SNRIS (SELECTIVE INHIBITORS/SEROTONIN AND

QL 1 / day BRISDELLE T2 PA QL 1 / day CELEXA T2 PA hydrobromide (10 mg/5 ml solution, 20 T1 QL 20 / day mg/10ml solution) citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 T1 QL 1 / day mg tablet)

PAGE 67 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T1 QL 1 / day desvenlafaxine succinate T1 QL 1 / day QL 1 / day EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) T2 PA QL 3 / day EFFEXOR XR 75 MG CAPSULE T2 PA QL 20 / day oxalate 5 mg/5 ml solution T2 PA escitalopram oxalate (5 mg tablet, 10 mg tablet) T1 QL 1.5 / day escitalopram oxalate 20 mg tablet T1 QL 1 / day FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, QL 1 / day ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG T2 CAPSULE) PA fluoxetine hcl 10 mg capsule T1 QL 1 / day fluoxetine hcl 20 mg capsule T1 QL 4 / day fluoxetine hcl 40 mg capsule T1 QL 2 / day QL 0.15 / day fluoxetine hcl 90 mg capsule dr T2 PA fluoxetine hcl 20 mg/5 ml solution T1 QL 20 / day QL 1.5 / day fluoxetine hcl (10 mg tablet, 60 mg tablet) T2 PA QL 4 / day fluoxetine hcl 20 mg tablet T2 PA maleate (100 mg cap er 24h, 150 mg cap er QL 2 / day T2 24h) PA fluvoxamine maleate (25 mg tablet, 50 mg tablet) T1 QL 1 / day

PAGE 68 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluvoxamine maleate 100 mg tablet T1 QL 3 / day QL 1 / day KHEDEZLA T2 PA QL 1.5 / day LEXAPRO (5 MG TABLET, 10 MG TABLET) T2 PA QL 1 / day LEXAPRO 20 MG TABLET T2 PA hcl T2 PA QL 6 / day hcl 100 mg tablet T2 PA QL 4 / day nefazodone hcl 150 mg tablet T2 PA QL 3 / day nefazodone hcl 200 mg tablet T2 PA QL 2.5 / day nefazodone hcl 250 mg tablet T2 PA QL 12 / day nefazodone hcl 50 mg tablet T2 PA QL 2 / day hcl (25 mg tab er 24h, 37.5 mg tab er 24h) T2 PA QL 1 / day paroxetine hcl 12.5 mg tab er 24h T2 PA paroxetine hcl (20 mg tablet, 40 mg tablet) T1 QL 1 / day paroxetine hcl 10 mg tablet T1 QL 1.5 / day paroxetine hcl 30 mg tablet T1 QL 2 / day

PAGE 69 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day paroxetine mesylate T2 PA QL 42 / day PAXIL 10 MG/5 ML SUSPENSION T2 PA QL 1 / day PAXIL (20 MG TABLET, 40 MG TABLET) T2 PA QL 1.5 / day PAXIL 10 MG TABLET T2 PA QL 2 / day PAXIL 30 MG TABLET T2 PA QL 2 / day PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) T2 PA QL 1 / day PAXIL CR 12.5 MG TABLET T2 PA QL 1 / day PEXEVA T2 PA QL 1 / day PRISTIQ T2 PA PROZAC 10 MG PULVULE T2 PA QL 4 / day PROZAC 20 MG PULVULE T2 PA QL 2 / day PROZAC 40 MG PULVULE T2 PA QL 1.5 / day SARAFEM 10 MG TABLET T2 PA QL 4 / day SARAFEM 20 MG TABLET T2 PA

PAGE 70 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl 20 mg/ml oral conc T1 QL 10 / day sertraline hcl (25 mg tablet, 50 mg tablet) T1 QL 1.5 / day sertraline hcl 100 mg tablet T1 QL 2 / day hcl 100 mg tablet T1 QL 4 / day trazodone hcl 150 mg tablet T1 QL 2 / day trazodone hcl 300 mg tablet T1 QL 1 / day trazodone hcl 50 mg tablet T1 QL 3 / day QL 1 / day TRINTELLIX T2 PA hcl (37.5 mg cap er 24h, 150 mg cap er 24h) T1 QL 1 / day venlafaxine hcl 75 mg cap er 24h T1 QL 3 / day venlafaxine hcl (37.5 mg tab er 24, 75 mg tab er 24, 150 QL 1 / day T2 mg tab er 24, 225 mg tab er 24) PA venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg T1 tablet, 75 mg tablet, 100 mg tablet) VIIBRYD 10-20 MG STARTER PACK T2 PA QL 1 / day VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) T2 PA QL 10 / day ZOLOFT 20 MG/ML ORAL CONC T2 PA QL 1.5 / day ZOLOFT (25 MG TABLET, 50 MG TABLET) T2 PA QL 2 / day ZOLOFT 100 MG TABLET T2 PA

PAGE 71 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg T1 tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) T1 ANAFRANIL T2 PA hcl (25 mg capsule, 50 mg capsule, 75 mg T1 capsule) hcl (10 mg tablet, 25 mg tablet, 50 mg T1 tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, T1 150 mg capsule) hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) T1 imipramine pamoate T1 NORPRAMIN T2 PA hcl (10 mg capsule, 25 mg capsule, 50 mg T1 capsule, 75 mg capsule) nortriptyline hcl 10 mg/5 ml solution T2 PA PAMELOR T2 PA hcl T2 PA SURMONTIL T2 PA TOFRANIL T2 PA maleate T2 PA

PAGE 72 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIEMETICS ANTIEMETICS, OTHER

QL 0.15 / day AKYNZEO 300-0.5 MG CAPSULE T2 PA COMPAZINE (5 MG TABLET, 10 MG TABLET, 25 MG T2 PA SUPPOSITORY) COMPRO T2 PA QL 4 / day DICLEGIS T2 PA 50 mg tablet T1 dimenhydrinate 50 mg/ml vial T2 PA QL 4 / day succinate/pyridoxine hcl (b6) T2 PA DRAMAMINE LESS DROWSY T0 DRIMINATE T1 hcl (12.5 mg tablet, 25 mg tab chew, 25 mg T1 tablet) MEDI-MECLIZINE T0 hcl (5 mg tablet, 5 mg/5 ml solution, 10 T1 mg tablet, 10 mg/10ml solution) metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis, T2 PA 10 mg/2 ml syringe) metoclopramide hcl 5 mg/ml vial T1 PA HM MOTION RELIEF 25 MG TABLET T1 MOTION RELIEF 25 MG TABLET T1 GNP MOTION SICKNES 25 MG TAB T1

PAGE 73 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HM MOTION SICKNESS 50 MG TAB T2 PA MOTION SICKNESS (25 MG TABLET, SM 25 MG TAB) T1 MOTION SICKNESS (CVS 50 MG TAB, SM 50 MG TAB) T1 MOTION SICKNESS II T0 MOTION SICKNESS RELIEF (CVS RELIEF TAB, RA RLF TB T0 CHEW, RELIEF TB CHEW) MOTION SICKNESS RELIEF (50 MG TABLET, GNP 50 MG T1 TAB) MOTION SICKNESS RELIEF (EQ 25 MG TAB, EQL 25 MG T1 TAB) MOTION SICKNESS RLF 25 MG TAB T1 MOTION-TIME T1 perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 T1 AL At least 18 yrs mg tablet) old T2 PA prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial) T2 PA prochlorperazine maleate (5 mg tablet, 10 mg tablet) T1 hcl in 0.9 % sodium chloride T1 REGLAN T2 PA T2 PA TIGAN (100 MG/ML VIAL, 300 MG CAPSULE) T2 PA TRANSDERM-SCOP T2 PA TRAVEL SICKNESS 25 MG TAB CHEW T1 TRAVEL SICKNESS 50 MG TABLET T1 trimethobenzamide hcl 300 mg capsule T1

PAGE 74 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VERTICALM T0 EMETOGENIC THERAPY ADJUNCTS

S ALOXI T2 PS PA QL 3 / fill aprepitant 125mg-80mg cap ds pk T2 PA QL 0.08 / day aprepitant (40 mg capsule, 125 mg capsule) T2 PA QL 0.15 / day aprepitant 80 mg capsule T2 PA QL 0.67 / day S CESAMET T2 PS PA QL 5 / day (2.5 mg capsule, 10 mg capsule) T1 PA QL 5 / day dronabinol 5 mg capsule T1 AL At least 2 yrs old PA QL 3 / fill EMEND TRIPACK T2 PA

EMEND (40 MG CAPSULE, 125 MG CAPSULE, 125 MG QL 0.08 / day T2 POWDER PACKET) PA QL 0.15 / day EMEND 80 MG CAPSULE T2 PA

PAGE 75 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / fill S EMEND 150 MG VIAL T2 PS PA QL 2 / fill S fosaprepitant dimeglumine T2 PS PA QL 6 / 30 days granisetron hcl 1 mg tablet T2 PA S granisetron hcl (1 mg/ml vial, 1 mg/ml(1) vial) T2 PS PA S granisetron hcl/pf T2 PS PA QL 5 / day MARINOL T2 PA ondansetron T1 QL 24 / 30 days ondansetron hcl 4 mg/5 ml solution T1 QL 20 / day ondansetron hcl (4 mg tablet, 8 mg tablet) T1 QL 24 / 30 days ondansetron hcl 24 mg tablet T1 S ondansetron hcl 2 mg/ml vial T2 PS PA S ondansetron hcl in 0.9 % sodium chloride (in 0.9 % 16 T2 PS mg/50ml piggyback, in 0.9 % 8 mg/50 ml piggyback) PA

PAGE 76 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 T2 PS mg/2 ml syringe, hcl/pf 4 mg/2 ml vial) PA S palonosetron hcl 0.25mg/5ml vial T2 PS PA QL 0.144 / day SANCUSO T2 PA S SUSTOL T2 PS PA QL 0.15 / day VARUBI 90 MG TABLET T2 PA QL 20 / day ZOFRAN 4 MG/5 ML ORAL SOLN T2 PA QL 0.8 / DAY ZOFRAN (4 MG TABLET, 8 MG TABLET) T2 PA QL 24 / 30 days ZUPLENZ T2 PA

3 DAY VAGINAL T0 3-DAY VAGINAL CREAM T1 ABELCET T2 PA AF T0 ALEVAZOL T2 PA AMBISOME T2 PA

PAGE 77 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 50 mg vial T2 PA ANCOBON T2 PA ANTI-FUNGAL 1% POWDER T1 ANTI-FUNGAL CREAM T1 ANTI-FUNGAL POWDER T2 PA (EQL TOP CREAM, SM TOPICAL CREAM, T1 TOPICAL CREAM) ANTIFUNGAL (LIQUID SPRAY, POWDER SPRAY, RA LIQUID T0 SPRAY) ANTIFUNGAL CREAM (1% CREAM, 2% TOPICAL CREAM, CARRINGTON 2% CREAM, CVS 1% CREAM, EQL 1% T1 CREAM, RA 1% CREAM, SM 1% CREAM) ANTIFUNGAL POWDER T2 PA ATHLETE'S FOOT 1% POWDER SPRAY T2 PA EQ ATHLETE'S FOOT 1% PWD SPRAY T2 PA ATHLETE'S FOOT (ATHLETE'S CREAM, ATHLETE'S CREAM, ATHLETE'S LIQUID SPRAY, ATHLETES CREAM, CVS ATHLETE'S CREAM, CVS ATHLETE'S LQ SPRAY, EQ T1 ATHLETE'S CREAM, EQL ATHLETE'S CREAM, GNP ATHLETE'S CREAM, SM ATHLETE'S CREAM) ATHLETE'S FOOT 2% POWDER T1 ATHLETE'S FOOT AF T1 ATHLETE'S FOOT SPRAY T2 PA ATHLETIC FOOT CREAM T1 BAZA ANTIFUNGAL T1 BENSAL HP T2 PA BLIS-TO-SOL T1

PAGE 78 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl T2 PA CANCIDAS T2 PA acetate T2 PA CICLODAN (0.77% CREAM, 0.77% CREAM KIT, 8% KIT) T2 PA CICLODAN 8% SOLUTION T1 QL 0.22 / day (0.77 % gel (gram), 1 % shampoo) T2 PA ciclopirox 8 % solution T1 QL 0.22 / day ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) T2 PA ciclopirox//// T2 PA (1 % cream (g), 1 % cream/appl, 1 % solution, T1 2 % cream/appl) clotrimazole 10 mg troche T2 PA CLOTRIMAZOLE AF T1 clotrimazole/ dip 1 %-0.05 % cream (g) T1 cream base no.206 T2 PA CRESEMBA 186 MG CAPSULE T2 PA S CRESEMBA 372 MG VIAL T2 PS PA CRITIC-AID CLEAR AF T1 DESENEX T1 DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 MG T2 PA TABLET) QL 1 / day DIFLUCAN 150 MG TABLET T2 PA

PAGE 79 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ECONASIL T2 PA nitrate 1 % cream (g) T2 PA ECOZA T2 PA ERAXIS (WATER DILUENT) T2 PA ERTACZO T2 PA EXELDERM (CREAM, SOLUTION) T2 PA EXODERM T2 PA EXTINA T2 PA (10 mg/ml susp recon, 40 mg/ml susp recon, T1 50 mg tablet, 100 mg tablet, 200 mg tablet) fluconazole 150 mg tablet T1 QL 1 / day fluconazole in sodium chloride, iso-osmotic (in 100mg/50ml pggybk btl, in 100mg/50ml piggyback, in T2 PA 200mg/0.1l pggybk btl, in 200mg/0.1l piggyback, in 400mg/0.2l pggybk btl, in 400mg/0.2l piggyback) (250 mg capsule, 500 mg capsule) T2 PA FOOT & SNEAKER T0 FORMULA 3 T1 FUNGI CURE T0 FUNGOID TINCTURE (2% TINCTURE, TINCTURE NAIL KIT) T2 PA FUNGOID-D T1 ultramicrosize T2 PA griseofulvin, microsize 125 mg/5ml oral susp T1 griseofulvin, microsize 500 mg tablet T2 PA GYNAZOLE 1 T2 PA

PAGE 80 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GYNE-LOTRIMIN T1 GYNE-LOTRIMIN-7 T1 INZO ANTIFUNGAL T1 CVS ITCH RELIEF 1% TOP CREAM T1 (10 mg/ml solution, 100 mg capsule) T2 PA JOCK ITCH (POWDER SPRAY, RA POWDER SPRAY) T2 PA JOCK ITCH (CREAM, EQ CREAM) T1 JOCK ITCH RELIEF T1 QL 0.267 / day JUBLIA T2 AL At least 18 yrs old PA QL 0.67 / day KERYDIN T2 AL At least 18 yrs old PA (2 % cream (g), 2 % shampoo) T1 ketoconazole (2 % foam, 200 mg tablet) T2 PA KETODAN (FOAM, FOAM KIT) T2 PA LAMISIL T2 PA LAMISIL AF T1 LAMISIL AT T1 PA LOPROX (0.77% CREAM, 0.77% CREAM KIT, 0.77% T2 PA SUSPENSION KIT, 0.77% TOPICAL SUSP, 1% SHAMPOO) LOTRIMIN AF 2% SPRAY POWDER T1 LOTRIMIN AF 1% CREAM T2 PA

PAGE 81 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOTRIMIN AF 2% POWDER T1 LOTRISONE T2 PA QL 2 / day T2 PA QL 2 / day LUZU T2 PA MENTAX T2 PA MICATIN T0 nitrate (2 % aero powd, 2 % cream (g)) T1 miconazole nitrate 2 % cream/appl T1 miconazole nitrate (200 mg-2 % kit, 1200mg-2% kit) T0 miconazole nitrate (100 mg supp.vag, 200 mg-2 % cmb pf T1 crm) miconazole nitrate 200 mg supp.vag T2 PA miconazole/cleanser 17 on wipe 200 mg-2 % kit T1 miconazole nitrate/ /petrolatum, T2 PA MICONAZORB AF T2 PA MICRO-GUARD T1 MONISTAT 3 COMBO PACK T0 MONISTAT 7 (7 COMBINATION PACK, 7 CREAM) T0 MYCAMINE T2 PA hcl (1 % cream (g), 1 % gel (gram), 2 % cream (g)) T2 PA NAFTIN (1% GEL, 2% CREAM, 2% GEL) T2 PA QL 0.767 / day NATACYN T2 PA

PAGE 82 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NIZORAL T2 PA NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET, T2 PA 300 MG/16.7 ML VIAL) NYAMYC T1 (500k unit tablet, 100000/g cream (g), 100000/g T1 oint. (g), 100000/g powder, 100000/ml oral susp) nystatin/ acetonide (nystatin/triamcin 100000-0.1 cream (g), nystatin/triamcin 100000-0.1 oint. T2 PA (g)) NYSTOP T1 CONTROL FOOT-SNEAKER T0 ONMEL T2 PA ORAVIG T2 PA nitrate T2 PA OXISTAT (CREAM, LOTION) T2 PA QL 0.3 / day PENLAC T2 PA (100 mg tablet dr, 200 mg/5ml oral susp) T2 PA REMEDY ANTIFUNGAL 2% CREAM T1 REMEDY ANTIFUNGAL 2% POWDER T1 REMEDY PHYTPLX ANTIFUNGAL OINT T2 PA REMEDY PHYTOPLEX ANTIFUNGAL 2% T1 RINGWORM T1 3 % oint. (g) T2 PA SECURA ANTIFUNGAL T1 SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) T2 PA

PAGE 83 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nitrate (1 % cream (g), 1 % solution) T1 T2 PA hcl T1 (0.4 % cream/appl, 0.8 % cream/appl) T1 terconazole 80 mg supp.vag T1 QL 1.5 / day TINACTIN (CREAM, JOCK ITCH CREAM, POWDER) T1 T1 triacetin T2 PA TRIPLE DYE T1 QL 20 / day S VFEND 40 MG/ML SUSPENSION T2 PS PA QL 4 / day VFEND (50 MG TABLET, 200 MG TABLET) T2 PA VFEND IV T2 PA QL 20 / day S 200 mg/5ml susp recon T2 PS PA QL 4 / day voriconazole (50 mg tablet, 200 mg tablet) T2 PA voriconazole 200 mg vial T2 PA VUSION T2 PA XOLEGEL T2 PA

PAGE 84 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZEASORB 2% POWDER T1 ZEASORB AF T1 ANTIGOUT AGENTS allopurinol 100 mg tablet T1 QL 3 / day allopurinol 300 mg tablet T1 QL 2 / day allopurinol sodium T2 PA ALOPRIM T2 PA 0.6 mg capsule T1 QL 2 / day QL 4 / day colchicine 0.6 mg tablet T2 PA QL 4 / day COLCRYS T2 PA QL 1 / day febuxostat T2 PA QL 0.07 / day S KRYSTEXXA T2 PS PA QL 2 / day MITIGARE T2 PA T1 QL 4 / day probenecid/colchicine T1 QL 2 / day QL 1 / day ULORIC T2 PA QL 1 / day ZURAMPIC T2 AL At least 18 yrs old PA

PAGE 85 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day ZYLOPRIM 100 MG TABLET T2 PA QL 2 / day ZYLOPRIM 300 MG TABLET T2 PA ANTIMIGRAINE AGENTS ALKALOIDS

CAFERGOT T2 PA QL 0.334 / DAY D.H.E.45 T2 PA mesylate 1 mg/ml ampul T2 PA QL 8 / 30 days dihydroergotamine mesylate 0.5mg/spry spray/pump T2 PA ERGOMAR T2 PA tartrate/caffeine T2 PA MIGERGOT SUPPOSITORY T2 PA QL 8 / 30 days MIGRANAL T2 PA SEROTONIN (5-HT) 1B/1D RECEPTOR

QL 0.4 / day malate T2 PA QL 0.6 / day AMERGE T2 PA QL 0.4 / day hydrobromide T2 PA QL 0.6 / day FROVA T2 PA

PAGE 86 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.6 / day succinate T2 PA IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN QL 0.167 / day INJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN T2 INJECT, 6 MG/0.5 ML VIAL) PA QL 6 / 30 days IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) T2 PA QL 0.3 / day IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) T2 PA QL 0.6 / day MAXALT T2 PA QL 0.6 / day MAXALT MLT T2 PA MIGRANOW T2 PA QL 0.6 / day hcl T2 PA ONZETRA XSAIL T2 PA QL 0.4 / day RELPAX T2 PA benzoate (5 mg tab rapdis, 5 mg tablet, 10 mg T1 QL 0.6 / day tab rapdis, 10 mg tablet) (5 mg spray, 20 mg spray) T1 QL 0.2 / DAY sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml QL 0.167 / DAY T2 pen injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr) PA sumatriptan succinate (6 mg/0.5ml syringe, 6 mg/0.5ml T1 QL 0.167 / DAY vial) sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 T1 QL 0.3 / day mg tablet)

PAGE 87 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.3 / day sumatriptan succinate/naproxen sodium T2 PA QL 0.134 / day SUMAVEL DOSEPRO T2 PA QL 0.3 / day TREXIMET T2 PA QL 0.134 / day ZEMBRACE SYMTOUCH T2 PA (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tab QL 0.2 / day T2 rapdis, 5 mg tablet) PA

ZOMIG (2.5 MG NASAL SPRAY, 2.5 MG TABLET, 5 MG QL 0.2 / day T2 NASAL SPRAY, 5 MG TABLET) PA QL 0.2 / day ZOMIG ZMT T2 PA ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS

BLOXIVERZ T2 PA hcl T1 MESTINON (60 MG TABLET, 60 MG/5 ML SOLUTION, 180 T2 PA MG TIMESPAN) methylsulfate (0.5 mg/ml vial, 1 mg/ml vial, 2 mg/2 ml syringe, 3 mg/3 ml syringe, 4 mg/4 ml syringe, T2 PA 5 mg/5 ml syringe) neostigmine methylsulfate in sterile water for injection T2 PA (60 mg tablet, 60 mg/5 ml T1 solution)

PAGE 88 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pyridostigmine bromide 180 mg tablet er T2 PA REGONOL T2 PA ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER (25 mg tablet, 100 mg tablet) T1 MYCOBUTIN T2 PA rifabutin T1 PA ANTITUBERCULARS

CAPASTAT SULFATE T2 PA 250 mg capsule T2 PA ethambutol hcl T1 (50 mg/5 ml solution, 100 mg tablet, 300 mg T1 tablet) isoniazid 100 mg/ml vial T2 PA MYAMBUTOL T2 PA PASER T2 PA QL 1.25 / day PRIFTIN T2 PA pyrazinamide 500 mg tablet T2 PA RIFADIN (150 MG CAPSULE, 300 MG CAPSULE, IV 600 MG T2 PA VIAL) RIFAMATE T2 PA rifampin (150 mg capsule, 300 mg capsule) T1 rifampin 600 mg vial T2 PA

PAGE 89 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RIFATER T2 PA SIRTURO 100 MG TABLET T2 PA TRECATOR T2 PA ANTINEOPLASTICS ALKYLATING AGENTS

ALKERAN 2 MG TABLET T2 PA S ALKERAN 50 MG VIAL T2 PS PA S bendamustine hcl T2 PS PA S BICNU T2 PS PA S busulfan T2 PS PA S BUSULFEX T2 PS PA S carmustine T2 PS PA (25 mg capsule, 50 mg capsule) T1 PA S cyclophosphamide (1 g vial, 2 g vial, 500 mg vial) T2 PS PA

PAGE 90 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S dacarbazine T2 PS PA S EVOMELA T2 PS PA GLEOSTINE T2 PA GLIADEL T2 PA S IFEX T2 PS PA S ifosfamide (1 g vial, 1 g/20 ml vial, 3 g vial, 3 g/60 ml vial) T2 PS PA S ifosfamide/mesna T2 PS PA LEUKERAN T1 MATULANE T2 PA melphalan T1 S melphalan hcl 50 mg vial T2 PS PA S MUSTARGEN T2 PS PA S MYLERAN T1 PS

PAGE 91 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG S CAPSULE, 100 MG VIAL, 140 MG CAPSULE, 180 MG T2 PS CAPSULE, 250 MG CAPSULE) PA S T1 PS PA S TREANDA T2 PS PA QL 3 / day VALCHLOR T2 PA S ZANOSAR T2 PS PA

QL 4 / day S T1 PS PA T1 CASODEX T2 PA T1 S NILANDRON T2 PS PA S T2 PS PA

PAGE 92 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day XTANDI T2 PA QL 4 / day S ZYTIGA 250 MG TABLET T2 PS PA QL 2 / day S ZYTIGA 500 MG TABLET T2 PS PA ANTIANGIOGENIC AGENTS

QL 1 / day S POMALYST T2 PS PA QL 1 / day S REVLIMID T2 PS PA QL 2 / day S THALOMID (150 MG CAPSULE, 200 MG CAPSULE) T2 PS PA QL 1 / day S THALOMID (50 MG CAPSULE, 100 MG CAPSULE) T2 PS PA

PAGE 93 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS /MODIFIERS

S EMCYT T2 PS PA FARESTON T2 PA QL 1.25 / day S FASLODEX T2 PS PA QL 1.25 / day S T2 PS PA SOLTAMOX T2 PA citrate (10 mg tablet, 20 mg tablet) T1 citrate T2 PA ANTIMETABOLITES

S ADRUCIL T2 PS PA S ALIMTA T2 PS PA S capecitabine T1 PS PA

PAGE 94 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S cladribine T2 PS PA S clofarabine T2 PS PA S CLOLAR T2 PS PA S cytarabine T2 PS PA S cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf T2 PS 20 mg/ml vial, cytarabine/pf 100 mg/5ml vial) PA DROXIA T2 PA EFUDEX T2 PA S ELITEK T2 PS PA S floxuridine 500 mg vial T2 PS PA fluorouracil (5 % cream (g), 5 % solution) T1 fluorouracil 2 % solution T2 PA S fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml T2 PS vial, 500mg/10ml vial) PA

PAGE 95 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S FOLOTYN T2 PS PA S gemcitabine hcl (1 g vial, 1 g/26.3ml vial, 2 g vial, 2 T2 PS g/52.6ml vial, 200 mg vial, 200mg/5.26 vial) PA S GEMZAR T2 PS PA HYDREA T2 PA hydroxyurea 500 mg capsule T1 QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET T2 PA QL 3 / day LONSURF 20 MG-8.19 MG TABLET T2 PA mercaptopurine 50 mg tablet T1 S NIPENT T2 PS PA PURIXAN T2 PA S TABLOID T2 PS PA QL 4 / day S XELODA T2 PS PA

PAGE 96 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTINEOPLASTICS, OTHER

S ABRAXANE T2 PS PA S ADRIAMYCIN (10 MG VIAL, 50 MG VIAL) T1 PS S ADRIAMYCIN (10 MG/5 ML VIAL, 20 MG/10 ML VIAL, 50 T2 PS MG/25 ML VIAL, 200 MG/100 ML VIAL) PA S amifostine crystalline T2 PS PA S ARRANON T2 PS PA S azacitidine T2 PS PA S bcg live T2 PS PA S bleomycin sulfate T1 PS PA S CAMPATH T2 PS PA

PAGE 97 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S CAMPTOSAR T2 PS PA S carboplatin (10 mg/ml vial, 150 mg vial) T2 PS PA S cisplatin T2 PS PA S COSMEGEN T2 PS PA CYRAMZA T2 PA S DACOGEN T2 PS PA S dactinomycin T2 PS PA S daunorubicin hcl (5 mg/ml vial, 20 mg vial) T2 PS PA S decitabine T2 PS PA S dexrazoxane hcl T2 PS PA

PAGE 98 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S DOCEFREZ T2 PS PA S (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/4 ml T2 PS vial, 80 mg/8 ml vial, 160 mg/8ml vial, 160mg/16ml vial) PA S DOXIL T2 PS PA S hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml vial, T2 PS 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial) PA S doxorubicin hcl peg-liposomal 2 mg/ml vial T2 PS PA S ELLENCE T2 PS PA S epirubicin hcl (50 mg vial, 50 mg/25ml vial, 200 mg vial, T2 PS 200mg/0.1l vial) PA ERWINAZE T2 PA S ETHYOL T2 PS PA S FARYDAK T2 PS PA

PAGE 99 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S fludarabine phosphate (50 mg vial, 50 mg/2 ml vial) T2 PS PA S FUSILEV T2 PS PA S HALAVEN T2 PS PA S IDAMYCIN PFS T2 PS PA S idarubicin hcl 1 mg/ml vial T2 PS PA S irinotecan hcl (40 mg/2 ml vial, 100 mg/5ml vial, T2 PS 500mg/25ml vial) PA S irinotecan hcl 300mg/15ml vial T1 PS S ISTODAX T2 PS PA S IXEMPRA T2 PS PA QL 0.15 / day S JEVTANA T2 PS PA

PAGE 100 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg T1 tablet, 25 mg tablet) S leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, T2 PS 350 mg vial, 500 mg vial) PA S levoleucovorin calcium (10 mg/ml vial, 50 mg vial) T2 PS PA S LIPODOX T2 PS PA S LIPODOX 50 T2 PS PA LYSODREN T2 PA MARQIBO T2 PA S mesna 100 mg/ml vial T2 PS PA S MESNEX (1 GRAM/10 ML VIAL, 400 MG TABLET) T2 PS PA S mitomycin (5 mg vial, 20 mg vial, 40 mg vial, 40mg/10ml T2 PS vial) PA S mitoxantrone hcl 2 mg/ml vial T2 PS PA

PAGE 101 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S MUTAMYCIN T1 PS S NAVELBINE T2 PS PA S ONCASPAR T2 PS PA S oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial, T2 PS 100mg/20ml vial) PA S 6 mg/ml vial T2 PS PA

PARAPLATIN (50 MG/5 ML VIAL, 150 MG/15 ML VIAL, 450 S T1 MG/45 ML VIAL, 600 MG/60 ML VIAL) PS S PHOTOFRIN T2 PS PA S PROLEUKIN T2 PS PA QL 18 / day PROVENGE T2 PA S T2 PS PA

PAGE 102 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S SYLATRON T2 PS PA SYNRIBO T2 PA S TAXOTERE T2 PS PA S teniposide T2 PS PA S TEPADINA 15 MG VIAL T2 PS PA S thiotepa 15 mg vial T2 PS PA S UVADEX T2 PS PA S valrubicin T2 PS PA S VALSTAR T2 PS PA S VELCADE T2 PS PA

PAGE 103 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S VIDAZA T2 PS PA S vinblastine sulfate T2 PS PA S VINCASAR PFS T2 PS PA S vincristine sulfate T2 PS PA S vinorelbine tartrate T2 PS PA S VORAXAZE T2 PS PA S XOFIGO T2 PS PA S ZALTRAP T2 PS PA S ZINECARD T2 PS PA

PAGE 104 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day S ZOLINZA T2 PS PA INHIBITORS, 3RD GENERATION 1 mg tablet T1 ARIMIDEX T2 PA AROMASIN T2 PA T1 FEMARA T2 PA 2.5 mg tablet T1 INHIBITORS

BELEODAQ T2 PA S ETOPOPHOS T2 PS PA S T2 PS PA S HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE, 4 MG T2 PS VIAL) PA S TOPOSAR T2 PS PA S topotecan hcl (4 mg vial, 4 mg/4 ml vial) T2 PS PA

PAGE 105 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S topotecan hcl 1 mg/ml(1) vial T2 PA MOLECULAR TARGET INHIBITORS

QL 2 / day S AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) T2 PS PA QL 1 / day S AFINITOR 2.5 MG TABLET T2 PS PA QL 1 / day S AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET) T2 PS PA QL 2 / day S AFINITOR DISPERZ 5 MG TABLET T2 PS PA QL 8 / day AL At least 18 yrs old ALECENSA T2 S PS PA QL 4 / day BOSULIF 100 MG TABLET T2 PA QL 1 / day BOSULIF 500 MG TABLET T2 PA

PAGE 106 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day CABOMETYX 20 MG TABLET T2 PA QL 2 / day CABOMETYX 40 MG TABLET T2 PA QL 1.5 / day CABOMETYX 60 MG TABLET T2 PA QL 2 / day CAPRELSA 100 MG TABLET T2 PA QL 1 / day CAPRELSA 300 MG TABLET T2 PA QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK T2 PA QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK T2 PA QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK T2 PA QL 2.5 / day COTELLIC T2 PA QL 1 / day ERIVEDGE T2 PA QL 2 / day S everolimus (5 mg tablet, 7.5 mg tablet) T2 PS PA QL 1 / day S everolimus 2.5 mg tablet T2 PS PA

PAGE 107 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day GILOTRIF T2 PA QL 8 / day S GLEEVEC 100 MG TABLET T2 PS PA QL 2 / day S GLEEVEC 400 MG TABLET T2 PS PA QL 1.25 / day IBRANCE 100 MG CAPSULE T2 PA QL 1 / day IBRANCE 125 MG CAPSULE T2 PA QL 1.667 / day IBRANCE 75 MG CAPSULE T2 PA QL 2 / day ICLUSIG 15 MG TABLET T2 PA QL 1 / day ICLUSIG 45 MG TABLET T2 PA QL 8 / day S mesylate 100 mg tablet T1 PS PA QL 2 / day S imatinib mesylate 400 mg tablet T1 PS PA

PAGE 108 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day IMBRUVICA 140 MG CAPSULE T2 PA QL 4 / day INLYTA T2 PA QL 1 / day IRESSA T2 PA QL 2 / day JAKAFI T2 PA QL 1 / day S KISQALI FEMARA 200 MG CO-PACK T2 PS PA QL 2 / day S KISQALI FEMARA 400 MG CO-PACK T2 PS PA QL 3 / day S KISQALI FEMARA 600 MG CO-PACK T2 PS PA S KYPROLIS (30 MG VIAL, 60 MG VIAL) T2 PS PA

LENVIMA (8 MG DAILY, 10 MG DAILY, 14 MG DAILY, 18 QL 3 / day T2 MG DAILY, 20 MG DAILY, 24 MG DAILY) PA QL 4 / day S MEKINIST 0.5 MG TABLET T2 PS PA

PAGE 109 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day S MEKINIST 2 MG TABLET T2 PS PA QL 4 / day NEXAVAR T2 PA QL 0.124 / day AL At least 18 yrs old NINLARO T2 S PS PA QL 1 / day S ODOMZO T2 PS PA QL 1 / day S SPRYCEL (100 MG TABLET, 140 MG TABLET) T2 PS PA QL 2 / day S SPRYCEL (70 MG TABLET, 80 MG TABLET) T2 PS PA QL 9 / day S SPRYCEL 20 MG TABLET T2 PS PA QL 3 / day S SPRYCEL 50 MG TABLET T2 PS PA

PAGE 110 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day STIVARGA T2 PA QL 1 / day SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) T1 PA QL 7 / day SUTENT 12.5 MG CAPSULE T1 PA QL 3 / day SUTENT 25 MG CAPSULE T1 PA QL 6 / day S TAFINLAR 50 MG CAPSULE T2 PS PA QL 4 / day S TAFINLAR 75 MG CAPSULE T2 PS PA QL 1 / day TAGRISSO T2 AL At least 18 yrs old PA QL 1 / day S TARCEVA (100 MG TABLET, 150 MG TABLET) T2 PS PA QL 6 / day S TARCEVA 25 MG TABLET T2 PS PA

PAGE 111 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day S TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) T2 PS PA QL 0.29 / day S temsirolimus T2 PS PA QL 0.29 / day S TORISEL T2 PS PA QL 6 / day S TYKERB T2 PS PA QL 4 / day VENCLEXTA T2 PA QL 1.5 / day VENCLEXTA STARTING PACK T2 PA QL 4 / day S VOTRIENT T2 PS PA QL 2 / day XALKORI T2 PA QL 8 / day S ZELBORAF T2 PS PA

PAGE 112 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day ZYDELIG T2 PA QL 8 / day AL At least 18 yrs old ZYKADIA 150 MG CAPSULE T2 S PS PA MONOCLONAL ANTIBODIES

ADCETRIS T2 PA ARZERRA T2 PA S AVASTIN T2 PS PA BLINCYTO (35 MCG VIAL, 35MCG VL W-STABILIZER) T2 PA S DARZALEX T2 PS PA S ERBITUX T2 PS PA S GAZYVA T2 PS PA S HERCEPTIN T2 PS PA

PAGE 113 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S KADCYLA T2 PS PA S KEYTRUDA T2 PS PA S OPDIVO (40 MG/4 ML VIAL, 100 MG/10 ML VIAL) T2 PS PA S PERJETA T2 PS PA S RITUXAN T2 PS PA S SYLVANT T2 PS PA S TECENTRIQ 1,200 MG/20 ML VIAL T2 PA UNITUXIN T2 PA S VECTIBIX T2 PS PA S YERVOY T2 PS PA

PAGE 114 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZEVALIN T2 PA

S bexarotene T2 PS PA PANRETIN T2 PA S TARGRETIN (1% GEL, 75 MG CAPSULE) T2 PS PA QL 90 / 365 days S 10 mg capsule T1 PS PA ANTIHELMINTHICS

QL 4 / day 200 mg tablet T1 PA QL 4 / day ALBENZA T2 PA BILTRICIDE T2 PA EMVERM T2 PA 3 mg tablet T1 SKLICE T2 PA STROMECTOL T2 PA

PAGE 115 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) T2 PA T1 PA atovaquone/ hcl T1 phosphate (250 mg tablet, 500 mg tablet) T1 PA COARTEM T2 PA DARAPRIM T2 PA sulfate 200 mg tablet T1 S IMPAVIDO T2 PS PA MALARONE T2 PA hcl T1 MEPRON T2 PA NEBUPENT T2 PA PENTAM 300 T2 PA isethionate 300 mg vial-neb T2 PA PLAQUENIL T2 PA phosphate T2 PA S 25 mg tablet T2 PS PA QL 42 / 365 days QUALAQUIN T2 PA

PAGE 116 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 42 / 365 days sulfate 324 mg capsule T1 PA PEDICULICIDES/SCABICIDES

EURAX (CREAM, LOTION) T2 PA T2 PA OVIDE T2 PA ANTIPARKINSON AGENTS benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg T1 tablet) benztropine mesylate (2 mg/2 ml ampul, 2 mg/2 ml vial) T2 PA COGENTIN T2 PA hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg T1 tablet) ANTIPARKINSON AGENTS, OTHER hcl (50 mg/5 ml solution, 100 mg capsule) T1 amantadine hcl 100 mg tablet T2 PA /levodopa/ T1 COMTAN T2 PA entacapone T2 PA QL 2 / day NUPLAZID 17 MG TABLET T2 PA STALEVO 100 T2 PA STALEVO 125 T2 PA

PAGE 117 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS STALEVO 150 T2 PA STALEVO 200 T2 PA STALEVO 50 T2 PA STALEVO 75 T2 PA TASMAR T2 PA T2 PA AGONISTS

QL 2 / day APOKYN T2 PA mesylate (2.5 mg tablet, 5 mg capsule) T2 PA MIRAPEX T2 PA MIRAPEX ER T2 PA NEUPRO T2 PA PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) T2 PA di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h, 1.5 mg tab er 24h, 2.25 mg tab er 24h, 3 mg tab er T2 PA 24h, 3.75 mg tab er 24h, 4.5 mg tab er 24h) pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 T1 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) REQUIP T2 PA QL 1 / day REQUIP XL T2 PA hcl (2 mg tab er 24h, 8 mg tab er 24h) T1 QL 1 / day ropinirole hcl (4 mg tab er 24h, 6 mg tab er 24h, 12 mg QL 1 / day T2 tab er 24h) PA

PAGE 118 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, T1 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) DOPAMINE PRECURSORS/L- DECARBOXYLASE INHIBITORS carbidopa 25 mg tablet T2 PA carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tab rapdis, carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tab rapdis, carbidopa/levodopa 25mg-100mg tablet, T1 carbidopa/levodopa 25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tab rapdis, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 50mg-200mg tablet er) QL 1 / day DUOPA T2 PA LODOSYN T2 PA RYTARY T2 PA SINEMET 10-100 T2 PA SINEMET 25-100 T2 PA SINEMET 25-250 T2 PA SINEMET CR T2 PA B (MAO-B) INHIBITORS

AZILECT T2 PA mesylate (0.5 mg tablet, 1 mg tablet) T2 PA hcl (5 mg capsule, 5 mg tablet) T1 ZELAPAR T2 PA

PAGE 119 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 1ST GENERATION/TYPICAL

AL At least 18 yrs HALDOL T2 old PA

AL At least 18 yrs HALDOL DECANOATE 100 T2 old PA

AL At least 18 yrs HALDOL DECANOATE 50 T2 old PA decanoate (50 mg/ml ampul, 50 mg/ml vial, T1 AL At least 18 yrs 100 mg/ml ampul, 100 mg/ml vial) old haloperidol lactate (2 mg/ml oral conc, 5 mg/ml ampul, 5 T1 AL At least 18 yrs mg/ml vial) old succinate (5 mg capsule, 10 mg capsule, 25 mg T1 AL At least 18 yrs capsule, 50 mg capsule) old 1st Generation/Typical

AL At least 18 yrs ADASUVE T2 old PA

AL At least 18 yrs hcl 25 mg/ml ampul T2 old PA chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg T1 AL At least 18 yrs tablet, 100 mg tablet, 200 mg tablet) old

AL At least 18 yrs (2.5 mg/ml ampul, 2.5 mg/ml vial) T2 old PA decanoate 25 mg/ml vial T1 AL At least 18 yrs old

PAGE 120 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml T1 AL At least 18 yrs elixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) old

AL At least 18 yrs fluphenazine hcl 2.5 mg/ml vial T2 old PA haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg T1 AL At least 18 yrs tablet, 10 mg tablet, 20 mg tablet) old

AL At least 18 yrs hcl T2 old PA ORAP T2 PA T2 PA hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, T1 AL At least 18 yrs 100 mg tablet) old thiothixene T1 AL At least 18 yrs old hcl T1 AL At least 18 yrs old 2ND GENERATION/ATYPICAL

QL 1 / day ABILIFY T2 AL At least 6 yrs old PA ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER T1 AL At least 18 yrs 400 MG SYR, ER 400 MG VL) old QL 30 / day 1 mg/ml solution T2 AL At least 18 yrs old PA QL 1 / Day aripiprazole (2 mg tablet, 15 mg tablet, 20 mg tablet) T1 AL At least 18 yrs old

PAGE 121 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day aripiprazole (5 mg tablet, 10 mg tablet, 30 mg tablet) T1 AL At least 18 yrs old QL 1 / day aripiprazole (10 mg tab rapdis, 15 mg tab rapdis) T2 AL At least 6 yrs old PA ARISTADA (ER 441 MG/1.6 ML SYRN, ER 662 MG/2.4 ML T1 AL At least 18 yrs SYRN, ER 882 MG/3.2 ML SYRN) old QL 8 / rx FANAPT TITRATION PACK T2 AL At least 18 yrs old PA QL 2 / day FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG T2 AL At least 18 yrs old TABLET) PA QL 2 / day GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG T2 AL At least 18 yrs CAPSULE, 80 MG CAPSULE) old PA

AL At least 18 yrs GEODON 20 MG/ML VIAL T2 old PA QL 8 / day INVEGA ER 1.5 MG TABLET T2 AL At least 18 yrs old PA QL 4 / day INVEGA ER 3 MG TABLET T2 AL At least 18 yrs old PA

PAGE 122 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day INVEGA ER 6 MG TABLET T2 AL At least 18 yrs old PA QL 1 / day INVEGA ER 9 MG TABLET T2 AL At least 18 yrs old PA

INVEGA SUSTENNA T1 AL At least 18 yrs old

INVEGA TRINZA T1 AL At least 18 yrs old

LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, QL 1 / Day T1 120 MG TABLET) AL At least 18 yrs old QL 1 / day LATUDA 80 MG TABLET T1 AL At least 18 yrs old QL 2 / day olanzapine (15 mg tab rapdis, 15 mg tablet) T1 AL At least 18 yrs old QL 6 / day olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet) T1 AL At least 18 yrs old QL 4 / day olanzapine 7.5 mg tablet T1 AL At least 18 yrs old QL 3 / day olanzapine (10 mg tab rapdis, 10 mg tablet) T1 AL At least 18 yrs old QL 1 / day olanzapine (20 mg tab rapdis, 20 mg tablet) T1 AL At least 18 yrs old

PAGE 123 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS olanzapine 10 mg vial T1 AL At least 18 yrs old QL 8 / day 1.5 mg tab er 24 T2 AL At least 18 yrs old PA QL 4 / day paliperidone 3 mg tab er 24 T2 AL At least 18 yrs old PA QL 2 / day paliperidone 6 mg tab er 24 T2 AL At least 18 yrs old PA QL 1 / day paliperidone 9 mg tab er 24 T2 AL At least 18 yrs old PA fumarate (25 mg tablet, 50 mg tab er 24h, 50 QL 6 / day T1 mg tablet) AL At least 18 yrs old QL 5 / day quetiapine fumarate 150 mg tab er 24h T1 AL At least 18 yrs old QL 4 / day quetiapine fumarate 200 mg tab er 24h T1 AL At least 18 yrs old quetiapine fumarate (300 mg tab er 24h, 400 mg tab er QL 2 / day T1 24h, 400 mg tablet) AL At least 18 yrs old QL 3 / day quetiapine fumarate 100 mg tablet T1 AL At least 18 yrs old

PAGE 124 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1.5 / day quetiapine fumarate 200 mg tablet T1 AL At least 18 yrs old QL 1 / day quetiapine fumarate 300 mg tablet T1 AL At least 18 yrs old QL 1 / day REXULTI T2 AL At least 18 yrs old PA QL 16 / day RISPERDAL 1 MG/ML SOLUTION T2 AL At least 18 yrs old PA QL 8 / day RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG T2 AL At least 18 yrs TABLET, 2 MG TABLET) old PA QL 5 / day RISPERDAL 3 MG TABLET T2 AL At least 18 yrs old PA QL 4 / day RISPERDAL 4 MG TABLET T2 AL At least 18 yrs old PA

RISPERDAL CONSTA T1 AL At least 18 yrs old QL 16 / day 1 mg/ml solution T1 AL At least 18 yrs old

PAGE 125 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day risperidone (4 mg tab rapdis, 4 mg tablet) T1 AL At least 18 yrs old risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg QL 8 / day tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 T1 AL At least 18 yrs mg tab rapdis, 2 mg tablet) old QL 5 / day risperidone (3 mg tab rapdis, 3 mg tablet) T1 AL At least 18 yrs old QL 2 / day SAPHRIS T2 AL At least 18 yrs old PA QL 6 / day SEROQUEL (25 MG TABLET, 50 MG TABLET) T2 AL At least 18 yrs old PA QL 3 / day SEROQUEL 100 MG TABLET T2 AL At least 18 yrs old PA QL 1.5 / day SEROQUEL 200 MG TABLET T2 AL At least 18 yrs old PA QL 1 / day SEROQUEL 300 MG TABLET T2 AL At least 18 yrs old PA QL 2 / day SEROQUEL 400 MG TABLET T2 AL At least 18 yrs old PA

PAGE 126 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 18 yrs SEROQUEL XR SAMPLE KIT T2 old PA QL 2 / day SEROQUEL XR (300 MG TABLET, 400 MG TABLET) T2 AL At least 18 yrs old PA QL 5 / day SEROQUEL XR 150 MG TABLET T2 AL At least 18 yrs old PA QL 4 / day SEROQUEL XR 200 MG TABLET T2 AL At least 18 yrs old PA QL 6 / day SEROQUEL XR 50 MG TABLET T2 AL At least 18 yrs old PA QL 1 / day VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MG T2 AL At least 18 yrs CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) old PA QL 2 / day hcl T1 AL At least 18 yrs old ziprasidone mesylate T1 PA QL 6 / day ZYPREXA (2.5 MG TABLET, 5 MG TABLET) T2 AL At least 18 yrs old PA

PAGE 127 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day ZYPREXA 10 MG TABLET T2 AL At least 18 yrs old PA QL 2 / day ZYPREXA 15 MG TABLET T2 AL At least 18 yrs old PA QL 1 / day ZYPREXA 20 MG TABLET T2 AL At least 18 yrs old PA QL 4 / day ZYPREXA 7.5 MG TABLET T2 AL At least 18 yrs old PA

AL At least 18 yrs ZYPREXA 10 MG VIAL T2 old PA QL 0.08 / day ZYPREXA RELPREVV (210 MG VIAL, 300 MG VIAL, 405 MG T2 AL At least 18 yrs VIAL) old PA

ZYPREXA RELPREVV (210 MG VL KIT, 300 MG VL KIT, 405 AL At least 18 yrs T2 old MG VL KIT) PA QL 3 / day ZYPREXA ZYDIS 10 MG TABLET T2 AL At least 18 yrs old PA QL 2 / day ZYPREXA ZYDIS 15 MG TABLET T2 AL At least 18 yrs old PA

PAGE 128 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day ZYPREXA ZYDIS 20 MG TABLET T2 AL At least 18 yrs old PA QL 6 / day ZYPREXA ZYDIS 5 MG TABLET T2 AL At least 18 yrs old PA TREATMENT-RESISTANT

QL 9 / day 100 mg tablet T1 AL At least 18 yrs old QL 4 / day clozapine 200 mg tablet T1 AL At least 18 yrs old QL 18 / day clozapine 25 mg tablet T1 AL At least 18 yrs old QL 3 / day clozapine 50 mg tablet T1 AL At least 18 yrs old QL 3 / day clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 150 mg T2 AL At least 18 yrs tab rapdis, 200 mg tab rapdis) old PA QL 9 / day clozapine 100 mg tab rapdis T2 AL At least 18 yrs old PA QL 9 / day CLOZARIL 100 MG TABLET T2 AL At least 18 yrs old PA

PAGE 129 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day CLOZARIL 200 MG TABLET T2 PA QL 18 / day CLOZARIL 25 MG TABLET T2 AL At least 18 yrs old PA QL 3 / day CLOZARIL 50 MG TABLET T2 PA QL 3 / day FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200 T2 AL At least 18 yrs MG ODT) old PA QL 9 / day FAZACLO 100 MG ODT T2 AL At least 18 yrs old PA QL 20 / day VERSACLOZ T2 AL At least 18 yrs old PA ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

S cidofovir 75 mg/ml vial T2 PS PA S CYTOVENE T2 PS PA FOSCAVIR T2 PA

PAGE 130 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ganciclovir T2 PS PA S ganciclovir sodium 500 mg vial T2 PS PA VALCYTE 50 MG/ML SOLUTION T2 PA QL 4 / day VALCYTE 450 MG TABLET T2 PA valganciclovir hcl 50 mg/ml soln recon T2 PA QL 4 / day valganciclovir hcl 450 mg tablet T2 PA QL 0.167 / DAY ZIRGAN T2 PA ANTI-HEPATITIS B (HBV) AGENTS

S adefovir dipivoxil T2 PS PA QL 20 / day S BARACLUDE 0.05 MG/ML SOLUTION T2 PS PA QL 1 / day S BARACLUDE (0.5 MG TABLET, 1 MG TABLET) T2 PS PA QL 1 / day S entecavir 0.5 mg tablet T1 PS PA

PAGE 131 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day entecavir 1 mg tablet T1 S PS S EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) T2 PS PA QL 1 / day S HEPSERA T2 PS PA S 100 mg tablet T1 PS QL 1 / day S VEMLIDY T2 PS PA ANTI-HEPATITIS C (HCV) AGENTS

QL 1 / day S DAKLINZA T2 PS PA

AL At least 6 yrs old EPCLUSA 400 MG-100 MG TABLET T2 S PS PA

AL At least 3 yrs old HARVONI 90-400 MG TABLET T2 S PS PA

PAGE 132 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, S 18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 T2 PS MILLION UNITS VIL) PA

AL At least 3 yrs old ledipasvir/sofosbuvir T2 S PS PA QL 6 / day S MODERIBA T1 PS PA S PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) T2 PS PA S PEGASYS PROCLICK T2 PS PA S PEGINTRON T1 PS PA QL 30 / day S REBETOL T2 PS PA QL 6 / day S RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) T1 PS PA

PAGE 133 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day S RIBASPHERE 400 MG TABLET T2 PS PA QL 2 / day S RIBASPHERE 600 MG TABLET T2 PS PA QL 2 / day S RIBASPHERE RIBAPAK T2 PS PA QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) T1 S PS

AL At least 6 yrs old sofosbuvir/velpatasvir T1 S PS PA S SOVALDI 400 MG TABLET T2 PS PA S VIEKIRA PAK T2 PS PA S VOSEVI T2 PS PA

PAGE 134 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ZEPATIER T2 PS PA ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

S GENVOYA T1 PS

ISENTRESS (25 MG TABLET CHEW, 100 MG POWDER S T1 PACKET, 100 MG TABLET CHEW, 400 MG TABLET) PS S STRIBILD T1 PS S TIVICAY T1 PS ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

S ATRIPLA T2 PS PA S COMPLERA T1 PS S EDURANT T1 PS S (50 mg capsule, 200 mg capsule, 600 mg tablet) T1 PS efavirenz// fumarate T1 S S INTELENCE T1 PS (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 S T1 mg tablet, 400 mg tab er 24h) PS

PAGE 135 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ODEFSEY T1 PS S RESCRIPTOR T2 PS PA S SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG T2 PS TABLET) PA S VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) T2 PS PA S VIRAMUNE XR T2 PS PA ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

S sulfate (20 mg/ml solution, 300 mg tablet) T1 PS S abacavir sulfate/lamivudine T1 PS S abacavir sulfate/lamivudine/ T1 PS S COMBIVIR T2 PS PA QL 1 / day DESCOVY T1 S PS

PAGE 136 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S T1 PS emtricitabine T1 S emtricitabine/tenofovir disoproxil fumarate T1 S S EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) T2 PS PA S EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG T2 PS TABLET) PA S EPZICOM T2 PS PA lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg S T1 tablet) PS S lamivudine/zidovudine T1 PS S RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE, 200 T2 PS MG/20 ML VIAL) PA S T1 PS S tenofovir disoproxil fumarate T1 PS S TRIZIVIR T2 PS PA

PAGE 137 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MG S T1 TABLET, 167 MG-250 MG TABLET) PS S TRUVADA 200 MG-300 MG TABLET T2 PS PA S VIDEX T2 PS PA S VIDEX EC T2 PS PA

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG S T1 TABLET, POWDER) PS S VIREAD 300 MG TABLET T2 PS PA S ZERIT T2 PS PA S ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) T2 PS PA zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg S T1 tablet) PS ANTI-HIV AGENTS, OTHER

QL 2 / day FUZEON T1 S PS

PAGE 138 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S PREZCOBIX T1 PS S SELZENTRY (150 MG TABLET, 300 MG TABLET) T1 PS PA S TRIUMEQ T1 PS S TYBOST T2 PS PA ANTI-HIV AGENTS, INHIBITORS

S APTIVUS 250 MG CAPSULE T1 PS S APTIVUS 100 MG/ML SOLUTION T2 PS PA S sulfate T1 PS S CRIXIVAN T2 PS PA S EVOTAZ T1 PS S calcium T1 PS S INVIRASE T1 PS

PAGE 139 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S KALETRA 80 MG-20 MG/ML SOLN T2 PS PA S KALETRA (100-25 MG TABLET, 200-50 MG TABLET) T1 PS S LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) T2 PS PA S / T1 PS S NORVIR 80 MG/ML SOLUTION T1 PS S NORVIR 100 MG TABLET T2 PS PA

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 S T1 MG TABLET, 600 MG TABLET, 800 MG TABLET) PS S REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, T2 PS 200 MG CAPSULE, 300 MG CAPSULE) PA S ritonavir T1 PS S VIRACEPT T1 PS ANTI- AGENTS

FLUMADINE T2 PA

PAGE 140 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75 T1 QL 20 / 365 days mg capsule) oseltamivir phosphate 6 mg/ml susp recon T1 QL 6 / DAY QL 40 / 365 days RELENZA T2 PA hcl T2 PA

TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MG QL 20 / 365 days T2 CAPSULE) PA QL 6 / DAY TAMIFLU 6 MG/ML SUSPENSION T2 PA ANTIHERPETIC AGENTS acyclovir 5 % cream (g) T1 QL 0.167 / DAY acyclovir 5 % oint. (g) T2 PA acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg T1 tablet, 800 mg tablet) acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg T2 PA vial) acyclovir sodium/dextrose 5 % in water T2 PA S ALFERON N T2 PS PA QL 0.167 / DAY DENAVIR T2 PA famciclovir T1 QL 2 / fill SITAVIG T2 AL At least 18 yrs old PA

PAGE 141 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS trifluridine 1 % drops T2 PA valacyclovir hcl (500 mg tablet, 1000 mg tablet) T1 VALTREX T2 PA QL 0.167 / day XERESE T2 AL At least 6 yrs old PA ZOVIRAX 5% CREAM T1 QL 0.167 / DAY QL 30 / fill ZOVIRAX 5% OINTMENT T2 PA ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG T2 PA TABLET, 800 MG TABLET) ANXIOLYTICS ANXIOLYTICS, OTHER

BREVITAL SODIUM T2 PA hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, T1 15 mg tablet, 30 mg tablet) T2 PA hcl (2 mg/2 ml vial, 2 mg/ml syrup, 5 mg/5 ml vial, 5 mg/ml vial, 5 mg/ml(1) vial, 10 mg/10ml vial, 10 T2 PA mg/2 ml vial) midazolam hcl in 0.9 % sodium chloride (in 0.9 % 2 mg/2 T2 PA ml syringe, in 0.9 % 5 mg/5 ml syringe) midazolam hcl in 0.9 % sodium chloride/pf (in 0.9 % nacl/pf 2 mg/2 ml syringe, in 0.9 % nacl/pf 5 mg/5 ml T1 syringe)

PAGE 142 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS midazolam hcl/pf (hcl/pf 2 mg/2 ml cartridge, hcl/pf 2 mg/2 ml syringe, hcl/pf 2 mg/2 ml vial, hcl/pf 5 mg/5 ml syringe, hcl/pf 5 mg/5 ml vial, hcl/pf 5 mg/ml cartridge, T2 PA hcl/pf 5 mg/ml syringe, hcl/pf 5 mg/ml(1) vial, hcl/pf 10 mg/2 ml syringe, hcl/pf 10 mg/2 ml vial)

QL 1 / day (0.5 mg tab er 24h, 1 mg tab er 24h) T2 PA QL 5 / day alprazolam (2 mg tab er 24h, 2 mg tab rapdis) T2 PA QL 3 / day alprazolam 3 mg tab er 24h T2 PA alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) T1 QL 4 / day alprazolam 2 mg tablet T1 QL 5 / day alprazolam (0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg QL 4 / day T2 tab rapdis) PA QL 10 / day ALPRAZOLAM INTENSOL T2 PA QL 3 / day ATIVAN (0.5 MG TABLET, 1 MG TABLET) T2 PA QL 5 / day ATIVAN 2 MG TABLET T2 PA ATIVAN (2 MG/ML VIAL, 4 MG/ML VIAL, 40 MG/10 ML T2 PA VIAL) chlordiazepoxide hcl 10 mg capsule T1 QL 30 / day chlordiazepoxide hcl 25 mg capsule T1 QL 12 / day chlordiazepoxide hcl 5 mg capsule T1 QL 4 / day

PAGE 143 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (0.5 mg tablet, 1 mg tablet) T1 QL 3 / day clonazepam 2 mg tablet T1 QL 10 / day clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 QL 3 / day T2 mg tab rapdis, 1 mg tab rapdis) PA QL 10 / day clonazepam 2 mg tab rapdis T2 PA QL 6 / day dipotassium 15 mg tablet T2 PA QL 24 / day clorazepate dipotassium 3.75 mg tablet T2 PA QL 12 / day clorazepate dipotassium 7.5 mg tablet T2 PA diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 T1 mg/ml oral conc, 10 mg tablet) diazepam (5 mg/ml cartridge, 5 mg/ml syringe, 5 mg/ml T2 PA vial) QL 3 / day KLONOPIN (0.5 MG TABLET, 1 MG TABLET) T2 PA QL 10 / day KLONOPIN 2 MG TABLET T2 PA QL 5 / day 2 mg/ml oral conc T2 PA lorazepam (0.5 mg tablet, 1 mg tablet) T1 QL 3 / day lorazepam 2 mg tablet T1 QL 5 / day lorazepam (2 mg/ml cartridge, 2 mg/ml syringe, 2 mg/ml T2 PA vial, 4 mg/ml cartridge, 4 mg/ml vial)

PAGE 144 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lorazepam in 0.9 % sodium chloride T2 PA lorazepam in 5 % dextrose and water T2 PA QL 5 / day LORAZEPAM INTENSOL T2 PA QL 4 / day T2 PA QL 12 / day TRANXENE T-TAB T2 PA VALIUM T2 PA QL 4 / day XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) T2 PA QL 5 / day XANAX 2 MG TABLET T2 PA QL 1 / day XANAX XR (0.5 MG TABLET, 1 MG TABLET) T2 PA QL 5 / day XANAX XR 2 MG TABLET T2 PA QL 3 / day XANAX XR 3 MG TABLET T2 PA BIPOLAR AGENTS MOOD STABILIZERS

EQUETRO T2 PA carbonate (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mg tablet er, 450 mg tablet er, 600 mg T1 capsule) T2 PA

PAGE 145 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LITHOBID T2 PA REGULATORS ANTIDIABETIC AGENTS acarbose 100 mg tablet T1 QL 3 / day acarbose 25 mg tablet T1 QL 12 / day acarbose 50 mg tablet T1 QL 6 / day QL 3 / day ACTOPLUS MET T2 PA QL 3 / day ACTOPLUS MET XR 15-1,000 MG TB T2 PA QL 1 / day ACTOPLUS MET XR 30-1,000 MG TB T2 PA QL 1 / day ACTOS T2 PA ADLYXIN T2 PA

AL At least 18 yrs alogliptin benzoate T2 old PA

AL At least 18 yrs alogliptin benzoate/metformin hcl T2 old PA

AL At least 18 yrs alogliptin benzoate/ hcl T2 old PA AMARYL T2 PA QL 3 / day AVANDIA 2 MG TABLET T2 PA

PAGE 146 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day AVANDIA 4 MG TABLET T2 PA BYDUREON T1 BYDUREON PEN T1 BYETTA T1 100 mg tablet T2 PA QL 3 / day chlorpropamide 250 mg tablet T2 PA QL 6 / day CYCLOSET T2 PA QL 1 / day DUETACT T2 PA QL 1 / DAY FARXIGA T1 AL At least 18 yrs old FORTAMET ER 500 MG TABLET T2 PA T1 (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 T1 mg tab er 24, 10 mg tablet) glipizide/metformin hcl (glipizide/metformin 2.5-500 mg T1 QL 4 / day tablet, glipizide/metformin 5 mg-500mg tablet) glipizide/metformin hcl 2.5-250 mg tablet T1 QL 8 / day QL 2.5 / day GLUCOPHAGE 1,000 MG TABLET T2 PA QL 5 / day GLUCOPHAGE 500 MG TABLET T2 PA

PAGE 147 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day GLUCOPHAGE 850 MG TABLET T2 PA QL 5 / day GLUCOPHAGE XR 500 MG TAB T2 PA QL 3 / day GLUCOPHAGE XR 750 MG TAB T2 PA GLUCOTROL T2 PA GLUCOTROL XL T2 PA GLUMETZA T2 PA glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) T1 glyburide,micronized T1 glyburide/metformin hcl (glyburide/metformin 2.5-500 T1 QL 4 / day mg tablet, glyburide/metformin 5 mg-500mg tablet) glyburide/metformin hcl 1.25-250mg tablet T1 QL 8 / day GLYNASE T2 PA QL 3 / day GLYSET T2 PA

GLYXAMBI T1 AL At least 18 yrs old HUMULIN R U-500 KWIKPEN T1

INVOKAMET T1 AL At least 18 yrs old

INVOKAMET XR T1 AL At least 18 yrs old QL 2 / DAY INVOKANA 100 MG TABLET T1 AL At least 18 yrs old

PAGE 148 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / DAY INVOKANA 300 MG TABLET T1 AL At least 18 yrs old QL 2 / DAY JANUMET T1 AL At least 18 yrs old

JANUMET XR T1 AL At least 18 yrs old QL 1 / DAY JANUVIA T1 AL At least 18 yrs old

JARDIANCE T1 AL At least 18 yrs old

JENTADUETO T1 AL At least 18 yrs old

AL At least 18 yrs JENTADUETO XR T2 old PA

AL At least 18 yrs KAZANO T2 old PA

AL At least 18 yrs KOMBIGLYZE XR T2 old PA QL 25 / day metformin hcl 500 mg/5ml solution T2 PA metformin hcl (500 mg tab er 24, 1000 mg tabergr24h) T2 PA metformin hcl (500 mg tab er 24h, 500 mg tablet) T1 QL 5 / day QL 5 / day metformin hcl 500 mg tabergr24h T2 PA

PAGE 149 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metformin hcl (750 mg tab er 24h, 850 mg tablet) T1 QL 3 / day metformin hcl 1000 mg tablet T1 QL 2.5 / day QL 3 / day miglitol T2 PA T1 QL 3 / day

AL At least 18 yrs NESINA T2 old PA

AL At least 18 yrs ONGLYZA T2 old PA

AL At least 18 yrs OSENI T2 old PA QL 1 / day pioglitazone hcl T1 AL At least 18 yrs old QL 1 / day pioglitazone hcl/glimepiride T2 PA QL 3 / day pioglitazone hcl/metformin hcl T2 PA QL 4 / day PRANDIN 1 MG TABLET T2 PA QL 8 / day PRANDIN 2 MG TABLET T2 PA QL 3 / day PRECOSE 100 MG TABLET T2 PA QL 12 / day PRECOSE 25 MG TABLET T2 PA

PAGE 150 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 6 / day PRECOSE 50 MG TABLET T2 PA (0.5 mg tablet, 1 mg tablet) T1 QL 4 / day repaglinide 2 mg tablet T1 QL 8 / day QL 5 / day repaglinide/metformin hcl T2 PA QL 25 / day RIOMET T2 PA QL 3 / day STARLIX T2 PA SYMLINPEN 120 T2 PA SYMLINPEN 60 T2 PA

SYNJARDY T1 AL At least 18 yrs old QL 4 / day 250 mg tablet T2 PA QL 2 / day tolazamide 500 mg tablet T2 PA QL 6 / day T2 PA

TRADJENTA T1 AL At least 18 yrs old TRULICITY (0.75 MG/0.5 ML PEN, 1.5 MG/0.5 ML PEN) T2 PA VICTOZA 2-PAK T1 VICTOZA 3-PAK T1 XIGDUO XR (5 MG-1,000 MG TABLET, 5 MG-500 MG T1 AL At least 18 yrs TABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET) old

PAGE 151 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLYCEMIC AGENTS 50 mg/ml oral susp T2 PA GLUCAGEN 1 MG HYPOKIT T1 QL 2 / 30 days GLUCAGEN DIAGNOSTIC 1 MG VIAL T2 PA QL 2 / 30 days GLUCAGON EMERGENCY KIT T2 PA glucagon hcl T2 PA lancing device/lancets T1 PROGLYCEM T2 PA

ADMELOG T1 ADMELOG SOLOSTAR T1 AFREZZA (4 UNIT CARTRIDGE, 90-4 UNIT / 90-8 UNIT) T2 PA APIDRA T2 PA APIDRA SOLOSTAR T2 PA BASAGLAR KWIKPEN U-100 T1 HUMALOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL) T1 HUMALOG KWIKPEN U-100 T1 HUMALOG KWIKPEN U-200 T2 PA HUMALOG MIX 50-50 T1 HUMALOG MIX 50-50 KWIKPEN T1 HUMALOG MIX 75-25 T1 HUMALOG MIX 75-25 KWIKPEN T1 HUMULIN 70-30 T1

PAGE 152 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HUMULIN 70/30 KWIKPEN T1 HUMULIN N T1 HUMULIN N KWIKPEN T1 HUMULIN R T1 HUMULIN R U-500 T1 aspart (100/ml (3) insuln pen, 100/ml cartridge, T1 100/ml vial) protamine /insulin aspart (art prot/insuln 70-30/ml insuln pen, art prot/insuln 70-30/ml T1 vial) 100/ml insuln pen T1 insulin lispro 100/ml vial T1 insulin lispro protamine and insulin lispro T1 LANTUS T1 LANTUS SOLOSTAR T1 LEVEMIR T1 LEVEMIR FLEXTOUCH T1 NOVOLIN 70-30 T2 PA NOVOLIN 70-30 FLEXPEN T2 PA NOVOLIN N T2 PA NOVOLIN N FLEXPEN T2 PA NOVOLIN R T2 PA NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL) T1 NOVOLOG FLEXPEN T1 NOVOLOG MIX 70-30 T1

PAGE 153 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NOVOLOG MIX 70-30 FLEXPEN T1 SOLIQUA 100-33 T2 PA TOUJEO SOLOSTAR T2 PA QL 1 / day TRESIBA FLEXTOUCH U-100 T2 PA QL 0.5 / day TRESIBA FLEXTOUCH U-200 T2 PA XULTOPHY 100-3.6 T2 PA BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ANTICOAGULANTS

ACD SOLUTION A T2 PA ACD-A SOLUTION T2 PA S ACTIVASE T2 PS PA AGGRASTAT (5 MG/100 ML VIAL, 12.5 MG/250 ML) T2 PA ANGIOMAX T2 PA argatroban T2 PA argatroban in 0.9 % sodium chloride (in 0.9 % 125 mg/125 vial, in 0.9 % 250 mg/250 iv soln, in 0.9 % 50 mg/50ml T2 PA vial) argatroban in sodium chloride, iso-osmotic T2 PA S ARIXTRA T2 PS PA

PAGE 154 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ATRYN T2 PA bivalirudin (250 mg vial, 250 mg vial port) T2 PA S CATHFLO ACTIVASE T2 PS PA citrate phosphate dextros soln T2 PA COUMADIN T2 PA ELIQUIS (2.5 MG TABLET, 5 MG TABLET) T1 enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 S T1 mg/ml syringe, 120mg/.8ml syringe, 150 mg/ml syringe, PS 300mg/3ml vial) S fondaparinux sodium T2 PS PA

FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000 UNIT/0.2 ML S SYR, 7,500 UNIT/0.3 ML SYR, 10,000 UNIT/ML SYRINGE, T2 PS 12,500 UNIT/0.5 ML SYR, 15,000 UNIT/0.6 ML SYR, 18,000 UNIT/0.72 ML, 95,000 UNIT/3.8 ML VL) PA heparin sodium,porcine T2 PA heparin sodium,porcine in 0.45 % sodium chloride T2 PA

PAGE 155 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS heparin sodium,porcine in 0.9 % sodium chloride (sod,porcine/0.9 % 100/100 ml iv soln, sod,porcine/0.9 % 100/ml kit, sod,porcine/0.9 % 10k/1000ml iv soln, sod,porcine/0.9 % 1k/1000 ml iv soln, sod,porcine/0.9 % 2000/500ml iv soln, sod,porcine/0.9 % 250/250 ml iv soln, sod,porcine/0.9 % 2500/500ml iv soln, sod,porcine/0.9 % T2 PA 25000/250 iv soln, sod,porcine/0.9 % 3000/500ml iv soln, sod,porcine/0.9 % 30k/1000ml iv soln, sod,porcine/0.9 % 4k/1000 ml iv soln, sod,porcine/0.9 % 500/500 ml iv soln, sod,porcine/0.9 % 5000/500ml iv soln, sod,porcine/0.9 % 5k/1000 ml iv soln, sod,porcine/0.9 % 6k/1000 ml iv soln) heparin sodium,porcine in 0.9 % sodium chloride/pf T2 PA heparin sodium,porcine/dextrose 5 % in water T2 PA heparin sodium,porcine/pf (sodium,porcine/pf 1 unit/ml syringe, sodium,porcine/pf 10 unit/ml syringe, sodium,porcine/pf 10 unit/ml vial, sodium,porcine/pf 100/ml (1) syringe, sodium,porcine/pf 200/2 ml syringe, T2 PA sodium,porcine/pf 300/3 ml syringe, sodium,porcine/pf 500/5 ml syringe, sodium,porcine/pf 1000/10 ml syringe, sodium,porcine/pf 1000/ml vial, sodium,porcine/pf 5000/0.5ml syringe, sodium,porcine/pf 5000/0.5ml vial) heparin sodium,porcine/pf (sodium,porcine/pf 100/ml (1) T1 vial, sodium,porcine/pf 5000/0.5ml cartridge) JANTOVEN T1

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML S SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML T2 PS SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 MG/3 ML VIAL) PA PRADAXA T1 protamine sulfate 10 mg/ml vial T2 PA RETAVASE T2 PA SAVAYSA T2 PA

PAGE 156 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium citrate (4 % (3 ml) syringe, 4 g/100 ml solution) T2 PA sodium citrate 4 % (4 ml) syringe T1 S THROMBATE III T2 PS PA TNKASE 50 MG KIT T2 PA TRICITRASOL T2 PA sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg T1 tablet, 10 mg tablet)

XARELTO DVT-PE TREAT START 30D T1 AL Up to 999 yrs old XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET) T1 BLOOD FORMATION MODIFIERS

QL 4 / day AGRYLIN T2 PA QL 4 / day anagrelide hcl T2 PA ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML S VIAL, 100 MCG/0.5 ML SYRINGE, 100 MCG/ML VIAL, 150 T2 PS MCG/0.3 ML SYRINGE, 200 MCG/0.4 ML SYRINGE, 200 PA MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE) S ARANESP 150 MCG/0.75 ML VIAL T1 PS S EPOGEN T1 PS

PAGE 157 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 ML S SYRINGE, 480 MCG/0.8 ML SAFE SYR, 480 MCG/0.8 ML T2 PS SYRINGE) PA S LEUKINE T2 PS PA

MIRCERA (50 MCG/0.3 ML SYRINGE, 75 MCG/0.3 ML S SYRINGE, 100 MCG/0.3 ML SYRINGE, 200 MCG/0.3 ML T2 PS SYRINGE) PA S MOZOBIL T2 PS PA S NEULASTA T2 PS PA S NEULASTA ONPRO T2 PS PA S NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, T2 PS 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) PA S NPLATE (250 MCG VIAL, 500 MCG VIAL) T2 PS PA S PROCRIT T2 PS PA

PAGE 158 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MG T2 PS TABLET, 75 MG TABLET) PA S ZARXIO T2 PS PA COAGULANTS

S ADVATE T2 PS PA S ADYNOVATE T2 PS PA S AFSTYLA T2 PS PA S ALPHANATE T2 PS PA S ALPHANINE SD T2 PS PA S ALPROLIX T2 PS PA AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, T2 PA 1,000 MG TABLET)

PAGE 159 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (250 mg/ml solution, 250 mg/ml vial, T2 PA 500 mg tablet, 1000 mg tablet) ASTRINGYN T2 PA S BENEFIX T2 PS PA COAGADEX T2 PA S CORIFACT T2 PS PA S CYKLOKAPRON (MG/10 ML AMP, MG/10 ML VL) T2 PS PA S ELOCTATE T2 PS PA S FEIBA NF T2 PS PA S HELIXATE FS T2 PS PA S HEMOFIL M T2 PS PA S HUMATE-P T2 PS PA

PAGE 160 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S IDELVION T2 PS PA S IXINITY T2 PS PA KCENTRA T2 PA S KOATE T2 PS PA S KOGENATE FS T2 PS PA S KOVALTRY T2 PS PA QL 6 / 90 dayplus LYSTEDA T2 PA S MONONINE T2 PS PA MONSEL'S T2 PA S NOVOEIGHT T2 PS PA S NOVOSEVEN RT T2 PS PA

PAGE 161 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S NUWIQ T2 PS PA S OBIZUR T2 PS PA S PROFILNINE T2 PS PA S RECOMBINATE T2 PS PA S RECOTHROM T2 PS PA S RIASTAP T2 PS PA S RIXUBIS T2 PS PA -JMI (5,000 UNIT EPIST, 5,000 UNITS SYR, 5,000 UNITS VIAL, 20,000 UNITS PUMP, 20,000 UNITS T2 PA SYR, 20,000 UNITS VIAL) TISSEEL VHSD (2 ML KIT, 2 ML PRIMA SYRNG, FROZEN 2 ML SYR, 4 ML KIT, 4 ML PRIMA SYRNG, FROZEN 4 ML SYR, T2 PA 10 ML KIT, 10 ML PRIMA SYRNG, FROZEN 10 ML SYR) S (1000 mg/10 ampul, 1000 mg/10 vial) T2 PS PA

PAGE 162 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tranexamic acid 650 mg tablet T1 QL 6 / day S TRETTEN T2 PS PA S VONVENDI T2 PS PA S WILATE T2 PS PA S XYNTHA T2 PS PA S XYNTHA SOLOFUSE T2 PS PA PLATELET MODIFYING AGENTS

AGGRASTAT 3.75 MG/15 ML VIAL T2 PA QL 2 / day AGGRENOX T2 PA QL 2 / day aspirin/dipyridamole T2 PA BRILINTA T1 QL 2 / day cilostazol T1 QL 2 / day clopidogrel bisulfate (75 mg tablet, 300 mg tablet) T1 QL 1 / day DEFINITY T2 PA

PAGE 163 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) T1 QL 4 / day dipyridamole 5 mg/ml vial T2 PA QL 1 / day EFFIENT T2 PA eptifibatide T2 PA INTEGRILIN T2 PA KENGREAL T2 PA LEXISCAN T2 PA OPTISON T2 PA QL 1 / day PLAVIX T2 PA prasugrel hcl T1 QL 1 / day REOPRO T2 PA YOSPRALA T2 PA QL 1 / day ZONTIVITY T2 AL At least 18 yrs old PA CARDIOVASCULAR AGENTS ALPHA- AGONISTS

CATAPRES T2 PA CATAPRES-TTS 1 T1 CATAPRES-TTS 2 T1 CATAPRES-TTS 3 T1 T2 PA

PAGE 164 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) T1 clonidine hcl/pf T2 PA DURACLON T2 PA hcl (1 mg tablet, 2 mg tablet) T1 T1 methyldopate hcl T2 PA hcl T1 ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA T2 PA DIBENZYLINE T2 PA mesylate (1 mg tablet, 2 mg tablet, 4 mg T1 tablet, 8 mg tablet) MINIPRESS T2 PA hcl 10 mg capsule T2 PA mesylate 5 mg vial T2 PA hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) T1 II RECEPTOR ANTAGONISTS

QL 1 / day ATACAND T2 PA QL 1 / day AVAPRO T2 PA QL 3 / day BENICAR T2 PA QL 1 / day candesartan cilexetil T2 PA

PAGE 165 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day COZAAR (25 MG TABLET, 50 MG TABLET) T2 PA QL 1 / day COZAAR 100 MG TABLET T2 PA QL 2 / day DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) T2 PA QL 1 / day DIOVAN 320 MG TABLET T2 PA QL 1 / day EDARBI T2 PA QL 1 / day eprosartan mesylate T2 PA irbesartan T1 QL 1 / day losartan potassium (25 mg tablet, 50 mg tablet) T1 QL 2 / day losartan potassium 100 mg tablet T1 QL 1 / day QL 1 / day MICARDIS T2 PA olmesartan medoxomil T1 QL 3 / day QL 1 / day T2 PA valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) T1 QL 2 / day valsartan 320 mg tablet T1 QL 1 / day ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

QL 2 / day ACCUPRIL T2 PA

PAGE 166 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day ALTACE T2 PA benazepril hcl (10 mg tablet, 40 mg tablet) T1 QL 2 / day benazepril hcl 20 mg tablet T1 QL 4 / day benazepril hcl 5 mg tablet T1 QL 3 / day captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 QL 4 / day T2 mg tablet) PA enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg T1 QL 2 / day tablet, 20 mg tablet) enalaprilat dihydrate 1.25 mg/ml vial T2 PA QL 5 / day EPANED T2 PA fosinopril sodium T1 QL 2 / day lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg T1 QL 1 / day tablet, 30 mg tablet) lisinopril 40 mg tablet T1 QL 2 / day QL 2 / day LOTENSIN (10 MG TABLET, 40 MG TABLET) T2 PA QL 4 / day LOTENSIN 20 MG TABLET T2 PA QL 1 / day moexipril hcl T2 PA QL 1 / day perindopril erbumine T2 PA QL 1 / day PRINIVIL T2 PA

PAGE 167 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 40 / day QBRELIS T2 PA quinapril hcl T1 QL 2 / day ramipril T1 QL 2 / day trandolapril T1 QL 2 / day QL 2 / day VASOTEC T2 PA

ZESTRIL (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET, QL 1 / day T2 20 MG TABLET, 30 MG TABLET) PA QL 2 / day ZESTRIL 40 MG TABLET T2 PA ANTIARRHYTHMICS

ADENOSCAN T2 PA (3 mg/ml syringe, 3 mg/ml vial) T2 PA hcl (100 mg tablet, 200 mg tablet, 400 mg T1 tablet) amiodarone hcl (50 mg/ml vial, 150 mg/3ml syringe) T2 PA amiodarone hcl/dextrose 5 % in water T2 PA BETAPACE T2 PA BETAPACE AF T2 PA CORVERT T2 PA phosphate T2 PA S T2 PS PA

PAGE 168 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS acetate T1 fumarate T2 PA hcl (150 mg capsule, 200 mg capsule, 250 mg T2 PA capsule) MULTAQ T2 PA NEXTERONE T2 PA NORPACE T2 PA NORPACE CR T2 PA PACERONE T2 PA hcl 500 mg/ml vial T2 PA hcl (225 mg cap er 12h, 325 mg cap er 12h, T2 PA 425 mg cap er 12h) propafenone hcl (150 mg tablet, 225 mg tablet, 300 mg T1 tablet) gluconate 324 mg tablet er T2 PA quinidine sulfate (200 mg tablet, 300 mg tablet) T2 PA RYTHMOL SR T2 PA SORINE T1 hcl (80 mg tablet, 120 mg tablet, 150mg/10ml vial, T1 160 mg tablet, 240 mg tablet) SOTYLIZE T2 PA S TIKOSYN T2 PS PA

PAGE 169 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BETA-ADRENERGIC BLOCKING AGENTS hcl (200 mg capsule, 400 mg capsule) T1 (25 mg tablet, 50 mg tablet, 100 mg tablet) T1 hcl (10 mg tablet, 20 mg tablet) T2 PA fumarate T1 BREVIBLOC (100 MG/10 ML VIAL, 2,000 MG/100 ML BAG, T2 PA 2,500 MG/250 ML BAG) QL 3 / day BYSTOLIC (5 MG TABLET, 10 MG TABLET) T2 PA QL 1 / day BYSTOLIC 2.5 MG TABLET T2 PA QL 2 / day BYSTOLIC 20 MG TABLET T2 PA T1 carvedilol phosphate (10 mg cpmp 24hr, 20 mg cpmp QL 2 / day T2 24hr, 40 mg cpmp 24hr) PA QL 1 / day carvedilol phosphate 80 mg cpmp 24hr T2 PA COREG T2 PA

COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR QL 2 / day T2 40 MG CAPSULE) PA

QL 1 / day COREG CR 80 MG CAPSULE T2 PA CORGARD T2 PA esmolol hcl (100mg/10ml syringe, 100mg/10ml vial) T2 PA

PAGE 170 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS esmolol hcl in sodium chloride, iso-osmotic T2 PA HEMANGEOL T2 PA INDERAL LA T2 PA INDERAL XL T2 PA INNOPRAN XL T2 PA hcl (5 mg/ml vial, 20 mg/4 ml cartridge, 20 mg/4 T2 PA ml syringe, 25 mg/5 ml syringe) labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg T1 tablet) LOPRESSOR (5 MG/5 ML AMPUL, 50 MG TABLET, 100 MG T2 PA TABLET) succinate T1 metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg T1 tablet, 75 mg tablet, 100 mg tablet) metoprolol tartrate (5 mg/5 ml ampul, 5 mg/5 ml T2 PA cartridge, 5 mg/5 ml vial) (20 mg tablet, 40 mg tablet, 80 mg tablet) T2 PA T2 PA hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa T1 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa 24h, 160 mg cap sa 24h) propranolol hcl 1 mg/ml vial T2 PA TENORMIN T2 PA maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) T2 PA TOPROL XL T2 PA

PAGE 171 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CALCIUM CHANNEL BLOCKING AGENTS

QL 1 / day ADALAT CC 30 MG TABLET T2 PA QL 2 / day ADALAT CC 60 MG TABLET T2 PA ADALAT CC 90 MG TABLET T2 PA AFEDITAB CR T1 QL 1 / day besylate (2.5 mg tablet, 5 mg tablet, 10 mg T1 QL 1 / day tablet) QL 3 / day CALAN T2 PA QL 1 / day CALAN SR T2 PA CARDENE I.V. (CARDENE I.V. 25 MG/10 ML AMPUL, CARDENE-DEX 20 MG/200 ML SOLN, CARDENE-NACL 20 T2 PA MG/200 ML SOLN, CARDENE-NACL 40 MG/200 ML IV) QL 4 / day CARDIZEM T2 PA QL 1 / day CARDIZEM CD (300 MG CAPSULE, 360 MG CAPSULE) T2 PA QL 4 / day CARDIZEM CD 120 MG CAPSULE T2 PA QL 3 / day CARDIZEM CD 180 MG CAPSULE T2 PA QL 2 / day CARDIZEM CD 240 MG CAPSULE T2 PA

PAGE 172 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MG QL 1 / day T2 TABLET) PA QL 4 / day CARDIZEM LA 120 MG TABLET T2 PA QL 3 / day CARDIZEM LA 180 MG TABLET T2 PA QL 2 / day CARDIZEM LA 240 MG TABLET T2 PA CARTIA XT 120 MG CAPSULE T1 QL 4 / day CARTIA XT 180 MG CAPSULE T1 QL 3 / day CARTIA XT 240 MG CAPSULE T1 QL 2 / day CARTIA XT 300 MG CAPSULE T1 QL 1 / day CLEVIPREX T2 PA DILT XR 120 MG CAPSULE T1 QL 4 / day DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) T1 hcl (180 mg cap er 24h, 180 mg cap er deg, 180 T1 QL 3 / day mg cap sa 24h) diltiazem hcl (300 mg cap er 24h, 360 mg cap er 24h) T1 QL 1 / day diltiazem hcl 240 mg cap er 24h T1 QL 2 / day diltiazem hcl (60 mg cap er 12h, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 240 mg cap er deg, 240 mg cap T1 sa 24h, 300 mg cap sa 24h, 360 mg cap sa 24h, 420 mg cap sa 24h) diltiazem hcl (300 mg tab er 24h, 360 mg tab er 24h, 420 T1 QL 1 / day mg tab er 24h) diltiazem hcl 180 mg tab er 24h T1 QL 3 / day

PAGE 173 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diltiazem hcl 240 mg tab er 24h T1 QL 2 / day diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg cap er 24h, 120 mg cap er deg, 120 mg cap sa 24h, 120 mg T1 QL 4 / day tablet) diltiazem hcl (5 mg/ml vial, 100 mg vial port) T2 PA diltiazem hcl in 0.9% nacl 125 mg/125 plast. bag T2 PA diltiazem hcl/d5w 125 mg/125 plast. bag T2 PA T1 QL 1 / day QL 2 / day 2.5 mg capsule T2 PA QL 4 / day isradipine 5 mg capsule T2 PA

MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG QL 1 / day T2 TABLET) PA QL 3 / day MATZIM LA 180 MG TABLET T2 PA QL 2 / day MATZIM LA 240 MG TABLET T2 PA hcl (2.5 mg/ml syringe, 20 mg capsule, 25 T2 PA mg/10ml ampul, 25 mg/10ml vial, 30 mg capsule) nicardipine hcl-0.9% sod chlor 1 mg/10 ml syringe T2 PA nicardipine in 5 % dextrose in water T2 PA nicardipine in sodium chloride, iso-osmotic T2 PA (10 mg capsule, 20 mg capsule) T1 QL 4 / day nifedipine (30 mg tab er 24, 30 mg tablet er, 90 mg tab er T1 QL 1 / day 24, 90 mg tablet er)

PAGE 174 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nifedipine (60 mg tab er 24, 60 mg tablet er) T1 QL 2 / day T2 PA QL 1 / day T2 PA QL 1 / day NORVASC T2 PA

NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 ML QL 120 / day T2 SOLUTION) PA QL 4 / day PROCARDIA T2 PA QL 1 / day PROCARDIA XL (30 MG TABLET, 90 MG TABLET) T2 PA QL 2 / day PROCARDIA XL 60 MG TABLET T2 PA QL 1 / day SULAR T2 PA TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MG T1 CAPSULE) TAZTIA XT 120 MG CAPSULE T1 QL 4 / day TAZTIA XT 180 MG CAPSULE T1 QL 3 / day TIADYLT ER (ER 240 MG CAPSULE, ER 300 MG CAPSULE, T1 ER 360 MG CAPSULE, ER 420 MG CAPSULE) TIADYLT ER 120 MG CAPSULE T1 QL 4 / day TIADYLT ER 180 MG CAPSULE T1 QL 3 / day TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER T2 PA 360 MG CAPSULE, ER 420 MG CAPSULE)

PAGE 175 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day TIAZAC ER 120 MG CAPSULE T2 PA QL 3 / day TIAZAC ER 180 MG CAPSULE T2 PA hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 40 mg T1 tablet) verapamil hcl (100 mg cap24h pct, 200 mg cap24h pct, QL 1 / day T2 300 mg cap24h pct, 360 mg cap24h pel) PA verapamil hcl (120 mg cap24h pel, 180 mg cap24h pel, T1 QL 1 / day 240 mg cap24h pel) verapamil hcl 2.5 mg/ml syringe T2 PA verapamil hcl (80 mg tablet, 120 mg tablet) T1 QL 3 / day verapamil hcl (120 mg tablet er, 180 mg tablet er, 240 mg T1 QL 1 / day tablet er) QL 1 / day VERELAN T2 PA QL 1 / day VERELAN PM T2 PA CARDIOVASCULAR AGENTS, OTHER

QL 2 / day ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) T2 PA QL 1 / day ACCURETIC 20-25 MG TABLET T2 PA AKOVAZ T2 PA ALDACTAZIDE 25-25 TABLET T2 PA QL 1 / day aliskiren hemifumarate T2 PA

PAGE 176 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS alprostadil 500 mcg/ml vial T2 PA hcl/ T1 QL 1 / day amlodipine besylate/atorvastatin calcium T2 PA amlodipine besylate/benazepril hcl T1 QL 1 / day amlodipine besylate/olmesartan medoxomil T1 QL 1 / day amlodipine besylate/valsartan (besylate/valsartan 5 mg- 320mg tablet, besylate/valsartan 10mg-160mg tablet, T1 QL 1 / day besylate/valsartan 10mg-320mg tablet) amlodipine besylate/valsartan 5 mg-160mg tablet T1 QL 2 / day QL 1 / day amlodipine besylate/valsartan/hydrochlorothiazide T2 PA QL 1 / day ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) T2 PA QL 2 / day ATACAND HCT 16-12.5 MG TAB T2 PA atenolol/chlorthalidone T1 QL 2 / day AVALIDE 150-12.5 MG TABLET T2 PA QL 1 / day AVALIDE 300-12.5 MG TABLET T2 PA QL 1 / day AZOR T2 PA benazepril hcl/hydrochlorothiazide T1 QL 1 / day QL 1 / day BENICAR HCT T2 PA

PAGE 177 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 6 / day BIDIL T2 PA bisoprolol fumarate/hydrochlorothiazide T1 BYVALSON T1 QL 1 / day QL 1 / day CADUET T2 PA candesartan cilexetil/hydrochlorothiazide QL 1 / day (candesartan/hydrochlorothiazid 32-12.5mg tablet, T2 candesartan/hydrochlorothiazid 32mg-25mg tablet) PA QL 2 / day candesartan/hydrochlorothiazid 16-12.5mg tablet T2 PA QL 2 / day captopril/hydrochlorothiazide T2 PA cardioplegic solution no.1 T2 PA cardioplegic solution no.10 T2 PA QL 2 / day CORLANOR (5 MG TABLET, 7.5 MG TABLET) T2 PA CORZIDE T2 PA DEMSER T2 PA DIGIFAB T2 PA DIGITEK T1 DIGOX T1 digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) T2 PA digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg T1 tablet) QL 1 / day DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) T2 PA

PAGE 178 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB, QL 2 / day T2 160-25 MG TABLET) PA hcl T2 PA dobutamine hcl in dextrose 5 % in water T2 PA dopamine hcl (200 mg/5ml vial, 400mg/10ml vial, T2 PA 800mg/10ml vial, 800mg/5ml vial) dopamine hcl 400 mg/5ml vial T1 dopamine hcl in dextrose 5 % in water T2 PA QL 2 / day DUTOPROL T2 PA DYAZIDE T2 PA QL 1 / day EDARBYCLOR T2 PA enalapril/hydrochlorothiazide 10 mg-25mg tablet T1 QL 2 / day enalapril/hydrochlorothiazide 5mg-12.5mg tablet T1 QL 2 / Day ENTRESTO T1 AL At least 18 yrs old sulfate (50mg/ml(1) ampul, 50mg/ml(1) vial) T2 PA ephedrine sulfate 50 mg/ml ampul T1 ephedrine sulfate in 0.9 % sodium chloride/pf (sulfate/0.9% nacl/pf 10 mg/5 ml syringe, sulfate/0.9% nacl/pf 100mg/10ml syringe, sulfate/0.9% nacl/pf T2 PA 10mg/ml(1) syringe, sulfate/0.9% nacl/pf 25 mg/5 ml syringe, sulfate/0.9% nacl/pf 50 mg/10ml syringe, sulfate/0.9% nacl/pf 50 mg/5 ml syringe) QL 1 / day EXFORGE T2 PA

PAGE 179 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day EXFORGE HCT T2 PA QL 2 / day fosinopril sodium/hydrochlorothiazide T2 PA QL 1 / day HYZAAR (100-12.5 TABLET, 100-25 TABLET) T2 PA QL 2 / day HYZAAR 50-12.5 TABLET T2 PA irbesartan/hydrochlorothiazide 150-12.5mg tablet T1 QL 2 / day irbesartan/hydrochlorothiazide 300-12.5mg tablet T1 QL 1 / day LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250 MCG TABLET, 500 MCG/2 ML AMPULE, T2 PA 500 MCG/2 ML VIAL) LANOXIN PEDIATRIC (100 MCG/ML AMPUL, 100 MCG/ML T2 PA VIAL) LEVOPHED T2 PA LEVOPHED BITARTRATE T2 PA lisinopril/hydrochlorothiazide T1 QL 2 / day LOPRESSOR HCT T2 PA losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide 100-12.5mg tablet, T1 QL 1 / day losartan/hydrochlorothiazide 100mg-25mg tablet) losartan/hydrochlorothiazide 50-12.5 mg tablet T1 QL 2 / day QL 1 / day LOTENSIN HCT T2 PA QL 1 / day LOTREL T2 PA

PAGE 180 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mannitol (5 % iv soln, 10 % iv soln, 20 % iv soln, 25 % vial) T2 PA MAXZIDE T2 PA MAXZIDE-25 MG T2 PA methyldopa/hydrochlorothiazide T2 PA metoprolol tartrate/hydrochlorothiazide T1 QL 1 / day MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) T2 PA QL 2 / day MICARDIS HCT 80-12.5 MG TABLET T2 PA milrinone lactate 1 mg/ml vial T2 PA milrinone lactate/dextrose 5 % in water T2 PA nadolol/bendroflumethiazide T2 PA NATRECOR T2 PA 500 mg capsule er T1 norepinephrine bitartrate (1 mg/ml ampul, 1 mg/ml vial) T2 PA norepinephrine bitartrate in 0.9 % sodium chloride (bit/0.9 % 16mg/250ml plast. bag, bit/0.9 % 16mg/500ml T2 PA plast. bag, bit/0.9 % 4mg/250ml plast. bag, bit/0.9 % 8 mg/250ml plast. bag, bit/0.9 % 8 mg/500ml plast. bag) norepinephrine bitartrate in 5 % dextrose in water (bitartrate/d5w 16mg/250ml plast. bag, bitartrate/d5w T2 PA 4mg/250ml plast. bag, bitartrate/d5w 8 mg/250ml plast. bag, bitartrate/d5w 8 mg/500ml plast. bag) QL 6 / DAY NORTHERA T2 PA olmesartan medoxomil/amlodipine QL 1 / day T2 besylate/hydrochlorothiazide PA

PAGE 181 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS olmesartan medoxomil/hydrochlorothiazide T1 QL 1 / day OSMITROL T2 PA 400 mg tablet er T1 hcl 10 mg/ml vial T2 PA phenylephrine hcl in 0.9 % sodium chloride (in 0.4mg/10ml syringe, in 0.5 mg/5ml syringe, in 0.5mg/10ml syringe, in 0.8mg/10ml syringe, in 1 mg/10 ml syringe, in 5 mg/50 ml syringe, in 20mg/250ml plast. bag, in 25mg/250ml plast. bag, in 30mg/250ml plast. T2 PA bag, in 40mg/250ml plast. bag, in 50mg/250ml plast. bag, in 80mg/250ml plast. bag, in 100mg/0.1l plast. bag, in 100mg/250 plast. bag, in 200mcg/2ml syringe, in 200mcg/5ml syringe) phenylephrine hcl in dextrose 5 % in water (hcl/dextrose 5 % 10mg/250ml plast. bag, hcl/dextrose 5 % 200mg/.25l T2 PA plast. bag, hcl/dextrose 5 % 20mg/250ml plast. bag, hcl/dextrose 5 % 50mg/250ml plast. bag) PLEGISOL T2 PA QL 1 / day PRESTALIA T2 PA propranolol hcl/hydrochlorothiazide T1 PROSTIN VR PEDIATRIC T2 PA quinapril hcl/hydrochlorothiazide QL 2 / day (quinapril/hydrochlorothiazide 10-12.5mg tablet, T2 quinapril/hydrochlorothiazide 20-12.5 mg tablet) PA QL 1 / day quinapril/hydrochlorothiazide 20 mg-25mg tablet T2 PA QL 2 / day RANEXA T2 PA

PAGE 182 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T1 QL 2 / day /hydrochlorothiazide T1 QL 1 / day TARKA T2 PA QL 1 / day TEKTURNA T2 PA QL 1 / day TEKTURNA HCT T2 PA QL 1 / day telmisartan/amlodipine besylate T2 PA QL 2 / day telmisartan/hydrochlorothiazid 80-12.5mg tablet T2 PA telmisartan/hydrochlorothiazide QL 1 / day (telmisartan/hydrochlorothiazid 40-12.5 mg tablet, T2 telmisartan/hydrochlorothiazid 80 mg-25mg tablet) PA TENORETIC 100 T2 PA TENORETIC 50 T2 PA trandolapril/verapamil hcl T2 PA /hydrochlorothiazide (triamterene/hydrochlorothiazid 37.5-25 mg capsule, triamterene/hydrochlorothiazid 37.5-25 mg tablet, T1 triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg-50mg tablet) QL 1 / day TRIBENZOR T2 PA QL 1 / day TWYNSTA T2 PA

PAGE 183 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 320-12.5mg tablet, T1 QL 1 / day valsartan/hydrochlorothiazide 320mg-25mg tablet) valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 80-12.5mg tablet, T1 QL 2 / day valsartan/hydrochlorothiazide 160-12.5mg tablet, valsartan/hydrochlorothiazide 160mg-25mg tablet) QL 2 / day VASERETIC T2 PA VAZCULEP T2 PA VECAMYL T2 PA QL 2 / day ZESTORETIC T2 PA ZIAC T2 PA DIURETICS, CARBONIC ANHYDRASE INHIBITORS (125 mg tablet, 250 mg tablet, 500 mg T1 capsule er) acetazolamide sodium T2 PA QL 4 / day KEVEYIS T2 PA DIURETICS, LOOP 0.5 mg tablet T1 bumetanide (0.25 mg/ml vial, 1 mg tablet, 2 mg tablet) T2 PA DEMADEX T2 PA EDECRIN T2 PA ethacrynate sodium T2 PA

PAGE 184 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ethacrynic acid T2 PA (10 mg/ml syringe, 10 mg/ml vial) T2 PA furosemide (10 mg/ml solution, 20 mg tablet, 40 mg T1 tablet, 40mg/5ml solution, 80 mg tablet) furosemide in 0.9 % sodium chloride T2 PA furosemide/dextrose 5 % in water T2 PA LASIX T2 PA SODIUM EDECRIN T2 PA torsemide T1 DIURETICS, POTASSIUM-SPARING

ALDACTAZIDE 50-50 TABLET T2 PA ALDACTONE T2 PA amiloride hcl 5 mg tablet T1 DYRENIUM T2 PA T2 PA INSPRA T2 PA spironolactone (25 mg tablet, 50 mg tablet, 100 mg T1 tablet) DIURETICS, chlorothiazide T1 chlorothiazide sodium T2 PA chlorthalidone T1 DIURIL T2 PA hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 T1 mg tablet, 50 mg tablet)

PAGE 185 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS indapamide T1 methyclothiazide T2 PA metolazone T1 MICROZIDE T2 PA SODIUM DIURIL T2 PA DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

QL 2 / day ANTARA 30 MG CAPSULE T2 PA QL 1 / day ANTARA 90 MG CAPSULE T2 PA QL 2 / day (40 mg tablet, 50 mg capsule, 54 mg tablet) T2 PA fenofibrate (120 mg tablet, 150 mg capsule, 160 mg QL 1 / day T2 tablet) PA fenofibrate nanocrystallized 145 mg tablet T1 QL 1 / day fenofibrate nanocrystallized 160 mg tablet T1 QL 1 / day fenofibrate nanocrystallized 48 mg tablet T1 QL 2 / day fenofibrate,micronized (130 mg capsule, 134 mg capsule, QL 1 / day T2 200 mg capsule) PA QL 2 / day fenofibrate,micronized 43 mg capsule T2 PA fenofibrate,micronized 67 mg capsule T1 QL 1 / day QL 1 / day fenofibric acid 105 mg tablet T2 PA QL 2 / day fenofibric acid 35 mg tablet T2 PA

PAGE 186 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day fenofibric acid (choline) 135 mg capsule dr T2 PA QL 2 / day fenofibric acid (choline) 45 mg capsule dr T2 PA QL 1 / day FENOGLIDE 120 MG TABLET T2 PA QL 2 / day FENOGLIDE 40 MG TABLET T2 PA QL 1 / day FIBRICOR 105 MG TABLET T2 PA QL 2 / day FIBRICOR 35 MG TABLET T2 PA 600 mg tablet T1 QL 2 / day QL 1 / day LIPOFEN 150 MG CAPSULE T2 PA QL 2 / day LIPOFEN 50 MG CAPSULE T2 PA QL 2 / day LOPID T2 PA QL 1 / day TRICOR 145 MG TABLET T2 PA QL 2 / day TRICOR 48 MG TABLET T2 PA QL 1 / day TRIGLIDE T2 PA QL 1 / day TRILIPIX DR 135 MG CAPSULE T2 PA

PAGE 187 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day TRILIPIX DR 45 MG CAPSULE T2 PA DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

QL 1 / day ALTOPREV T2 PA atorvastatin calcium T1 QL 1 / day QL 1 / day CRESTOR T2 PA QL 2 / day fluvastatin sodium 40 mg capsule T2 PA QL 1 / day fluvastatin sodium (20 mg capsule, 80 mg tab er 24h) T2 PA QL 1 / day LESCOL 20 MG CAPSULE T2 PA QL 2 / day LESCOL 40 MG CAPSULE T2 PA QL 1 / day LESCOL XL T2 PA QL 1 / day LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) T2 PA LIPITOR 80 MG TABLET T2 PA QL 1 / day LIVALO T2 PA (10 mg tablet, 20 mg tablet) T1 QL 1 / day lovastatin 40 mg tablet T1 QL 2 / day

PAGE 188 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day PRAVACHOL T2 PA pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg T1 QL 1 / day tablet) pravastatin sodium 80 mg tablet T1 rosuvastatin calcium T1 QL 1 / day (10 mg tablet, 20 mg tablet, 40 mg tablet) T1 QL 1.5 / day simvastatin (5 mg tablet, 80 mg tablet) T1 QL 1 / day QL 1.5 / day ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) T2 PA QL 1 / day ZOCOR 80 MG TABLET T2 PA DYSLIPIDEMICS, OTHER cholestyramine (with ) 4 g powder T1 QL 24 / day cholestyramine (with sugar) 4 g powd pack T1 QL 4 / day cholestyramine/ 4 g powder T1 QL 24 / day cholestyramine/aspartame 4 g powd pack T1 QL 4 / day QL 1 / day colesevelam hcl 3.75 g powd pack T2 PA colesevelam hcl 625 mg tablet T1 QL 6 / day QL 30 / day COLESTID GRANULES T2 PA QL 6 / day COLESTID (FLAVORED GRANULES, GRANULES PACKET) T2 PA QL 4 / day COLESTID 1 GM TABLET T2 PA

PAGE 189 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 6 / day colestipol hcl (5 g granules, 5 g packet) T2 PA colestipol hcl 1 g tablet T1 QL 4 / day ENDUR-ACIN ER 250 MG TABLET T0 ENDUR-ACIN ER 500 MG TABLET T1 ezetimibe T1 QL 1 / day QL 1 / day ezetimibe/simvastatin T2 PA

JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG QL 1 / day T2 CAPSULE, 60 MG CAPSULE) PA QL 2 / day JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) T2 PA niacin (750 mg tab er 24h, 1000 mg tab er 24h, 1000 mg T1 QL 2 / day tablet er) niacin 250 mg tablet T0 niacin (500 mg tab er 24h, 500 mg tablet er) T1 QL 3 / day niacin (500 mg tablet, 750 mg tablet er) T1 niacin 250 mg tablet er T1 niacinamide 500 mg tablet T1 QL 12 / day NIACOR T2 PA QL 2 / day NIASPAN (ER 750 MG TABLET, ER 1,000 MG TABLET) T2 PA QL 3 / day NIASPAN ER 500 MG TABLET T2 PA QL 0.08 / day S PRALUENT PEN T2 PS PA

PAGE 190 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREVALITE POWDER T1 QL 24 / day PREVALITE PACKET T1 QL 4 / day QL 24 / day QUESTRAN POWDER T2 PA QL 4 / day QUESTRAN PACKET T2 PA QL 24 / day QUESTRAN LIGHT T2 PA QL 0.13 / day S REPATHA PUSHTRONEX T2 PS PA QL 0.08 / day S REPATHA SURECLICK T2 PS PA QL 0.08 / day S REPATHA SYRINGE T2 PS PA SLO-NIACIN 250 MG TABLET T1 QL 4 / day VASCEPA T2 PA QL 1 / day VYTORIN T2 PA QL 1 / day WELCHOL 3.75G PACKET T2 PA

PAGE 191 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 6 / day WELCHOL 625 MG TABLET T2 PA QL 1 / day ZETIA T2 PA VASODILATORS, DIRECT-ACTING ARTERIAL CORLOPAM (10 MG/ML AMPUL, 10 MG/ML VIAL, 20 T2 PA MG/2 ML AMPUL, 20 MG/2 ML VIAL) hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, T1 100 mg tablet) hydralazine hcl 20 mg/ml vial T2 PA (2.5 mg tablet, 10 mg tablet) T1 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS amyl nitrite T2 PA QL 4 / day DILATRATE-SR T2 PA QL 1.25 / day GONITRO T2 PA QL 4 / day ISOCHRON T2 PA QL 12 / day ISORDIL T2 PA QL 12 / day ISORDIL TITRADOSE T2 PA isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg T1 QL 12 / day tablet, 30 mg tablet) QL 12 / day isosorbide dinitrate 40 mg tablet T2 PA

PAGE 192 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isosorbide dinitrate 40 mg tablet er T1 QL 4 / day isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 T1 QL 2 / day mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h) QL 1 / day MINITRAN T2 PA NITRO-BID T1 QL 4 / day QL 1 / day NITRO-DUR T2 PA QL 4 / day NITRO-TIME T2 PA nitroglycerin (2.5 mg capsule er, 6.5 mg capsule er, 9 mg QL 4 / day T2 capsule er) PA nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24) T1 QL 1 / day QL 1 / day nitroglycerin (0.4mg/hr patch td24, 0.6mg/hr patch td24) T2 PA QL 0.8 / day nitroglycerin 400mcg/spr spray T2 PA nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl) T1 QL 6 / day QL 6 / day nitroglycerin 0.6 mg tab subl T2 PA nitroglycerin 50 mg/10ml vial T2 PA nitroglycerin in 5 % dextrose in water T2 PA QL 0.8 / DAY NITROLINGUAL T2 PA QL 0.3 / day NITROMIST T2 PA

PAGE 193 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NITROPRESS T2 PA nitroprusside sodium T2 PA QL 6 / day NITROSTAT T2 PA CENTRAL AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS,

AL 4.0 to 17.0 yrs T2 old PA

ADDERALL XR (20 MG CAPSULE, 25 MG CAPSULE, 30 MG QL 2 / DAY T1 CAPSULE) AL 4.0 to 17.0 yrs old

ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG QL 1 / DAY T1 CAPSULE) AL 4.0 to 17.0 yrs old

AL 4.0 to 17.0 yrs ADZENYS XR-ODT T2 old PA

AL 4.0 to 17.0 yrs sulfate T2 old PA

AL 4.0 to 17.0 yrs DESOXYN T2 old PA

AL 4.0 to 17.0 yrs DEXEDRINE T2 old PA

PAGE 194 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulf-saccharate/amphetamine sulf- QL 2 / DAY aspartate (dextroamphetamine/amphetamine 20 mg cap er 24h, dextroamphetamine/amphetamine 25 mg cap er T2 AL 4.0 to 17.0 yrs old 24h, dextroamphetamine/amphetamine 30 mg cap er 24h) PA dextroamphetamine sulf-saccharate/amphetamine sulf- QL 1 / DAY aspartate (dextroamphetamine/amphetamine 5 mg cap er 24h, dextroamphetamine/amphetamine 10 mg cap er T2 AL 4.0 to 17.0 yrs old 24h, dextroamphetamine/amphetamine 15 mg cap er 24h) PA dextroamphetamine sulf-saccharate/amphetamine sulf- aspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg tablet, T1 AL 4.0 to 17.0 yrs dextroamphetamine/amphetamine 12.5 mg tablet, old dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg tablet, dextroamphetamine/amphetamine 30 mg tablet) dextroamphetamine sulfate (5 mg capsule er, 5 mg/5 ml AL 4.0 to 17.0 yrs T2 old solution, 10 mg capsule er, 15 mg capsule er) PA dextroamphetamine sulfate (5 mg tablet, 10 mg tablet) T1 AL 4.0 to 17.0 yrs old

AL 4.0 to 17.0 yrs DYANAVEL XR T2 old PA

AL 4.0 to 17.0 yrs EVEKEO T2 old PA

AL 4.0 to 17.0 yrs hcl T2 old PA

AL 4.0 to 17.0 yrs PROCENTRA T2 old PA

PAGE 195 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VYVANSE (20 MG CAPSULE, 30 MG CAPSULE, 40 MG QL 1 / DAY CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG T1 AL 4.0 to 17.0 yrs CAPSULE) old

VYVANSE 10 MG CAPSULE T1 AL 4.0 to 17.0 yrs old

AL 4.0 to 17.0 yrs ZENZEDI T2 old PA ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

AL 4.0 to 17.0 yrs APTENSIO XR T2 old PA hcl T1 QL 1 / DAY clonidine hcl 0.1 mg tab er 12h T1

CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 54 QL 1 / DAY T1 MG TABLET) AL 4.0 to 17.0 yrs old QL 2 / DAY CONCERTA ER 36 MG TABLET T1 AL 4.0 to 17.0 yrs old QL 1 / DAY DAYTRANA T1 AL 4.0 to 17.0 yrs old QL 1 / day hcl (20 mg cpbp 50-50, 40 mg cpbp T2 AL 4.0 to 17.0 yrs 50-50) old PA QL 1 / DAY dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp T2 AL 4.0 to 17.0 yrs old 50-50, 35 mg cpbp 50-50) PA

PAGE 196 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 AL 4.0 to 17.0 yrs T2 old mg tablet) PA

FOCALIN T1 AL 4.0 to 17.0 yrs old FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG QL 1 / DAY CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE, 30 MG T1 AL 4.0 to 17.0 yrs CAPSULE, 35 MG CAPSULE) old

FOCALIN XR 40 MG CAPSULE T1 AL 4.0 to 17.0 yrs old guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg T1 tab er 24h, 4 mg tab er 24h) INTUNIV T2 PA

AL 4.0 to 18.0 yrs KAPVAY T2 old PA

AL 4.0 to 17.0 yrs METADATE ER T2 old PA

AL 4.0 to 17.0 yrs METHYLIN T2 old PA hcl (10 mg cpbp 30-70, 10 mg cpbp 50- 50, 18 mg tab er 24, 20 mg cpbp 30-70, 20 mg cpbp 50- QL 1 / DAY 50, 20 mg csbp 40-60, 27 mg tab er 24, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 30 mg csbp 40-60, 40 mg cpbp 30-70, T2 AL 4.0 to 17.0 yrs old 40 mg cpbp 50-50, 40 mg csbp 40-60, 50 mg cpbp 30-70, 50 mg csbp 40-60, 54 mg tab er 24, 60 mg cpbp 30-70, 60 PA mg csbp 40-60) QL 2 / DAY methylphenidate hcl (10 mg csbp 40-60, 36 mg tab er 24) T2 AL 4.0 to 17.0 yrs old PA

PAGE 197 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg/5 ml solution, 10 mg tab chew, 10 mg tablet er, 10 AL 4.0 to 17.0 yrs T2 old mg/5 ml solution, 15 mg csbp 40-60, 20 mg tablet er, 60 PA mg cpbp 50-50) methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mg T1 AL 4.0 to 17.0 yrs tablet) old

AL 4.0 to 17.0 yrs QUILLICHEW ER T2 old PA

AL 4.0 to 17.0 yrs QUILLIVANT XR T2 old PA

AL 4.0 to 17.0 yrs RITALIN T2 old PA QL 1 / DAY RITALIN LA T2 AL 4.0 to 17.0 yrs old PA QL 1 / DAY STRATTERA T2 PA QPD 1 per day CENTRAL NERVOUS SYSTEM, OTHER

8 HOUR ACETAMINOPHEN ER 650 MG T1 GNP 8HR ACETAMINOPHEN ER 650MG T0 8 HOUR PAIN RELIEF T1 8HR ARTHRITIS PAIN T1 8HR ARTHRITIS PAIN RELIEF T1

PAGE 198 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS acetaminophen (80 mg tab rapdis, 80mg/0.8ml drops susp, 160 mg tab rapdis, 160 mg/5ml elixir, 325 mg T0 capsule, 325/10.15 solution) acetaminophen 160 mg/5ml oral susp T0 acetaminophen (120 mg supp.rect, 160 mg tab chew, 160 mg/5ml liquid, 160 mg/5ml solution, 650 mg supp.rect, T1 650mg/20.3 solution) acetaminophen (325 mg tablet, 500 mg tablet, 650 mg T1 tablet er) QL 12 / day ALLZITAL T2 PA EQ ARTHRITIS PAIN ER 650 MG T0 GS ARTHRITIS PAIN ER 650 MG T1 ARTHRITIS PAIN RELIEF (ARTHRITIS ER 650 MG CAPLT, ARTHRITIS RELF ER 650 MG, ARTHRITIS RLF ER 650 MG, CVS ARTHRIT RLF ER 650 MG, EQL ARTHRIT RLF ER 650 MG, GNP ARTHRIT RLF ER 650 MG, HM ARTHRIT RLF ER T1 650 MG, HM ARTHRITIS ER 650 MG, QC ARTHRITIS ER 650 MG, SM ARTHRIT RLF ER 650 MG, SM ARTHRITIS ER 650 MG, SM ARTHRITIS RELF ER 650) ARTHRITIS PAIN RELIEF (HV ARTHRIT RLF ER 650 MG, KRO ARTHRIT RLF ER 650 MG, PUB ARTHRITIS ER 650 MG, RA T0 ARTHRITIS ER 650 MG) ARTHRITIS PAIN ER 650 MG GELTB T0 ATHENOL T0 BETATEMP T1 BUPAP T1 QL 6 / day butalbital/acetaminophen (butalbital/acetaminophen 50mg-300mg capsule, butalbital/acetaminophen 50mg- T1 QL 6 / day 325mg tablet)

PAGE 199 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 12 / day butalbital/acetaminophen 25mg-325mg tablet T2 PA QL 6 / day butalbital/acetaminophen 50mg-300mg tablet T2 PA butalbital/acetaminophen/caffeine (butalb/acetaminophen/caffeine 50-300-40 capsule, T1 QL 6 / day butalb/acetaminophen/caffeine 50-325-40 capsule, butalb/acetaminophen/caffeine 50-325-40 tablet) butalbital/aspirin/caffeine 50-325-40 capsule T1 QL 6 / day CHILD FEVER REDUCER T0 CHILD FEVER REDUCER-PAIN RELVR T0 CHILD PAIN REL-FEVER REDUCER T0 CHILDREN'S ACETAMINOPHEN T1 CHILD'S EASY-MELTS 80 MG TAB T1 GNP CHLD'S EASY-MELTS 80 MG TB T0 CHILD FEVER REDUCER 120 MG SUP T1 CVS CHILD FEVER RED 120 MG SUP T0 CHILDREN'S FEVER REDUCING T0 CHILD'S MAPAP 160 MG TAB CHEW T0 CHILDREN'S MAPAP 80 MG TAB CHW T1 NON-ASPIRIN CHILD'S DROPS T1 CHILDREN'S NON-ASPIRIN (160 MG/5 ML SUSP, RA 160 T0 MG/5 ML) CHILDREN'S PAIN AND FEVER T1 CHILDREN'S PAIN RELIEF (160 MG/5 ML SUS, QC 160 T1 MG/5 ML)

PAGE 200 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CHILDREN'S PAIN RELIEF (CVS 160 MG/5 ML, KRO 160 T0 MG/5 ML, PUB 160 MG/5 ML) CHILDREN'S PAIN RELIEVER T1 CHILDREN'S PAIN-FEVER (CHILD 160 MG/5 ML, GS CHLD 160 MG/5 ML, HM CHLD 160 MG/5 ML, SM CHLD 160 T1 MG/5 ML) CHILDREN'S PAIN-FEVER (CVS CHILD 160 MG/5, EQ CHLD 160 MG/5 ML, GNP CHILD 160 MG/5, KRO CHILD 160 T0 MG/5) CHILDREN'S SILAPAP T1 CHILDREN'S TACTINAL T1 ED-APAP T1 QL 6 / day ESGIC (50-325-40 MG TABLET, CAPSULE) T2 PA FEVER REDUCER-PAIN RELIEVER T0 FEVERALL (80 MG, 325 MG) T1 QL 6 / day FIORICET T2 PA QL 6 / day FIORINAL T2 PA FORTAMET ER 1,000 MG TABLET T2 PA QL 4 / day HORIZANT ER 300 MG TABLET T2 PA QL 2 / day HORIZANT ER 600 MG TABLET T2 PA INFANT FEVER-PAIN RELIEVER T0 GNP INFANT PAIN RELIEF SUSP T0

PAGE 201 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INFANT PAIN RELIEF SUSP T1 GNP INFANT PAIN-FEVER 160 MG/5 T0 INFANT PAIN-FEVER 160 MG/5 ML T1 INFANT'S PAIN RELIEF T1 INFANTS' FEVER-PAIN RELIEVER T0 CVS INFNT PAIN RLF 160 MG/5 ML T0 INFANTS' PAIN RELIEF (GNP INFNT RLF 160 MG/5 ML, INFANT RELIEF 160 MG/5 ML, QC INFANT RLF 160 MG/5 T1 ML, QC INFNT RLF 160 MG/5 ML) INFANT PAIN RELV 80 MG/0.8 ML T0 SM INFANT PAIN RLF 160 MG/5 ML T1 GS INFANT PAIN-FEVER 160 MG/5 T1 INFANTS' PAIN-FEVER (CVS 160 MG/5, EQ 160 MG/5, KRO T0 160 MG/5) INFANTS' PAIN-FEVER (HM INFANT 160 MG/5, INFANTS T1 160 MG/5 ML, SM INFANT 160 MG/5) JR PAIN & FEVER T0 JR. STR NON-ASPIRIN PAIN T1 JUNIOR PAIN RELIEVER T0 LITTLE REMEDIES FEVER-PAIN T0 MAPAP (160 MG/5 ML LIQUID, 160 MG/5 ML SUSPENSION, 325 MG TABLET, 500 MG CAPLET, 500 MG T1 CAPSULE, 500 MG/15 ML LIQUID) MAPAP ARTHRITIS PAIN T1 MASOPHEN T1 metformin hcl 1000 mg tab er 24 T2 PA NAMZARIC (14 MG CAPSULE, 28 MG CAPSULE) T2 PA

PAGE 202 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NIMBEX T2 PA NON-ASPIRIN 80 MG TAB CHEW T0 NON-ASPIRIN (160 MG/5 ML ELIX, 325 MG TABLET) T1 NON-ASPIRIN EXTRA STRENGTH (CVS 500 MG CAPLET, T0 CVS 500 MG GELTAB, RA 500 MG CAPLET) NON-ASPIRIN EXTRA STRENGTH (NON ASPIRIN 500 MG CAPLET, NON-ASPIRIN 500 MG CAPLET, NON-ASPIRIN 500 T1 MG TABLET, NON-ASPIRIN X-STR 167 MG/5 ML) NON-ASPIRIN PAIN RELIEF T1 NORTEMP (80 MG/0.8 ML DROP, 160 MG/5 ML SUSP) T1 NUEDEXTA T1 PA QL 300 / day OFIRMEV T2 PA PAIN & FEVER T1 PAIN RELIEF 160 MG/5 ML LIQUID T0 PAIN RELIEF (325 MG TABLET, CVS 325 MG TABLET, GNP 325 MG TABLET, 500 MG CAPLET, 500 MG GELCAP, 500 MG TABLET, ER 650 MG CAPLET, GS 500 MG CAPLET, GS 500 MG TABLET, HM 500 MG CAPLET, HM 500 MG T1 GELCAP, HM 500 MG TABLET, HM ER 650 MG CPLT, QC 325 MG TABLET, QC 500 MG CAPLET, SM 500 MG GELCAP) PAIN RELIEF (GNP 500 MG GELCAP, GNP ER 650 MG CPLT, PUB 500 MG CAPLET, PUB 500 MG GELTAB, PUB 500 MG T0 TABLET) PAIN RELIEF ADULT T0 GNP PAIN RELIEF 500 MG CAPLET T0 PAIN RELIEF EXTRA STRENGTH (500 MG CAPLET, 500 MG T1 TABLET)

PAGE 203 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PAIN RELIEVER (325 MG TABLET, HM 325 MG TABLET, SM 325 MG TABLET, 500 MG CAPLET, 500 MG GELCAP, 500 T1 MG TABLET, HM 500 MG TABLET, SM 500 MG CAPLET, SM 500 MG GELCAP, SM 500 MG TABLET, SM ER 650 MG) PAIN RELIEVER (CVS 500 MG CPLT, EQ 325 MG TABLET, EQ 500 MG CAPLET, ER 650 MG CAPLET, GNP 325 MG T0 TAB, GNP 500 MG CAPLT, GNP 500 MG TAB) PAIN RELIEVER ADULT T0 PAIN RELIEVER JUNIOR STRENGTH T1 PEDIACARE FEVER REDUCER T0 PHARBETOL T1 QL 6 / day PHRENILIN FORTE T2 PA QUELICIN T2 PA RILUTEK T2 PA T2 PA SHAKE THAT ACHE T0 TACTINAL T1 TENCON T1 QL 6 / day S tetrabenazine T1 PS PA TYLOPHEN T1 VANATOL LQ T2 PA (10 mg vial, 20 mg vial) T2 PA VTOL LQ T2 PA

PAGE 204 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XENAZINE T2 PA QL 6 / day ZEBUTAL T2 PA AGENTS

QL 1 / day CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) T2 PA QL 2 / day CYMBALTA 60 MG CAPSULE T2 PA hcl (20 mg capsule dr, 30 mg capsule dr) T1 QL 1 / day QL 2 / day duloxetine hcl 40 mg capsule dr T2 PA duloxetine hcl 60 mg capsule dr T1 QL 2 / day QL 2 / day LYRICA (225 MG CAPSULE, 300 MG CAPSULE) T2 PA LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG QL 3 / day CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG T2 CAPSULE) PA QL 30 / day LYRICA 20 MG/ML ORAL SOLUTION T2 PA (225 mg capsule, 300 mg capsule) T1 QL 2 / day pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule, T1 QL 3 / day 100 mg capsule, 150 mg capsule, 200 mg capsule) QL 30 / day pregabalin 20 mg/ml solution T2 PA

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG QL 2 / day T2 TABLET, 100 MG TABLET, TITRATION PACK) PA

PAGE 205 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MULTIPLE SCLEROSIS AGENTS

QL 2 / day AMPYRA T2 PA QL 1 / day AUBAGIO T1 S PS QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) T1 S PS QL 0.15 / day AVONEX PEN T1 S PS QL 0.5 / day BETASERON (0.3 MG KIT, 0.3 MG VIAL) T1 S PS QL 1 / day COPAXONE 20 MG/ML SYRINGE T1 S PS QL 0.434 / day S COPAXONE 40 MG/ML SYRINGE T2 PS PA QL 2 / day S dalfampridine 10 mg tab er 12h T2 PS PA QL 0.5 / day S EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) T2 PS PA

PAGE 206 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day S GILENYA 0.5 MG CAPSULE T1 PS PA QL 1 / day S 20 mg/ml syringe T1 PS PA QL 0.434 / day S glatiramer acetate 40 mg/ml syringe T2 PS PA QL 1 / day S GLATOPA 20 MG/ML SYRINGE T2 PS PA QL 0.434 / day S GLATOPA 40 MG/ML SYRINGE T2 PS PA QL 0.04 / day S PLEGRIDY 125 MCG/0.5 ML SYRING T1 PS PA QL 1 / lifetime S PLEGRIDY SYRINGE STARTER PACK T1 PS PA

PAGE 207 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.04 / day S PLEGRIDY 125 MCG/0.5 ML PEN T1 PS PA QL 1 / lifetime S PLEGRIDY PEN INJ STARTER PACK T1 PS PA QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML T1 S SYRINGE) PS S REBIF TITRATION PACK T1 PS QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) T1 S PS S REBIF REBIDOSE TITRATION PACK T1 PS QL 2 / day S TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE) T1 PS PA QL 2 / day S TECFIDERA STARTER PACK T2 PS PA QL 0.6 / day TYSABRI T2 PA

PAGE 208 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DENTAL AND ORAL AGENTS

AQUORAL T2 PA CAPHOSOL T2 PA hcl T2 PA CHLORASEPTIC T1 gluconate 0.12 % T1 CLINPRO 5000 T2 PA COUGH DROPS (DROPS, DROPS 5.8 MG, EQ DROPS, GNP DROPS, RA DROPS 5.8 MG, SM DROPS, SM DROPS 5.8 T1 MG) DEBACTEROL (SOLUTION, SWABSTICK) T2 PA DENTA 5000 PLUS T1 DENTAGEL T1 EPISIL T2 PA EVOXAC T2 PA fluoride (sodium) 1.1 % paste (ml) T2 PA FLUORIDEX T2 PA S KEPIVANCE T2 PS PA lidocaine hcl 2 % solution T1 MUCOSITISRX T2 PA NUMOISYN (LIQUID, LOZENGE) T2 PA ORA RELIEF T1 S ORAFATE T2 PS PA

PAGE 209 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ORAL RELIEF T1 ORALONE T1 ORASEP T2 PA PAROEX T2 PA PERIDEX T2 PA PERIOGARD T1 PHENASEPTIC T1 hcl (5 mg tablet, 7.5 mg tablet) T2 PA PREVIDENT (0.2% RINSE, 1.1% GEL, 5000 BOOSTER PLUS, T2 PA DENTAL RINSE) PREVIDENT 5000 T2 PA PREVIDENT 5000 ENAMEL PROTECT T2 PA PREVIDENT 5000 PLUS T2 PA PREVIDENT 5000 SENSITIVE T2 PA PROTHELIAL T2 PA SALAGEN T2 PA SALIVAMAX T2 PA SF T1 SF 5000 PLUS T1 /potassium nitrate T2 PA SORE THROAT LOZENGE T1 SORE THROAT SPRAY (EQL SPRAY, GNP SPRAY, GS SPRAY, T1 HM SPRAY, PUB SPRAY, QC SPRAY, SM SPRAY, SPRAY) THROAT SPRAY T1

PAGE 210 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 0.1 % paste (g) T1 DERMATOLOGICAL AGENTS

A AND D T1 A AND D DIAPER RASH T1 ABREVA T1 ABSORICA T2 PA QL 1.667 / day ACANYA T2 AL Up to 18 yrs old PA QL 2 / day acitretin (17.5 mg capsule, 25 mg capsule) T2 PA QL 4 / day acitretin 10 mg capsule T2 PA CLEANSING BAR T1 AL Up to 18 yrs old ACNE MEDICATION 2.5% GEL T1 ACNE MEDICATION (5% GEL, 5% LOTION, 10% GEL, 10% T1 AL Up to 18 yrs old LOTION) ACNE TREATMENT CLEANSING BAR T1 AL Up to 18 yrs old ACNECLEAR T1 AL Up to 18 yrs old AL Up to 18 yrs old ACNEFREE T2 PA AL Up to 18 yrs old ACNEFREE SEVERE T2 PA QL 3 / day ACZONE (5% GEL, 7.5% GEL PUMP) T2 PA

PAGE 211 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1.5 / day (0.1 % cream (g), 0.1 % gel (gram), 0.3 % gel T2 AL Up to 19 yrs old (gram), 0.3 % gel w/pump) PA QL 2 / day adapalene 0.1 % lotion T2 PA QL 1.5 / day adapalene/benzoyl T2 AL Up to 18 yrs old PA ADVANCED ACNE WASH T1 AL Up to 18 yrs old ADVANCED EXFOLIATING CLEANSER T1 AL Up to 18 yrs old AL Up to 18 yrs old AKTIPAK T2 PA ALA-CORT T2 PA ALA-QUIN T2 PA ALA-SCALP T2 PA dipropionate (0.05 % cream (g), 0.05 % T1 oint. (g)) ALCORTIN A T2 PA QL 0.434 / day ALDARA T2 PA ALTABAX T2 PA (0.1 % cream (g), 0.1 % lotion) T2 PA lactate (12 % cream (g), 12 % lotion) T1 QL 2 / DAY AMNESTEEM T1 PA

PAGE 212 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANACAINE T2 PA ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% T2 PA CRM SINGLE, 2.5%-1% LOTION) ANECREAM5 T1 SM ANTI- 0.5% SHAMPOO T1 ANTI-ITCH (CVS 1% CREAM, 2% CREAM, 2%-0.1% CREAM, EQ CREAM, EQL 2%-0.1% CREAM, GNP 2% CREAM, GS 1% T1 CREAM, KRO 2%-0.1% CREAM, QC 1% CREAM, QC CREAM, RA 2%-0.1% CREAM, SM 2% CREAM) ANTI-ITCH (EQL CREAM, RA CREAM) T0 ANTI-ITCH 1% CREAM T1 ANTI-ITCH (EQL OINTMENT, OINTMENT) T0 ANTI-ITCH (LOTION, RA OINTMENT) T0 ANTI-ITCH CREAM T1 ANTI-ITCH VAGINAL T1 ANTI-ITCH WITH ALOE T1 (CVS OINTMENT, OINTMENT, SM 500 T1 UNIT/GM OINT) ANTIBIOTIC + PAIN RELIEF T1 ANTIBIOTIC PLUS PAIN RELIEF (ANTIBIOTIC PLUS PAIN CR, T1 KRO ANTIBIOTIC-PAIN CRM) ANTIBIOTIC-PAIN RELIEF T1 CLEANSER T2 PA APEXICON E T2 PA APRIZIO PAK II T2 PA AQUA GLYCOLIC HC T2 PA

PAGE 213 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AQUANIL HC T0 ARTHRITIS PAIN RELIEF 0.1% CRM T1 ARTHRITIS PAIN RELIEVING T1 ARTISS T2 PA ASPERCREME LIDOCAINE 4% CREAM T0 ASTRINGENT SOLUTION T1 ATOPAVO T2 PA ATOPICLAIR T2 PA QL 1.5 / day ATRALIN T2 PA ATRAPRO DERMAL SPRAY T2 PA ATRAPRO HYDROGEL T2 PA AVAR (9.5%-5% FOAM, 9.5-5% CLEANSING PADS, T2 PA CLEANSER) AVAR LS (10%-2% FOAM, 10-2% CLEANSING PADS, T2 PA CLEANSER) AVAR-E T2 PA AVAR-E GREEN T2 PA AVAR-E LS T2 PA INTENSE RELIEF T1 AVENOVA T2 PA AVITA (CREAM, GEL) T2 PA AVO CREAM T2 PA QL 1.667 / DAY 15 % gel (gram) T2 PA

PAGE 214 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day AZELEX T2 PA QL 0.434 / day bacitracin 500 unit/g oint. (g) T1 PA bacitracin 500 unit/g packet T1 bacitracin zinc 500 unit/g oint. (g) T1 bacitracin zinc 500 unit/g oint pack T1 BACITRAYCIN PLUS 500 UNIT/GM T0 BACTROBAN T2 PA balsam peru/castor oil T2 PA BANOPHEN ANTI-ITCH T1 BEAU RX T2 PA QL 1.667 / day BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) T2 AL Up to 18 yrs old PA QL 1.6 / day BENZAMYCIN T2 AL Up to 18 yrs old PA QL 3.334 / day BENZEFOAM ULTRA T2 AL Up to 18 yrs old PA AL Up to 18 yrs old BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) T2 PA QL 2 / day BENZEPRO 5.3% EMOLLIENT FOAM T1 AL Up to 18 yrs old QL 3.334 / day BENZEPRO 9.8% FOAM T2 AL Up to 18 yrs old PA

PAGE 215 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS compound T2 PA benzoin/aloe vera/storax/tolu balsam T2 PA AL Up to 18 yrs old 7 % cleanser T2 PA benzoyl peroxide 5.3% foam T1 AL Up to 18 yrs old QL 3.334 / day benzoyl peroxide 9.8 % foam T1 AL Up to 18 yrs old benzoyl peroxide (2.5 % gel (gram), 5 % cleanser, 5 % gel T1 AL Up to 18 yrs old (gram), 6 % cleanser, 10 % cleanser, 10 % gel (gram)) benzoyl peroxide microspheres T1 AL Up to 18 yrs old BESER T2 PA BETA HC T0 BETA MED T1 betamethasone dipropionate (0.05 % cream (g), 0.05 % T2 PA gel (gram), 0.05 % lotion, 0.05 % oint. (g)) betamethasone/propylene glyc 0.05 % cream (g) T1 betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % lotion, T2 PA betamethasone/propylene 0.05 % oint. (g)) 0.12 % foam T2 PA betamethasone valerate (0.1 % cream (g), 0.1 % lotion, T1 0.1 % oint. (g)) BETASAL T1 BIAFINE T2 PA BIONECT (CREAM, GEL) T2 PA BLUE GEL T1

PAGE 216 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BP 10-1 T2 PA QL 2 / day BP 5.3% FOAM T1 AL Up to 18 yrs old AL Up to 18 yrs old BPO (4% GEL, 8% GEL) T2 PA QL 2 / day BPO 6% FOAMING CLOTHS T2 AL Up to 18 yrs old PA calamine/ liquid lotion T1 calamine/zinc oxide 8 %-8 % lotion T1 calamine/zinc oxide/phenol liq 8%-8%-1% suspension T1 calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 T1 QL 2 / day % solution) calcipotriene 0.005 % foam T2 PA QL 3 / day calcipotriene/betamethasone 0.005-.064 oint. (g) T2 PA calcipotriene/betamethasone 0.005-.064 suspension T2 PA QL 2 / day CALCITRENE T2 PA QL 3.334 / day 3 mcg/g oint. (g) T2 PA CAPEX SHAMPOO T2 PA (0.025 % cream (g), 0.1 % cream (g), 0.15 % T1 liquid) CAPSFENAC PAK T2 PA CAPZASIN 0.15% LIQUID T1

PAGE 217 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CAPZASIN-HP T1 CARAC T2 PA CARRINGTON MOISTURE BARRIER T1 CEM-UREA T2 PA CENTANY T2 PA CENTANY AT T2 PA CERAMAX SKIN BARRIER CREAM T2 PA CERAVE MOISTURIZING LOTION T1 CETACAINE T2 PA CETAPHIL (DAILY ADVANCE LOTION, MOISTURIZING T1 LOTION) CETAPHIL RESTORADERM T1 CLARAVIS T2 PA BP CLEANSING WASH T2 PA CLEARASIL ULTRA T1 QL 75 / 30 days CLEOCIN T 1% GEL T2 PA CLEOCIN T (LOION, PLEDGES, SOLUION) T2 PA CLINDACIN ETZ 1% PLEDGET T1 CLINDACIN P T1 QL 2.5 / DAY CLINDAGEL T2 PA QL 1.667 / day clindamycin phosphate 1 % foam T2 PA QL 75 / 30 days clindamycin phosphate 1 % gel (gram) T2 PA

PAGE 218 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2.5 / DAY clindamycin phosphate 1 % gel daily T2 PA AL Up to 19 yrs old clindamycin phosphate 1 % lotion T2 PA clindamycin phosphate 1 % med. swab T1 clindamycin phosphate 1 % solution T1 AL Up to 19 yrs old QL 1.5 / day clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) T1 AL Up to 18 yrs old QL 1.667 / day clindamycin phos/benzoyl perox 1.2%-2.5% gel w/pump T2 PA QL 1.667 / day clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 T2 AL Up to 18 yrs old % gel (gram), phos/benzoyl 1 % gel w/pump) PA QL 2 / day clindamycin phosphate/tretinoin T2 PA propionate (0.05 % cream (g), 0.05 % gel T1 (gram), 0.05 % oint. (g), 0.05 % solution) (0.05 % foam, 0.05 % lotion, 0.05 % T2 PA shampoo, 0.05 % spray) clobetasol propionate/emoll 0.05 % cream (g) T1 clobetasol propionate/emoll 0.05 % foam T2 PA CLOBEX (SHAMPOO, SPRAY, TOPICAL LOTION) T2 PA pivalate 0.1 % cream (g) T2 PA CLODAN (KIT, SHAMPOO) T2 PA CLODERM T2 PA clotrimazole/betamethasone dip 1 %-0.05 % lotion T2 PA

PAGE 219 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CONDYLOX T2 PA QL 2 / day CORDRAN 0.05% CREAM T2 PA QL 4 / day CORDRAN 0.05% LOTION T2 PA QL 0.04 / day CORDRAN 4 MCG/SQ CM TAPE LARGE T2 PA CORDRAN 0.05% OINTMENT T2 PA CORMAX T2 PA CORTAID T1 CORTANE-B T2 PA CVS 1% CREAM T1 CVS CORTISONE 1% LOTION T0 CORTISONE WITH ALOE T1 QL 0.25 / day CORTISPORIN CREAM T2 PA QL 0.5 / day CORTISPORIN OINTMENT T2 PA CORTIZONE-10 (CREME, LOTION, OINTMENT) T0 CORTIZONE-10 PLUS 1% CREME T0 CORTIZONE-10 PLUS CREME T0 S COSENTYX (2 SYRINGES) T2 PS PA S COSENTYX PEN T2 PS PA

PAGE 220 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S COSENTYX PEN (2 PENS) T2 PS PA S COSENTYX SYRINGE T2 PS PA cream base no.126 T2 PA CRITIC-AID T1 CUTIVATE (CREAM, LOTION) T2 PA DAKIN'S (0.125% SOLUTION, 0.25% SOLUTION) T1 QL 3 / day dapsone (5 % gel (gram), 7.5 % gel w/pump) T2 PA DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) T2 PA DERMACINRX LEXITRAL T2 PA DERMACINRX SILAPAK T2 PA DERMACINRX THERAZOLE PAK T2 PA DERMAREST ECZEMA T0 DERMAREST PSORIASIS 3% SHAMPOO T1 DERMASEPTIN T1 DERMATOP T2 PA DERMAZENE CREAM T2 PA DERMAZINC 2% SHAMPOO T1 DESONATE T2 PA (0.05 % cream (g), 0.05 % gel (gram), 0.05 % T2 PA lotion, 0.05 % oint. (g))

PAGE 221 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DESOWEN (CREAM, LOTION) T2 PA (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 % cream (g), 0.25 % oint. (g), 0.25 % T2 PA spray) DEXERYL T2 PA DHS SAL T1 DIAPER RASH (GNP OINTMENT, OINTMENT) T0 DIAPER RASH OINTMENT (EQL OINTMENT, KRO T0 OINTMENT, OINTMENT) QL 2 / day diclofenac epolamine T2 PA diclofenac sodium 1.5 % drops T2 PA diclofenac sodium 1 % gel (gram) T1 QL 1000 / 30 days QL 3.334 / DAY diclofenac sodium 3 % gel (gram) T2 PA DICLOFEX DC T2 PA QL 1.5 / day DIFFERIN (0.1% CREAM, 0.3% GEL, 0.3% GEL PUMP) T2 AL Up to 19 yrs old PA DIFFERIN 0.1% GEL T1 AL Up to 18 yrs old QL 1.967 / day DIFFERIN 0.1% LOTION T2 AL Up to 19 yrs old PA diacetate (0.05 % cream (g), 0.05 % oint. (g)) T2 PA DIPROLENE T2 PA DOUBLE ANTIBIOTIC (RA OINT, SM OINT) T1

PAGE 222 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day DOVONEX T2 PA QL 49 / fill doxepin hcl 5 % cream (g) T2 PA DRITHOCREME HP T2 PA DRYSOL T2 PA QL 1.5 / day DUAC T2 AL Up to 18 yrs old PA AL Up to 18 yrs old EFFACLAR DUO T2 PA ELETONE T2 PA QL 2.5 / day ELIDEL T1 AL At least 2 yrs old PA ELIMITE T2 PA ELOCON (CREAM, OINTMENT) T2 PA EMPRICAINE-II T2 PA EMULSION SB T2 PA QL 2 / day ENSTILAR T2 AL At least 18 yrs old PA EPICERAM T2 PA QL 1.5 / day EPIDUO T2 AL Up to 18 yrs old PA

PAGE 223 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1.667 / day EPIDUO FORTE T2 AL Up to 18 yrs old PA EPIFIX AMNIOTIC MEMBRANE T2 PA EPIFOAM T2 PA ERY T2 PA QL 1 / day ERYGEL T2 PA QL 1 / day erythromycin base in 2 % gel (gram) T2 PA erythromycin base in ethanol 2 % med. swab T2 PA erythromycin base in ethanol 2 % solution T1 AL Up to 18 yrs old QL 1.6 / day erythromycin base/benzoyl peroxide T2 AL Up to 18 yrs old PA ethyl chloride T2 PA EUCERIN DAILY REPLENISHING LOT T1 QL 1.667 / day EVOCLIN T2 PA QL 3.73 / day FABIOR T2 AL Up to 34 yrs old PA QL 50 / 30 days FINACEA (FOAM, GEL) T2 PA FIRST AID ANTIBIOTIC (EQL OINT, GS OINT) T1 FIRST AID ANTIBIOTIC-PAIN RLF T1

PAGE 224 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day FLECTOR T2 PA acetonide (0.01 % cream (g), 0.01 % oil, 0.01 T2 PA % solution, 0.025 % cream (g), 0.025 % oint. (g)) /shower cap T2 PA (0.05 % cream (g), 0.05 % gel (gram), 0.05 % T2 PA oint. (g), 0.05 % solution, 0.1 % cream (g)) fluocinonide/emollient base T2 PA FLUOROPLEX T2 PA fluorouracil 0.5 % cream (g) T2 PA FLUOVIX PLUS T2 PA QL 2 / day flurandrenolide 0.05 % cream (g) T2 PA QL 4 / day flurandrenolide 0.05 % lotion T2 PA flurandrenolide 0.05 % oint. (g) T2 PA propionate (0.005 % oint. (g), 0.05 % cream T1 (g)) 0.05 % lotion T2 PA FORMA-RAY T2 PA GENADUR NAIL T2 PA gentamicin sulfate 0.1 % cream (g) T1 gentamicin sulfate 0.1 % oint. (g) T1 GERI-HYDROLAC 12% CREAM T1 GERI-HYDROLAC (5% LOTION, 12% LOTION) T0

PAGE 225 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLYDO T2 PA GORMEL T1 GRAFIX CORE 5CM X 5CM MATRIX T2 PA GRAFIX PRIME 5CM X 5CM MATRIX T2 PA GRX HEMORRHOIDAL T0 H-CHLOR 12 T1 T2 PA halobetasol propionate 0.05 % cream (g) T1 halobetasol propionate 0.05 % oint. (g) T2 PA HALOG (CREAM, OINTMENT) T2 PA HEMORRHOIDAL COOLING GEL T0 HEMORRHOIDAL CREAM T1 HEMORRHOIDAL MEDICATED WIPES T1 HEMORRHOIDAL OINTMENT (CVS OINTMENT, EQ OINTMENT, EQL OINTMENT, GNP OINTMENT, GS OINTMENT, HM OINTMENT, KRO OINTMENT, OINTMENT, T1 PUB OINTMENT, QC OINTMENT, RA OINTMENT, SM OINTMENT) HEMORRHOIDAL PADS (EQ 50% PADS, MEDICATED 50% T1 PAD, PADS, RA MEDICATED PADS) HEMORRHOIDAL (, CVS, EQL, GS, KRO, T0 PUB, QC) SM HEMORRHOIDAL SUPPOSITORY T1 HIGH POTENCY CAPSAICIN T1 HPR T2 PA HPR PLUS EMOLLIENT FOAM T2 PA

PAGE 226 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYDRO 40 T2 PA (0.5 % cream (g), 0.5 % oint. (g), 1 % cream (g), 1 % crm/pe app, 1 % lotion, 1 % oint. (g), 2.5 % T1 cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. (g)) 1 % cream (g) T0 hydrocortisone acetate (0.5 % cream (g), 1 % oint. (g)) T1 hydrocortisone acetate/iodoquinol/aloe vera T2 PA hydrocortisone/lidocaine/aloe 0.55%-2.8% gel w/appl T2 PA hydrocortisone acetate/pramoxine hcl (hydrocortisone/pramoxine 1 %-1 % cream/appl, hydrocortisone/pramoxine 2.5 %-1 % cream (g), T2 PA hydrocortisone/pramoxine 2.5 %-1 % cream/appl, hydrocortisone/pramoxine 2.5-1%(4g) cream/appl) (0.1 % cream (g), 0.1 % lotion, 0.1 T2 PA % oint. (g), 0.1 % solution) hydrocortisone butyrate/emoll 0.1 % cream (g) T2 PA (0.2 % cream (g), 0.2 % oint. (g)) T2 PA hydrocortisone/aloe vera (hydrocortisone/aloe 0.5 % T1 cream (g), hydrocortisone/aloe 1 % cream (g)) hydrocortisone/iodoquinol T2 PA hydrocortisone/mineral oil/petrolatum,white T1 HYDROCREAM T0 HYGEL T2 PA HYGIENIC CLEANSING PADS T1 HYLATOPICPLUS (EMOLLIENT FOAM, LOTION) T2 PA HYSEPT 0.25% SOLUTION T1 ICE BLUE GEL T1

PAGE 227 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.434 / day imiquimod 5 % cream pack T1 AL At least 12 yrs old /sodium 2 % tincture T2 PA (10 mg capsule, 20 mg capsule, 30 mg T2 PA capsule, 40 mg capsule) ITCH RELIEF (CREAM, CVS 2%-0.1% CREAM, GS CREAM) T1 QL 1.5 / day ivermectin 1 % cream (g) T2 PA KENALOG T2 PA KERAFOAM T2 PA KERALAC T2 PA KERALYT 6% GEL T2 PA QL 4 / day KLARON T2 PA LAC-HYDRIN FIVE T0 LATISSE T2 PA LC-5 T1 LEVULAN T2 PA LICE KILLING (CVS SHAMPOO, EQ SHAMPOO, EQL T0 SHAMPOO, KRO SHAMPOO) LICE KILLING (GS SHAMPOO, HM SHAMPOO, SB T1 SHAMPOO, SHAMPOO, SM SHAMPOO) LICE PYRINYL SHAMPOO T0 LICE TREATMENT (1% CREME RINSE, CVS 1% CRM RINS, HM 1% CRM RINSE, SHAMPOO, SM 1% CRM RINSE, SM T1 )

PAGE 228 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GNP LICE TREATMENT SHAMPOO T0 lidocaine 5 % adh. patch T1 QL 3 / day lidocaine (4 % cream (g), 5 % cream (g), 5 % oint. (g)) T1 lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 3 % cream (g), 3 T2 PA % lotion, 40 mg/ml solution) lidocaine hcl (4 % cream (g), 4 % solution) T1 lidocaine/hydrocortisone ac 3 %-0.5 % cream (g) T2 PA lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream/appl, T2 PA lidocaine/hydrocortisone 3-2.5%(7g) gel w/appl) lidocaine/ (lidocaine/prilocaine 2.5 cream (g), T1 lidocaine/prilocaine 2.5 kit) lidocaine/tetracaine T2 PA QL 3 / day LIDODERM T2 PA LIDODOSE T1 QL 1 / day LIDOPIN T2 PA LIDOPRIL T2 PA LIDOPURE PATCH T2 PA LIDORX T2 PA LIDOVEX T2 PA T2 PA LOCOID (CREAM, LOTION, SOLUTION) T2 PA LOCOID LIPOCREAM T2 PA LOUTREX T2 PA

PAGE 229 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LUXAMEND T2 PA LUXIQ T2 PA MAJOR-PREP HEMORRHOIDAL T1 MEDI-PADS T1 CVS MEDICATED PADS T1 menthol 2 % gel (gram) T2 PA methoxsalen 10 mg cap lq rap T2 PA (liquid, oil) T2 PA METROCREAM T1 METROGEL (GEL, PUMP) T1 METROLOTION T1 metronidazole (0.75 % cream (g), 0.75 % lotion, 1 % gel T1 (gram), 1 % gel w/pump) metronidazole 0.75 % gel (gram) T2 PA MICORT HC 2.5% CREAM T2 PA MICROCYN T2 PA MICROCYN HYDROGEL T2 PA MINERAL FREEZ T1 minoxidil 5 % foam T2 PA QL 1 / day MIRVASO (GEL, GEL PUMP) T2 PA MOISTURE BARRIER OINTMENT T1 MOISTURIZING CREAM T1 MOISTURIZING LOTION T1

PAGE 230 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 T1 % solution) 2 % oint. (g) T1 mupirocin calcium T2 PA MUSCLE RUB T2 PA MUSCLE RUB ULTRA STRENGTH T2 PA MYORISAN T2 PA NATROBA T2 PA NEO-SYNALAR 0.5%-0.025% CREAM T2 PA NEOSALUS (CREAM, FOAM, LOTION) T2 PA NEOSALUS CP T2 PA NEUAC 1.2-5% KIT T2 PA QL 1.5 / day NEUAC GEL T2 AL Up to 18 yrs old PA NOBLE FORMULA 2% SHAMPOO T1 NOBLE FORMULA HC 1% CREAM T0 QL 8 / day NOLIX 0.05% CREAM T2 PA QL 4 / day NOLIX 0.05% LOTION T2 PA NORITATE T2 PA NUOX T2 PA NUVAIL T2 PA NUVAKAAN-II T2 PA

PAGE 231 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OC8 T1 AL Up to 19 yrs old OIL-FREE 2% ACNE WASH T1 PA OLUX T2 PA OLUX-E T2 PA QL 1.667 / day ONEXTON 1.2%-3.75% GEL T1 AL Up to 19 yrs old QL 1.967 / day ONEXTON GEL PUMP T2 AL Up to 19 yrs old PA QL 12 / day OVACE T2 PA QL 15.767 / day OVACE PLUS 10% WASH T2 PA QL 2 / day OVACE PLUS 10% CREAM T2 PA QL 3.334 / day OVACE PLUS 9.8% FOAM T2 PA QL 4 / day OVACE PLUS 9.8% LOTION T2 PA QL 8 / day OVACE PLUS 10% SHAMPOO T2 PA QL 12 / day OVACE PLUS WASH T2 PA OXSORALEN-ULTRA T2 PA AL Up to 18 yrs old PACNEX T2 PA

PAGE 232 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PACNEX HP T2 PA PACNEX LP T2 PA PAIN EASE MEDIUM STREAM SPRAY T2 PA PAIN EASE MIST SPRAY T2 PA PAIN RELIEVING CREAM T1 PANDEL T2 PA PANOXYL (CLEANSING BAR, FOAMING WASH) T1 AL Up to 18 yrs old PANOXYL 3% CREAM T1 AL Up to 19 yrs old /cetyl alcohol/stearyl alc/prop gly/sod lauryl sulf T1 QL 3.8 / day PENNSAID 2% PUMP T2 PA PENNSAID 2% SOLUTION PACKET T2 PA PERIGUARD T1 permethrin 5 % cream (g) T1 petrolatum,white/lanolin T1 PICATO T2 PA QL 2.5 / day T1 AL At least 2 yrs old PA T1 PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% CLNSING CLOTH, T2 PA 9.8-4.8% CREAM, 9.8-4.8% LOTION) PLIAGLIS T2 PA PODOCON-25 T2 PA

PAGE 233 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS podofilox 0.5 % solution T1 POLYSPORIN T2 PA PONTOCAINE T2 PA PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1% CREAM, 2.5%-1% LOTION, 2.5%-1% T2 PA OINTMENT) PRAMOSONE E T2 PA pramoxine hcl 1 % foam T1 PRE-ATTACHED LTA KIT T2 PA PRE-MOISTENED HEMORRHOIDAL T1 (0.1 % cream (g), 0.1 % oint. (g)) T2 PA PREPARATION H HC 1% CREAM T1 PREPARATION H SUPPOSITORY T0 PRESERA T2 PA PRIKAAN T2 PA PRIKAAN LITE T2 PA PRILOVIX PLUS T2 PA PRIZOPAK II T2 PA PROCORT T2 PA PROCTO-MED HC T1 PROCTOFOAM-HC T1 PROMISEB T2 PA PROSHIELD PLUS T1 QL 3.334 / DAY PROTOPIC 0.03% OINTMENT T2 AL At least 3 yrs old PA

PAGE 234 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3.334 / DAY PROTOPIC 0.1% OINTMENT T2 AL At least 19 yrs old PA PRUCLAIR T2 PA QL 49 / fill PRUDOXIN T2 PA PRUMYX T2 PA PRUTECT T2 PA PSORCON T2 PA PSORIASIS MEDICATED T1 S QUTENZA T2 PS PA RADIAGUARD T2 PA RADIAPLEXRX T2 PA RECEDO T2 PA RECTASMOOTHE T1 RECTICARE 5% CREAM T1 RECTIV T2 PA QL 1 / day REGRANEX T2 PA REMEDY CALAZIME T1 REMEDY NUTRASHIELD T1 REMEDY SKIN REPAIR T1

PAGE 235 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05% T1 AL 12.0 to 18.0 yrs CREAM, 0.1% CREAM) old QL 50 / 30 days RETIN-A MICRO T2 PA

RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.08% QL 50 / 30 days T2 GEL, PUMP 0.1% GEL) PA RIAX T1 AL Up to 19 yrs old RID (ESSENTIAL KIT, KILLING SHAMPOO) T0 RISAMINE T1 ROSADAN (CREAM, CREAM KIT, GEL, GEL KIT) T2 PA ROSANIL T2 PA ROSULA 10%-4.5% WASH T2 PA RYNODERM T2 PA SALEX 6% SHAMPOO T2 PA salicylic acid (6 % cream (g), 6 % lotion) T1 salicylic acid (6 % crm er (g), 6 % foam, 6 % gel (gram), 6 % lotion er, 6 % shampoo, 26 % liquid, 27.5 % liq-film, 28.5 T2 PA % sol-filmer) SALIMEZ FORTE T2 PA SALKERA T2 PA SALVAX T2 PA SANADERMRX T2 PA SANTYL T2 PA SCALACORT T2 PA SCALPICIN T0

PAGE 236 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SEBEX T1 SEBUDERM T2 PA SECURA DIMETHICONE T1 SECURA EXTRA PROTECTIVE T1 SECURA PROTECTIVE CREAM T1 (2.25 % shampoo, 2.5 % lotion) T1 SELRX T2 PA SELSUN BLUE DEEP CLEAN SHAMPOO T1 SELSUN BLUE NATURALS T1 SENSI-CARE BODY CREAM T1 SILA III T2 PA SILAZONE-II T2 PA SILVADENE T2 PA nitrate (0.5 % solution, 10 % oint. (g), 10 % solution, T2 PA 25 % solution, 50 % solution) /potassium nitrate T2 PA silver sulfadiazine 1 % cream (g) T1 SILVRSTAT T2 PA skin cleanser cleanser T1 PA SKIN PROTECTANT A AND D T1 SKIN TREATMENT T0 bar T1 QL 3.334 / DAY SOLARAZE T2 PA

PAGE 237 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SONAFINE T2 PA QL 1 / day SOOLANTRA T2 PA SOOTHING CARE T0 SORE MUSCLE RUB T1 QL 4 / day SORIATANE 10 MG CAPSULE T2 PA QL 2 / day SORIATANE 25 MG CAPSULE T2 PA QL 2 / day SORILUX T2 PA spinosad T2 PA SPRAY AND STRETCH T2 PA SSD T1 SSS 10-5 (10-5 CREAM, 10-5 FOAM) T2 PA S STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 T2 PS MG/ML SYRINGE, 130 MG/26 ML VIAL) PA STUDIO 35 MOISTURIZING SKIN T1 QL 12 / day sodium (10 % cleanser, 10 % clnsr gel) T2 PA QL 8 / day sulfacetamide sodium 10 % shampoo T2 PA QL 4 / day sulfacetamide sodium 10 % suspension T2 PA

PAGE 238 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfacetamide sodium/ (sodium/sulfur 8 %-4 % suspension, sodium/sulfur 9 %-4 % cleanser, sodium/sulfur 9 %-4.5 % cleanser, sodium/sulfur 9.8%- 4.8% cleanser, sodium/sulfur 10 %-2 % cleanser, sodium/sulfur 10 %-2 % cream (g), sodium/sulfur 10 %-4 T2 PA % med. pad, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w) cleanser, sodium/sulfur 10- 5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) suspension) sulfacetamide sodium/sulfur 10-5%(w/w) lotion T1 sulfacetamide T2 PA sodium/sulfur/avobenzone/octinoxate/octyl sal sulfacetamide sodium/sulfur/skin cleanser comb no.23 T2 PA sulfacetamide sodium/sulfur/urea T2 PA SULFACLEANSE 8-4 T2 PA SULFAMYLON POWDER PACKET T2 PA SUMADAN (9%-4.5% WASH, KIT) T2 PA SUMADAN XLT T2 PA SUMAXIN (9%-4% WASH, CLEANSING PADS) T2 PA SUMAXIN CP T2 PA SUMAXIN TS T2 PA SYNALAR (0.01% SOLUTION, 0.025% CREAM, 0.025% T2 PA CREAM KIT, 0.025% OINTMENT, 0.025% OINTMENT KIT) SYNALAR TS T2 PA SYNERA T2 PA SYNERDERM T2 PA T-PLUS T1

PAGE 239 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T-SAL T1 QL 3 / day TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) T2 PA 0.03 % oint. (g) T1 QL 3.334 / DAY QL 3.334 / DAY tacrolimus 0.1 % oint. (g) T2 PA S TALTZ AUTOINJECTOR T2 PS PA S TALTZ AUTOINJECTOR (2 PACK) T2 PS PA S TALTZ AUTOINJECTOR (3 PACK) T2 PS PA S TALTZ SYRINGE T2 PS PA QL 1.47 / day 0.1 % cream (g) T2 PA

TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% CREAM, 0.1% QL 1 / day T2 GEL) PA TEMOVATE (CREAM, OINTMENT) T2 PA TERA-GEL TAR T1 TERSI FOAM T2 PA TEXACORT T2 PA

PAGE 240 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THERA-GEL T1 THERA-GESIC T1 CVS THERAPEUTIC 3% DANDRF SHMP T1 THERAPEUTIC MINERAL ICE T1 THERAPEUTIC SHAMPOO (SHAMPOO, SHAMPOO 0.5%) T1 THERAPEUTIC T+PLUS T1 QL 1.47 / day TOLAK T2 PA TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, T2 PA 0.25% CREAM, 0.25% OINTMENT, 0.25% SPRAY) TOVET EMOLLIENT T2 PA TOVET KIT T2 PA TRETIN-X (0.05% COMBO PACK, 0.075% CREAM) T2 PA tretinoin 0.025 % cream (g) T1 AL 12.0 to 18.0 yrs old tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.05 % T1 cream (g), 0.1 % cream (g)) QL 1.5 / day tretinoin 0.05 % gel (gram) T2 PA tretinoin microspheres (0.04 % gel (gram), 0.04 % gel QL 1.667 / day T2 w/pump, 0.1 % gel (gram), 0.1 % gel w/pump) PA TRI-CHLOR T2 PA triamcinolone acetonide 0.147mg/g aerosol T2 PA

PAGE 241 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.05 % oint. (g), 0.1 % cream (g), T1 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g)) TRIANEX T2 PA trichloroacetic acid (25 % soln recon, 50 % soln recon, 75 % soln recon, 80 % soln recon, 85 % soln recon, 90 % soln T2 PA recon, 100 % soln recon) TRIDERM T2 PA TRIDESILON T2 PA TRIPLE ANTIBIOTIC (CURAD OINT, GNP OINTMENT, HM OINTMENT, KRO OINTMENT, OINTMENT, OINTMENT PKT, T1 QC OINTMENT, SM OINTMENT) TRIPLE ANTIBIOTIC EXTRA T1 TRIPLE ANTIBIOTIC PLUS T1 TRIPLE ANTIBIOTIC-PAIN RELIEF T1 TRIVIX T2 PA ULESFIA T2 PA ULTRASAL-ER T2 PA ULTRAVATE (CREAM, OINTMENT) T2 PA ULTRAVATE X (CREAM PACK, OINTMENT PAC) T2 PA UMECTA T2 PA UNSCENTED CREAM T1 URAMAXIN (20% FOAM, 45% NAIL GEL) T2 PA URE-K T2 PA

PAGE 242 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS urea (35 % foam, 39 % cream (g), 40 % cream (g), 40 % lotion, 45 % cream (g), 45 % gel (ml), 45 % lotion, 47 % T2 PA cream (g), 50 % cream (g), 50 % sol/pf app) urea 20 % cream (g) T1 UREACIN-20 T1 UREVAZ T2 PA UTOPIC T2 PA VANICREAM HC T1 VANOS T2 PA QL 0.84 / day VANOXIDE-HC T2 PA VASELINE WHITE T2 PA QL 3.334 / day VECTICAL T2 PA QL 2 / day VELTIN T2 PA VENELEX OINTMENT T2 PA VERDESO T2 PA VEREGEN T2 PA VIRASAL T2 PA A AND D GRX OINTMENT T1 1150/1.25 liquid T1 a and d oint. (g) T1 vits a and d/white pet/lanolin oint. (g) T1 QL 1000 / 30 days VOLTAREN T2 PA

PAGE 243 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS WAL-DRYL 2%-0.1% CREAM T1 REMOVER (CVS GEL PEN, GEL, GEL PEN, RA GEL) T2 PA XERAC AC T2 PA XRYLIX T2 PA QL 2 / DAY ZENATANE T1 PA QL 2 / day ZIANA T2 PA ZILACAINE PATCH T2 PA zinc oxide (40 % oint. (g), oint. (g)) T0 zinc oxide 20 % oint. (g) T1 ZINC OXIDE DIAPER CREAM T1 ZIONODIL T2 PA ZIONODIL-100 T2 PA ZITHRANOL T2 PA QL 30 / fill ZONALON T2 PA ZOSTRIX HP T1 ZOSTRIX HP FOOT T1 QL 56 / 60 days ZYCLARA (CREAM, CREAM PUMP) T2 PA QL 56 / 30 days ZYCLARA 2.5% CREAM PUMP T2 PA

PAGE 244 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ENZYME REPLACEMENT/MODIFIERS

ADAGEN T2 PA S ALDURAZYME T2 PS PA AMMONUL T2 PA S BUPHENYL (500 MG TABLET, POWDER) T2 PS PA QL 2 / day S CERDELGA T2 PS PA S CEREZYME T2 PS PA CREON T1 CYSTADANE T2 PA QL 13 / day CYSTAGON 150 MG CAPSULE T2 PA QL 40 / day CYSTAGON 50 MG CAPSULE T2 PA S ELAPRASE T2 PS PA ELELYSO T2 PA

PAGE 245 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S FABRAZYME T2 PS PA KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 T2 PA MG POWDER PACKET) S LUMIZYME T2 PS PA S miglustat T2 PS PA NAGLAZYME T2 PA nitisinone T2 PA ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG T2 PA CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) PANCREAZE T2 PA PERTZYE (DR 4,000 UNIT CAPSULE, DR 8,000 UNIT T2 PA CAPSULE, DR 16,000 UNIT CAPSULE) QL 3 / day PROCYSBI DR 25 MG CAPSULE T2 PA QL 1 / day PROCYSBI DR 75 MG CAPSULE T2 PA QL 20 / day RAVICTI T2 PA /sodium phenylacetate T2 PA S (0.94 g/g powder, 100 % powder, T2 PS 500 mg tablet) PA

PAGE 246 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS STRENSIQ T2 PA SUCRAID T2 PA VIMIZIM T2 PA VIOKACE T2 PA S VPRIV T2 PS PA ZAVESCA T2 PA ZENPEP T1 GASTROINTESTINAL AGENTS , GASTROINTESTINAL

ANASPAZ T2 PA ATROPEN T2 PA sulfate (0.05 mg/ml syringe, 0.1 mg/ml disp syrin, 0.1 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial, 2 T2 PA mg/5 ml syringe) atropine sulfate 0.8 mg/2ml syringe T1 atropine sulfate in 0.9 % sodium chloride (sulfate/0.9 0.8 T2 PA mg/2ml syringe, sulfate/0.9 1 mg/2.5ml syringe) atropine sulfate/0.9 %sod chlr 2 mg/5 ml syringe T1 BENTYL T2 PA chlordiazepoxide/ T2 PA CUVPOSA T2 PA dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 T1 mg tablet)

PAGE 247 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dicyclomine hcl (10 mg/ml ampul, 10 mg/ml vial) T2 PA DONNATAL (ELIXIR, TABLET) T2 PA ED-SPAZ T2 PA glycopyrrolate (0.2 mg/ml vial, 0.4mg/2ml syringe, T2 PA 0.6mg/3ml syringe, 1 mg/5 ml syringe) glycopyrrolate (1 mg tablet, 2 mg tablet) T1 glycopyrrolate in sterile water/pf (in water/pf 0.4mg/2ml syringe, in water/pf 0.6mg/3ml syringe, in water/pf 1 T2 PA mg/5 ml syringe) GLYRX-PF T2 PA hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet, 0.125mg/ml drops, 0.375 mg tab er T2 PA 12h, 125mcg/5ml elixir) HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) T2 PA LEVBID T2 PA LEVSIN (0.125 MG TABLET, 0.5 MG/ML AMPUL) T2 PA LEVSIN-SL T2 PA LIBRAX T2 PA methscopolamine bromide (2.5 mg tablet, 5 mg tablet) T2 PA NULEV T2 PA OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) T2 PA OSCIMIN SL T2 PA OSCIMIN SR T2 PA phenobarb/hyoscy/atropine/scop 16.2mg/5ml elixir T1 PA phenobarb/hyoscy/atropine/scop 16.2 mg tablet T2 PA

PAGE 248 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHENOHYTRO TABLET T2 PA 15 mg tablet T1 SYMAX T2 PA SYMAX DUOTAB T2 PA SYMAX-SL T2 PA SYMAX-SR T2 PA GASTROINTESTINAL AGENTS, OTHER

ABATINEX T0 ACID GONE T1 ACID GONE ANTACID T1 ACTIGALL T2 PA ADULT 50 + T0 ADULT PROBIOTIC T0 ADVANCED ANTACID T1 ADVANCED ANTACID-ANTIGAS (EQL LIQUID, KRO LIQUID) T0 ADVANCED ANTACID-ANTIGAS (GS LIQUID, HM SUSP, T1 LIQUID, SM SUSP) ADVANCED PROBIOTIC T0 ALCALAK T0 ALIGN (4 MG CAPSULE, 10.5 MG CHEW TABLET) T0 ALIGN JR T0 ALMACONE T1 ALMACONE-2 T1 aluminum hydroxide (320 mg/5ml oral susp, 600 mg/5ml T1 oral susp)

PAGE 249 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTACID (750 MG CHEW TABLET, CVS 750 MG CHEW TABLET, CVS KIDS 750 MG CHEW, EQ 500 MG CHEW TABLET, EQ LIQUID, EQL 500 MG CHEW TABLET, EQL T0 LIQUID, EQL SUSPENSION, GNP 500 MG CHEW TABLET, GNP 750 MG TAB CHEW, GNP SUSPENSION, PUB 500 MG CHEW TABLET) ANTACID (500 MG CHEW TABLET, 500 MG CHEWABLE TABLET, EX-STR 750 MG TAB CHEW, EX-STR TABLET CHEW, GNP LIQUID, GS 500 MG CHEWABLE TAB, HM 500 T1 MG CHEW TABLET, LIQUID, QC 500 MG CHEW TABLET, QC SUSPENSION, RA 500 MG CHEWABLE TAB, SM 500 MG CHEW TABLET, SM SUSPENSION, SUSPENSION) ANTACID TABLET CHEW T0 ANTACID CALCIUM T1 ANTACID EXTRA STRENGTH (CVS EX-STR 750 MG CHEW, CVS XTRA STR CHEW TAB, EQ EXTRA STR CHEW TAB, GNP T0 XTRA STR CHEW TAB, SM 750 MG CHEW TABLET) ANTACID EXTRA STRENGTH (EQ EX-STR 750 MG CHWTB, EQ EX-STR CHEW TABLET, EQL EXTRA STR CHEW TAB, EXTRA STRENGTH CHW TAB, GNP EXT STRGTH CHW TAB, T1 HM EX-STR 750 MG CHWTB, QC XTRA STR CHEW TAB, SM EX-STR TAB CHEW, SM XTRA STR CHEW TAB, XTRA STRENGTH CHEW TAB) ANTACID M T0 ANTACID MAXIMUM STRENGTH (MAXIMUM LIQ, SM T1 MAX SUSP) ANTACID PLUS ANTI- (CVS LIQ, LIQUID) T0 ANTACID PLUS ANTI-GAS (GS LIQ, RELF LIQ, SUSP) T1 ANTACID PLUS GAS RELIEF T1 ANTACID ULTRA STRENGTH (CVS STR SOFTCHEW, T0 STRENGTH SOFTCHW)

PAGE 250 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTACID ULTRA STRENGTH (CVS TAB CHEW, EQ STR TAB T0 CHEW, STR 1,000 MG CHW, STR TAB CHEWABLE) EQL ANTACID ULTRA STR TAB CHEW T1 ANTACID WITH SIMETHICONE T1 ANTACID-ANTIGAS (ANTACID ANTI-GAS LIQUID, ANTACID- ANTIGAS LIQUID, ANTACID-ANTIGAS SUSPENSION, CVS ANTACID-ANTIGAS LIQUID, GNP ANTACID-ANTIGAS SUSPENSION, HM ANTACID ANTI-GAS SUSPENSION, HM T1 ANTACID-ANTIGAS SUSPENSION, KRO ANTACID-ANTIGAS LIQUID, QC ANTACID-ANTIGAS MAX STR, QC ANTACID- ANTIGAS SUSPENSION, SM ANTACID-ANTIGAS LIQUID) ANTACID-ANTIGAS (GNP ANTACID ANTI-GAS LIQUID, PUB T0 ANTACID-ANTI GAS SUSP, RA ANTACID-ANTIGAS LIQUID) ANTACID-GAS RELIEF T0 ANTI-DIARRHEAL (2 MG SOFTGEL, CVS 2 MG SFTGEL, HM T0 2 MG SOFTGEL, QC 2 MG SOFTGEL, RA 2 MG SOFTGEL) ANTI-DIARRHEAL (1 MG/7.5 ML SOL, 1 MG/7.5 ML SUS, 2 MG CAPLET, 2 MG TABLET, CVS 2 MG CAPLET, EQ 2 MG CAPLET, EQ 2 MG SFTGEL, EQL 2 MG CAPLET, GNP 2 MG CAPLET, GS 1 MG/7.5 ML, GS 2 MG CAPLET, HM 2 MG T1 CAPLET, KRO 2 MG CAPLET, QC 2 MG CAPLET, RA 2 MG CAPLET, SM 1 MG/7.5 ML, SM 2 MG CAPLET, SM 2 MG SOFTGEL) CVS ANTI-DIARRHEAL SUSPENSION T0 ANTI-GAS (180 MG, CVS 180 MG, QC 180 MG) T1 BACID T0 BAN-ACID T0 BIOGAIA T0 BIOGAIA PROTECTIS BABY T0 BIOGAIA PROTECTIS BABY-VIT D3 T0

PAGE 251 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BISMATROL (525 MG/15 ML SUSP, 525 MG/30 ML SUSP, T1 TABLET CHEW) BISMUTH T0 BISMUTH MAXIMUM STRENGTH T0 262 mg tab chew T1 CAL-GEST T1 CALCIUM ANTACID (CALCIUM 500 MG CHW TAB, CALCIUM 750 MG TB CHEW, CALCIUM 1,000 MG TAB, CALCIUM EX-STR TABLET, GS CAL 500 MG CHEW TAB, GS T1 CAL 750 MG CHEW TAB, HM CAL 500 MG CHEW TAB, HM CAL 750 MG CHEW TAB, SM CAL 500 MG CHEW TAB, SM CAL 750 MG CHEW TAB) CALCIUM ANTACID (CALCIUM ULTRA-STR CHEW, HM CAL T0 1000 MG CHEW TB) CALCIUM ANTACID (CVS 1,000 MG, EX-STR CHEW, PUB T0 750 MG) calcium carbonate (300mg(750) tab chew, 400(1000) tab T0 chew) calcium carbonate 320mg(750) tab chew T2 PA calcium carbonate (200(500)mg tab chew, 260mg(648) T1 tablet) CHENODAL T2 PA CHILDREN'S CHEWABLE PROBIOTIC T0 CHILDREN'S PEPTO T0 CHILDREN'S SOOTHE T0 QL 7 / day CHOLBAM 250 MG CAPSULE T2 PA QL 4 / day CHOLBAM 50 MG CAPSULE T2 PA

PAGE 252 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMFORT GEL T0 CONTROLLED DELIVERY PROBIOTIC T0 cromolyn sodium 20 mg/ml oral conc T2 PA CULTURELLE (10B CAPSULE, 15B CAPSULE) T0 CULTURELLE DIGESTIVE HEALTH (CAP, CHW) T0 CULTURELLE HEALTH-WELLNESS T0 CULTURELLE KIDS (CHEWABLE TAB, PACKET) T0 CULTURELLE KIDS GENTLE-GO T0 CULTURELLE KIDS PURELY PROB T0 DIAMODE T1 RELIEF (262 MG/15 ML, SUSPENSION) T0 QC DIARRHEA RLF 262 MG/15 ML T1 DIFF-STAT (471 MG CAPSULE, POWDER PACKET) T0 DIGESTIVE ADV PROBIO 250M GMMY T0 DIGESTIVE PROBIOTIC (CVS CAP, CVS CAPS, EQL CAP, T0 TRUNATURE) DIGESTIVE RELIEF SUSPENSION T1 DIOTAME T0 hcl/atropine sulfate (hcl/atropine 2.5- T1 .025/5 liquid, hcl/atropine 2.5-.025mg tablet) ENTEREG T2 PA ENZYMATIC DIGESTANT TABLET T1 CHEWS ANTACID T0 FLORAJEN T0 FLORAJEN BIFIDOBLEND T0

PAGE 253 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLORAJEN3 T0 FLORAJEN4KIDS T0 FLORANEX (GRANULES PACKET, TABLET) T0 FLORASTOR T0 FLORASTORKIDS T0 FLORAVANCE T0 FOAMING ANTACID LIQUID T1 GAS RELIEF (CVS GAS RELIEF 125 MG SOFTGEL, EQ GAS RELIEF 125 MG CHEW TAB, EQ GAS RELIEF 125 MG SOFTGEL, EQL GAS RELIEF 125 MG CHEW TAB, EQL GAS RELIEF 125 MG SOFTGEL, EQL GAS RELIEF 180 MG SOFTGEL, GAS RELIEF 20 MG/0.3 ML DROPS, GAS RELIEF 125 MG CHEW TABLET, GAS RELIEF 125 MG SOFTGEL, GAS RELIEF 180 MG SOFTGEL, GAS RELIEF (SIMETH) 80 MG CHEW, GNP GAS RELIEF 125 MG SOFTGEL, GS GAS RELIEF 125 MG SOFTGEL, HM GAS RELIEF 125 MG CHEW T1 TAB, HM GAS RELIEF 125 MG SOFTGEL, HM GAS RELIEF(SIMETH) 80MG CHW, KRO GAS RELIEF 180 MG SOFTGEL, PUB GAS RELIEF 125 MG SOFTGEL, PUB GAS RELIEF 180 MG SOFTGEL, QC GAS RELIEF 125 MG SOFTGEL, QC GAS RELIEF 125 MG TAB CHEW, RA GAS RELIEF 125 MG SOFTGEL, SM GAS REL ANTIFLATUENT 180 MG, SM GAS RELIEF 125 MG CHEW TAB, SM GAS RELIEF 125 MG SOFTGEL, SM GAS RELIEF 180 MG SOFTGEL, SM GAS RELIEF(SIMETH) 80MG CHW) GAS RELIEF (CVS GAS RELF(SIMETH) 80 MG CHW, CVS GAS RELIEF 125 MG CHEW TAB, CVS GAS RELIEF EX-STR DROPS, EQL GAS RELIEF DROPS, GAS RELIEF DROPS, GNP T0 GAS RELIEF 125 MG CHEW TAB, RA GAS RELIEF 125 MG TAB CHEW) GNP GAS RLF(SIMETH) 80 MG CHEW T1 GAS-X EXTRA STRENGTH SOFTGEL T1

PAGE 254 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GAS-X ULTRA STRENGTH T1 GASTROCROM T2 PA GATTEX T2 PA GAVISCON 80-14.2 MG TAB CHEW T1 GERBER SOOTHE T0 GERI-LANTA T1 GERI-MOX T0 GERI-PECTATE T0 HEARTBURN ANTACID T1 CVS HEARTBURN RELIEF CHEW TAB T1 GNP INFANT GAS RELIEF DROPS T0 INFANT GAS RELIEF (GAS RELIEF DROPS, GAS RLF 20 T1 MG/0.3 ML) INFANTS' GAS RELIEF (CVS INFT GAS RLF 20 MG/0.3 ML, HM INF GAS RELIEF 20 MG/0.3 ML, INF GAS REL 20 T1 MG/0.3 ML DROP, INFANTS' GAS RLF 20 MG/0.3 ML, SM INF GAS RELIEF 20 MG/0.3 ML) INFANTS' GAS RELIEF (EQ INF GAS RELIEF 20 MG/0.3 ML, GAS RELIEF DROPS 20 MG/0.3 ML, KRO INFT GAS RLF 20 T0 MG/0.3 ML, PUB INFANTS' GAS RELIEF DROPS) INTESTINEX T0 GNP K-PEC SUSPENSION T0 K-PEC SUSPENSION T1 KALA T0 KAO-TIN SUSPENSION T1 KAOPECTATE 262 MG/15 ML SUSP T1 KAOPECTATE EXTRA STRENGTH LIQ T0

PAGE 255 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LACTINEX (BD, CHEWABLE TABLET) T0 LACTO-PECTIN T0 acidophilus (0.5 mg tablet, 1 mg wafer, 1b tablet, 2b cell tablet, 100 mg capsule, 100mm cell T0 capsule, 500mm cell tablet, capsule, tab chew) l.acidoph,/b.bif/s.therm 175 mg capsule T0 lactobacillus acidophilus/ longum (acidophilus/bifido 15 mg capsule dr, acidophilus/bifido T0 16 mg capsule dr) lactobacillus acidophilus/fructooligosaccharides T0 lactobacillus acidophilus/lactobacillus bifidus T0 lactobacillus acidophilus/lactobacillus sporogenes T0 lactobacillus acidophilus/pectin (acidophilus/pect tab T0 chew, acidophilus/pect 75 mm-100 capsule) lactobacillus acidophilus/pectin, citrus (acidophilus/pectin, 25mm-100mg tablet, T0 acidophilus/pectin, 100mm-10mg capsule) lansoprazole/amoxicillin trihydrate/clarithromycin T1 QL 112 / 365 days EQ LIQUID ANTACID SUSP T0 GNP LIQUID ANTACID SUSPENSION T0 LIQUID ANTACID SUSPENSION T1 LOMOTIL T2 PA hcl 1mg/7.5ml liquid T1 loperamide hcl (1 mg/5 ml liquid, 2 mg capsule, 2 mg T1 tablet) MAALOX ADVANCED SUSPENSION T1 MAALOX MAXIMUM STRENGTH T1

PAGE 256 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MAG-AL T0 MAG-AL PLUS T1 MAG-AL PLUS XS T1 MAGLOX T1 420 mg tablet T1 GNP MASANTI LIQUID T0 MASANTI LIQUID T1 METABIOTIC T0 MI ACID T1 MI-ACID (MI ACID SUSPENSION, MI-ACID 400-400-40 MG/10 ML LQ, MI-ACID GAS 80 MG TAB CHEW, MI-ACID T1 MAX STRENGTH LIQUID) MINTOX T1 MINTOX MAXIMUM STRENGTH T1 MINTOX PLUS T1 MORE-DOPHILUS T0 MOTOFEN T2 PA QL 1 / day MOVANTIK T1 AL At least 18 yrs old PA S MYTESI T2 PS PA QL 1 / day OCALIVA T2 PA

PAGE 257 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OMECLAMOX-PAK COMBO PACK T1 QL 112 / 365 days QL 80 / 365 days OMECLAMOX-PAK DAILY CARD T2 PA ONE-A-DAY TRUBIOTICS T0 opium tincture T2 PA T2 PA PEDIA-LAX PROBIOTIC YUMS T0 PEP-T-MED T0 PEPTIC RELIEF T1 PHILLIPS' COLON HEALTH T0 PHILLIPS' MOM TABLET CHEW T1 PINK BISMUTH (GNP 262 MG/15 ML, GNP CAPLET, GNP MAX-STR SUSP, GNP TABLET CHEW, QC 262 MG CAPLET, T0 RA 262 MG/15 ML, RA CAPLET, RA TABLET CHEW) PUB PINK BISMUTH MAX STR LIQ T0 PINK BISMUTH (262 MG/15 ML SUSP, CAPLET, MAX-STR T1 SUSP, QC TABLET CHEW, TABLET CHEW) PRE B2 T0 PREORBOTIC T0 PROBIOTIC (1 B CFU-250 MG CAP, CVS 3 BIL CELL CAPS, 5 BILLION CELL CAP, CVS DR 10 BIL CELL, EQ 5 BILL CELL CAP, RA 5 BILL CELL CAP, 15 BILLION CELL CAP, CVS 20 BIL T0 CELL CAP, CVS 20 BIL CELL CAPS, 250 MG CAPSULE, CVS GUMMIES, HM 250 MG CAPSULE, RA GUMMIES, SOFTGEL) PROBIOTIC & ACIDOPHILUS T0 PROBIOTIC 4X T0

PAGE 258 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROBIOTIC ACIDOPHILUS BEADS T0 PROBIOTIC ACIDOPHILUS BIOBEADS T0 PROBIOTIC ACIDOPHILUS-PECTIN T0 PROBIOTIC COLON CARE T0 PROBIOTIC COLON SUPPORT (GNP 240 MG CAPSULE, KRO T0 COLON SUPPT CAP) PROBIOTIC COMPLEX T0 PROBIOTIC DIGESTIVE CARE T0 PROBIOTIC FORMULA T0 PROBIOTIC GOLD ACIDOPHILUS T0 PROBIOTIC PEARLS T0 PROBIOTIC PEARLS COMPLETE T0 PROBIOTIC WITH PREBIOTIC T0 PROVELLA T0 PYLERA T1 QL 120 / 365 days QL 3 / day RELISTOR 150 MG TABLET T2 PA RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML T2 PA SYRINGE, 12 MG/0.6 ML VIAL) RESTORA SPRINKLES T2 PA RI-GEL T1 RI-GEL II T1 RI-MOX T1 RI-MOX PLUS T0 RISA-BID T0

PAGE 259 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RISAQUAD T0 RISAQUAD-2 T0 RULOX T1 SENIOR PROBIOTIC T0 simethicone (40mg/0.6ml drops susp, 80 mg tab chew, T1 125 mg capsule, 125 mg tab chew, 180 mg capsule) SMOOTH ANTACID T1 SMOOTH DISSOLVING ANTACID T0 sodium bicarbonate (325 mg tablet, 650 mg tablet) T1 SOOTHE (262 MG CAPLET, 262 MG CHEWABLE TABLET, 262 MG/15 ML SUSPENSION, 525 MG/30 ML T0 SUSPENSION, REGULAR STRENGTH SUSP, SUSPENSION) RELIEF (CVS RELF 525 MG/30 ML, CVS RELIEF MAX STR LIQ, CVS RLF 262 MG CAPLET, EQL RELIEF LIQUID, EQL RLF 262 MG CHEW TB, EQL RLF 525 MG/15 ML, EQL RLF 525 MG/30 ML, GS RELIEF 525 MG/30 ML, GS RLF 262 MG CHEW TAB, HM RELIEF 262 MG/15 ML, HM RELIEF 525 MG/15 ML, HM RELIEF 525 MG/30 ML, HM RLF 262 MG CHEW TAB, KRO RLF 262 MG CHEW TB, T1 KRO RLF 262 MG/15 ML, RELIEF 262 MG/15 ML, RELIEF 525 MG/15 ML, RELIEF MAX STR LIQUID, RLF 262 MG/15 ML SUSP, RLF 525 MG/30 ML SUSP, SM RELIEF 262 MG/15 ML, SM RELIEF 525 MG/30 ML, SM RELIEF CAPLET, SM RELIEF LIQUID, SM RELIEF MAX STR LIQ, SM RLF 262 MG CHEW TAB) STOMACH RELIEF (CVS RLF 262 MG CHEW TB, EQ RELIEF 262 MG/15 ML, EQ RLF 262 MG CHEW TAB, EQL RLF 262 MG/15 ML, GNP RLF 262 MG/15 ML, KRO RELIEF 1,050 T0 MG/30, PUB RLF 262 MG CHEW TB, RA RELIEF 262 MG/15 ML, RA RELIEF MAX STR LIQ, RELIEF 262 MG CHEW TAB) STOMACH RELIEF ORIGINAL T0

PAGE 260 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SUPER PROBIOTIC T0 TAME THE FLAME T0 TUMS KIDS 300 MG (750) CHEWTAB T1 TUMS FRESHERS T1 TUMS SMOOTHIES T1 TUMS ULTRA T1 ULTRA A-D T1 ULTRA FLORA PLUS T0 GNP ANTACID ULTRA TAB CHEW T0 ULTRA STRENGTH ANTACID (SM CALCIUM TAB CHEW, T1 ULTRA TABLET CHEW) UROMAG T0 URSO T2 PA URSO FORTE T2 PA ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) T1 VISBIOME (PROBIOTIC 112.5B CAP, 450 BILLION PACKET, T0 PROBIOTIC 450B POWDER, PROBIOTIC 900B POWDER) VSL#3 (CAPSULE, PACKET) T0 VSL#3 DS T0 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

ACID CONTROL T1 ACID CONTROLLER (10 MG TABLET, CVS 10 MG TAB, CVS T1 20 MG TAB, QC 10 MG TAB) ACID CONTROLLER COMPLETE T1

PAGE 261 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ACID REDUCER (10 MG TABLET, 20 MG TABLET, EQ 20 MG TABLET, GNP 20 MG TABLET, RA 10 MG TABLET, RA 20 MG TABLET, 75 MG TABLET, CVS 75 MG TABLET, EQL 75 MG TABLET, GS 75 MG TABLET, HM 75 MG TABLET, SM 20 MG TABLET, SM 75 MG TABLET, 150 MG TABLET, CVS T1 150 MG TABLET, EQ 10 MG TABLET, EQ 150 MG TABLET, EQL 150 MG TABLET, GNP 10 MG TABLET, GNP 75 MG TABLET, GS 150 MG TABLET, PUB 10 MG TABLET, RA 150 MG TABLET, SM 10 MG TABLET, SM 150 MG TABLET) ACID REDUCER (EQ 200 MG TABLET, KRO 200 MG TABLET, T2 PA SM 200 MG TABLET) ACID REDUCER 150 T1 ACID REDUCER COMPLETE T2 PA (200 mg tablet, 300 mg tablet, 400 mg tablet, T2 PA 800 mg tablet) cimetidine hcl T2 PA COMPLETE (CVS TABLET CHEW, GNP TABLET CHEW, HM T2 PA TABLET CHEW, RA TABLET CHEW, TABLET CHEW) DUAL ACTION T1 DUAL ACTION COMPLETE T1 famotidine (10 mg tablet, 40 mg tablet, 40mg/5ml oral T1 susp) famotidine 10 mg/ml vial T2 PA famotidine in 0.9 % nacl 20 mg/5 ml syringe T2 PA famotidine in sodium chloride, iso-osmotic/pf T2 PA famotidine/pf T2 PA HEARTBURN PREVENTION T1 HEARTBURN RELIEF (10 MG TABLET, 20 MG TABLET, EQL T1 75 MG TAB)

PAGE 262 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEARTBURN RELIEF (200 MG TABLET, SM 200 MG TAB) T2 PA KRO HEARTBURN RELIEF 150 MG TB T1 HEARTBURN RELIEF 150 T1 QL 2 / day 150 mg capsule T2 PA nizatidine 300 mg capsule T2 PA nizatidine 150mg/10ml solution T2 PA PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 ML T2 PA ORAL SUSP) hcl (15 mg/ml syrup, 75 mg tablet, 150 mg T1 tablet, 300 mg tablet) ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial, 150 mg T2 PA capsule, 300 mg capsule) TUMS DUAL ACTION T1 WAL-ZAN 150 T1 WAL-ZAN 75 T1 ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 300 MG T2 PA TABLET, 1,000 MG/40 ML VIAL) IRRITABLE BOWEL SYNDROME AGENTS

AL At least 18 yrs alosetron hcl T2 old PA QL 2 / day AMITIZA T1 AL At least 18 yrs old PA QL 1 / day LINZESS (145 MCG CAPSULE, 290 MCG CAPSULE) T1 AL At least 6 yrs old PA

PAGE 263 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 18 yrs LOTRONEX T2 old PA QL 2 / day VIBERZI T2 PA LAXATIVES

ADULT GLYCERIN T1 ALOPHEN PILLS T0 BENEFIBER POWDER PACKET T1 BISA-LAX EC 5 MG TABLET T1 GNP BISA-LAX EC 5 MG TABLET T0 bisacodyl 10 mg supp.rect T2 PA bisacodyl 5 mg tablet dr T1 FLEET BISACODYL EC 5 MG TAB T1 BISCOLAX T1 calcium carbonate/vitamin d3 600 mg-400 tablet T1 calcium polycarbophil T1 CHEST CONGESTION RELIEF (CONGEST RLF 400 MG TAB, HM CONGEST RLF 400 MG TB, SM CONGESTION RELIEF T1 CAP) CHOCOLATED LAXATIVE T1 CITROMA T0 CITRUCEL (POWDER, POWDER S-F) T1 CLEARLAX (EQ POWDER, EQL POWDER, GNP POWDER, T0 SW POWDER) CLEARLAX (GS POWDER, HM POWDER, POWDER, SM T1 POWDER)

PAGE 264 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COL-RITE T0 COLYTE WITH FLAVOR PACKETS T2 PA CONSTULOSE T1 CORRECTOL T0 DAILY FIBER (CVS DAILY 0.52 CAP, EQ DAILY 0.52 CAP) T1 DIOCTO (50 MG/5 ML LIQUID, 60 MG/15 ML SYRUP) T1 DIOCTYL T1 DOCU LIQUID T1 DOCUPRENE T0 calcium 240 mg capsule T1 docusate sodium 100 mg capsule T1 docusate sodium (50 mg/5 ml liquid, 60 mg/15ml syrup, T1 100 mg tablet, 250 mg capsule) DOCUSIL T1 DOK (100 MG SOFTGEL, 100 MG TABLET) T1 DOK 250 MG SOFTGEL T0 DOK PLUS T1 DSS T0 DUCODYL T1 DULCOEASE T0 DULCOLAX 10 MG SUPPOSITORY T0 DULCOLAX STOOL SOFTENER T0

PAGE 265 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (CVS ENEMA READY TO USE, ENEMA READY TO USE, ENEMA READY-TO-USE, EQL ENEMA READY TO USE, GNP ENEMA READY TO USE, HM ENEMA READY TO USE, T1 HM ENEMA READY TO USE TWIN PAK, QC READY TO USE ENEMA, RA ENEMA TWIN PACK, SM ENEMA READY TO USE, SM ENEMA READY TO USE TWIN PAK) CVS ENEMA DISPOSABLE T0 ENEMA T1 ENEMEEZ (MINI ENEMA, PLUS MINI ENEMA) T1 ENULOSE T1 FAST RELIEF LAXATIVE T0 FENESIN IR T1 FIBER (0.52 GRAM CAPSULE, CVS 0.52 G CAPSULE, HM 0.52 GRAM CAPSULE, HM 500 MG CAPLET, HM POWDER, T1 PUB CAPSULE, QC CAPSULE, RA CAPSULE, SM 625 MG CAPLET, SM POWDER, TABLET) FIBER LAXATIVE (625 MG CAPLET, 625 MG TABLET, T1 CAPSULE, SM 500 MG CPLT, SM 625 MG TAB) FIBER SMOOTH (POWDER, TEXTURE PWD) T1 FIBER TABS T1 FIBER THERAPY (500 MG CAPLET, CAPLET, CVS 500 MG CAPLT, CVS CAPSULE, EQ 0.52 GRAM CAP, EQ CAPLET, T1 EQL 500 MG CPLT, EQL POWDER, GNP 500 MG CAPLT, POWDER, RA CAPSULE) FIBER-LAX T1 G-FENESIN T1 GAVILAX T1 GAVILYTE-C T1 GAVILYTE-G T1

PAGE 266 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GAVILYTE-N T2 PA GENERLAC T1 GENTLE LAXATIVE (5 MG TABLET, CVS EC 5 MG TB, EC 5 MG TABLET, KRO EC 5 MG TB, 10 MG SUPPOSIT, CVS 10 T0 MG SUPP, EQ DR 5 MG TAB) GENTLE LAXATIVE (EQL EC 5 MG TB, GNP EC 5 MG TB, 10 MG SUPP, GNP 10 MG SUPP, HM 10 MG SUPP, QC 10 MG T1 SUPP, SM EC 5 MG TAB) GENTLELAX T0 GERI-KOT T2 PA glycerin (adult supp.rect, pediatric supp.rect) T1 GLYCOLAX T1 GOLYTELY (PACKET, SOLUTION) T2 PA guaifenesin 400 mg tablet T1 HEALTHYLAX T1 KAO-TIN 240 MG SOFTGEL T1 KONSYL (520 MG CAPSULE, PSYLLIUM FIBER PACKET, T1 PSYLLIUM FIBER POWDER) KONSYL FIBER T1 KRISTALOSE T2 PA 10 g packet T2 PA lactulose (10 g/15 ml solution, 20 g/30 ml solution) T1 LAX STOOL SOFTENER WITH SENNA T1 LAXACLEAR T0

PAGE 267 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LAXATIVE (5 MG TABLET, CVS 15 MG PILLS, EC 5 MG TABLET, HM EC 5 MG TABLET, RA EC 5 MG TABLET, 25 MG T1 PILL, 25 MG TABLET, EQL 25 MG TABLET, QC 25 MG TABLET, SM TABLET) LAXATIVE (GNP EC 5 MG TABLET, PUB EC 5 MG TABLET) T0 LAXATIVE FEMININE T1 LAXATIVE MAXIMUM STRENGTH T1 LAXATIVE SUPPOSITORY (10 MG SUPPOSITORY, SM 10 T1 MG SUPPOSITORY, SM PEDIATRIC SUPPOS) LUBRICANT 0.3%-0.4% EYE DROPS T1 LUBRICATING EYE T1 MAGIC BULLET T0 magnesium citrate solution T1 2400 mg/10 oral susp T1 magnesium hydroxide 400 mg/5ml oral susp T0 METAMUCIL MULTIHEALTH FIBER T1 MIDNITE FOR T2 PA MIDNITE MENOPAUSE T2 PA mineral oil enema T1 MOVE IT ALONG T0 MOVIPREP T2 PA MUCOSA T1 RELIEF (400 MG TABLET, KRO 400 MG TABLET, QC T1 400 MG CAPLET) MUCUS RELIEF CHEST T1 NATURA-LAX T1

PAGE 268 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NATURAL DAILY FIBER T2 PA NATURAL FIBER (EQL LAXATIVE CAP, GNP LAXATIVE CAP, T1 GNP POWDER, LAX POWDER, LAXATIVE CAPSULE) NATURAL FIBER LAXATIVE T1 NATURAL FIBER POWDER T1 EQ NATURAL LAXATIVE 8.6 MG TAB T1 QC NATURAL VEG LAXATIVE TABLET T1 NATURAL VEGETABLE POWDER T1 NULYTELY WITH FLAVOR PACKS T2 PA

OSMOPREP T2 PA FLEET PEDIA-LAX SUPPOSITORIES T1 PEDIA-LAX ENEMA T1 PEDIATRIC ENEMA T0 peg 3350/sod sulf/sod bicarb/sod chloride/ (peg3350/sod sulf,bicarb,cl/kcl 236-22.74g soln T1 recon, peg3350/sod sulf,bicarb,cl/kcl 240-22.72g soln recon) PEG-PREP T2 PA PERDIEM T1 PHILLIPS' LAXATIVE T1 PHILLIPS' MILK OF MAGNESIA T1 3350 17g/dose powder T1 polyethylene glycol 3350 (3350 powder, 3350 17g powd T1 pack) POWDERLAX POWDER T0 QL 2 / fill PREPOPIK T2 PA

PAGE 269 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROMOLAXIN T0 psyllium husk 0.52g capsule T1 PURE AND GENTLE SALINE ENEMA T0 CVS PURELAX POWDER T1 CVS PURELAX POWDER PACKET T0 READY TO USE ENEMA (HM MIN OIL ENEMA, MINERAL T1 OIL ENEMA, SM ENEMA) REGULOID (3.4 G/12 G POWDER, 3.4 G/7 G POWDER, T1 CAPSULE, LAXATIVE POWDER) SALINE ENEMA T0 SEN-O-TAB T1 SENEXON T1 SENEXON-S T1 SENNA (HM SENNA 8.6 MG TABLET, SENNA 8.6 MG T1 TABLET, SENNA SYRUP, SENNA-TIME 8.6 MG TABLET) SENNA LAX (GNP SENNA LAX 8.6 MG TABLET, SENNA LAX T1 8.6 MG TABLET, SENNA-LAX 8.6 MG TABLET) SENNA LAXATIVE (8.6 MG TABLET, CVS 8.6 MG TAB, GS T1 8.6 MG TAB, SM 8.6 MG TAB) SENNA PLUS (8.6-50 MG TABLET, CVS TABLET, GNP T1 TABLET, TABLET) SENNA-S (8.6-50 MG TABLET, EQ TABLET, HM TABLET, SM T1 TABLET, TABLET) SENNA-S LAXATIVE T1 SENNA-TIME S T1 SENNO T1 sennosides 8.8mg/5ml syrup T1

PAGE 270 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sennosides/docusate sodium T1 SENOKOT EXTRA STR 17.2 MG TAB T1 SILACE (50 MG/5 ML LIQUID, 60 MG/15 ML SYRUP) T1 SMOOTHLAX POWDER T0 SMOOTHLAX POWDER PACKET T1 sodium chloride/sodium bicarbonate/potassium T1 chloride/peg SOF-LAX T1 solution 70 % solution T2 PA LAXATIVE PLUS T2 PA CVS STOOL SOFTENER 50 MG SFTGL T0 STOOL SOFTENER (50 MG/5 ML LIQ, 60 MG/15 ML SYR, 100 MG CAPSULE, 100 MG SOFTGEL, EQL 100 MG SFGL, HM 100 MG SFTGL, KRO 100 MG SFGL, QC 100 MG SFTGL, 240 MG SOFTGEL, CVS 240 MG SFGL, EQ 100 MG SFTGL, T1 GNP 60 MG/15 ML, HM 100 MG TAB, SM 100 MG SFTGL, SM 240 MG SFTGL, 250 MG SOFTGEL, HM 250 MG SFTGL, SM 250 MG SFTGL) STOOL SOFTENER (100 MG TABLET, CVS 100 MG CAP, CVS 100 MG SFTG, CVS 250 MG SFGL, CVS SOFTGEL, GNP 50 T0 MG/5 ML, GNP 100 MG SFGL, GNP 250 MG SFGL, RA 100 MG CAP, SM 100 MG TAB) STOOL SOFTENER-LAXATIVE (HM TAB, QC TAB, SM TAB, T1 TABLET) STOOL SOFTENER-STIMULANT LAX (CVS TB, EQ TAB, EQL T1 TB, GNP TB, HM TAB, SM TAB, TABLET) SUPPOSITORY T1 QL 354 / fill SUPREP T2 PA

PAGE 271 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SURFAK T1 TRILYTE WITH FLAVOR PACKETS T2 PA TUSSIN 400 MG TABLET T1 GS ULTRA LUBRICANT EYE DROPS T1 WAL-MUCIL 0.52 G CAPSULE T1 SM WOMAN'S LAXATIVE 5 MG TAB T1 WOMAN'S LAXATIVE TABLET T0 CVS WOMEN'S GENTLE LAX EC 5 MG T0 WOMEN'S GENTLE LAXATIVE (EC 5 MG TAB, GNP EC 5 T1 MG) WOMEN'S LAXATIVE (EQ 5 MG TAB, RA TABLET) T0 WOMEN'S LAXATIVE 5 MG TABLET T1 WOMEN'S LAXATIVE (EQ WOMEN'S EC 5 MG TB, T0 WOMANS TABLET, WOMEN'S EC 5 MG TAB) PROTECTANTS

CARAFATE 1 GM/10 ML SUSP T1 CARAFATE 1 GM TABLET T2 PA CYTOTEC T2 PA misoprostol (100 mcg tablet, 200 mcg tablet) T1 sucralfate 1 g tablet T1 PUMP INHIBITORS

ACID REDUCER DR 20 MG CAP T2 PA QL 2 / day ACIPHEX T2 PA QL 1 / day ACIPHEX SPRINKLE T2 PA

PAGE 272 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day DEXILANT T2 PA ESOMEP-EZS T2 PA esomeprazole magnesium (20 mg capsule dr, 40 mg T1 QL 1 / day capsule dr) esomeprazole magnesium (10 mg suspdr pkt, 20 mg QL 1 / day T2 suspdr pkt, 40 mg suspdr pkt) PA esomeprazole sodium T2 PA QL 1 / day esomeprazole T2 PA HEARTBURN TREATMENT T1 QL 1 / day HEARTBURN TREATMENT 24 HOUR T1 lansoprazole (15 mg capsule dr, 30 mg capsule dr) T1 QL 1 / day QL 1 / day lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) T2 PA NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10 QL 1 / day MG PACKET, DR 20 MG CAPSULE, DR 20 MG PACKET, DR T2 40 MG CAPSULE, DR 40 MG PACKET) PA NEXIUM I.V. T2 PA (10 mg capsule dr, 20 mg capsule dr, 40 mg T1 QL 1 / day capsule dr) omeprazole 20 mg tablet dr T2 PA omeprazole magnesium (20 mg capsule dr, 20 mg tablet T2 PA dr)

PAGE 273 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS omeprazole/sodium bicarbonate (omeprazole/sodium 20- 1680mg packet, omeprazole/sodium 20mg-1.1g capsule, T2 PA omeprazole/sodium 40-1680mg packet, omeprazole/sodium 40mg-1.1g capsule) pantoprazole sodium 20 mg tablet dr T1 QL 1 / day pantoprazole sodium 40 mg tablet dr T1 QL 2 / day pantoprazole sodium (40 mg granpkt dr, 40 mg vial) T2 PA

PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 MG QL 1 / day T2 SOLUTAB, DR 30 MG CAPSULE) PA PREVACID 24HR T1 PRILOSEC T2 PA QL 1 / day PROTONIX (DR 20 MG TABLET, 40 MG SUSPENSION) T2 PA QL 2 / day PROTONIX DR 40 MG TABLET T2 PA PROTONIX IV T2 PA QL 2 / day rabeprazole sodium 20 mg tablet dr T2 PA ZEGERID (20 MG CAPSULE, 20 MG PACKET, 40 MG T2 PA CAPSULE) QL 1 / day ZEGERID 40 MG PACKET T2 PA GENITOURINARY AGENTS ANTISPASMODICS, URINARY

QL 1 / day hydrobromide T2 PA

PAGE 274 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day DETROL T2 PA QL 1 / day DETROL LA T2 PA QL 2 / day DITROPAN XL 10 MG TABLET T2 PA QL 1 / day DITROPAN XL 5 MG TABLET T2 PA QL 1 / day ENABLEX T2 PA hcl T2 PA QL 1 / day GELNIQUE (GEL PUMP, GEL ) T2 PA QL 1 / day MYRBETRIQ T2 PA chloride 5 mg/5 ml syrup T1 QL 20 / day oxybutynin chloride (10 mg tab er 24, 15 mg tab er 24) T1 QL 2 / day oxybutynin chloride 5 mg tab er 24 T1 QL 1 / day oxybutynin chloride 5 mg tablet T1 QL 4 / day QL 0.357 / day OXYTROL T2 PA OXYTROL FOR WOMEN T2 PA succinate T1 QL 1 / day QL 1 / day tartrate (2 mg cap er 24h, 4 mg cap er 24h) T2 PA

PAGE 275 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day tolterodine tartrate (1 mg tablet, 2 mg tablet) T2 PA TOVIAZ T1 QL 1 / day 60 mg cap er 24h T1 QL 1 / day QL 2 / day trospium chloride 20 mg tablet T2 PA QL 1 / day VESICARE T2 PA BENIGN PROSTATIC HYPERTROPHY AGENTS hcl T1 QL 1 / day QL 1 / day AVODART T2 PA QL 1 / day CARDURA XL T2 PA QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) T2 PA 0.5 mg capsule T1 QL 1 / day QL 1 / day dutasteride/ hcl T2 PA 5 mg tablet T1 QL 1 / day QL 2 / day FLOMAX T2 PA QL 1 / day JALYN T2 PA QL 1 / day PROSCAR T2 PA

PAGE 276 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day RAPAFLO T2 PA QL 1 / day T2 PA QL 1 / day (2.5 mg tablet, 5 mg tablet) T2 AL At least 18 yrs old PA tamsulosin hcl T1 QL 2 / day hcl T1 QL 1 / day UROXATRAL T2 PA GENITOURINARY AGENTS, OTHER

AMINOACETIC ACID T2 PA chloride (5 mg tablet, 10 mg tablet, 25 mg T1 tablet, 50 mg tablet) CERVIDIL T2 PA /sodium citrate T1 S CUPRIMINE T2 PA CURITY STERILE SALINE 0.9% IRR T1 CYTRA-2 T1 CYTRA-3 T2 PA CYTRA-K ( PACKET, ORAL SOLUTION) T1 S DEPEN T2 PA

PAGE 277 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day ELMIRON T2 PA FEM PH T2 PA urologic solution T2 PA HEMABATE T2 PA K-PHOS NO.2 T2 PA LITHOSTAT T2 PA mannitol/sorbitol solution T2 PA MEDICATED DOUCHE T1 ORACIT T2 PA S penicillamine 250 mg capsule T2 PA QL 4 / DAY penicillamine 250 mg tablet T1 S PA hcl (100 mg tablet, 200 mg tablet) T1 PHOSPHA 250 NEUTRAL T1 potassium citrate (5 tablet er, 10 tablet er, 15 tablet er) T1 potassium citrate/citric acid T1 povidone-iodine 0.3 % solution T1 PREPIDIL T2 PA PROSTIN E2 VAGINAL SUPPOSITORY T2 PA PYRIDIUM T2 PA RELAGARD T2 PA

PAGE 278 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RESECTISOL T2 PA RIMSO-50 T2 PA SHOHL'S MODIFIED T2 PA sodium chloride irrig solution 0.9 % irrig soln T2 PA sorbitol solution (solution 3 % irrig soln, solution 3.3 % T2 PA irrig soln) SUMMER'S EVE MEDICATED DOUCHE T1 THIOLA T2 PA URECHOLINE T2 PA UROCIT-K T2 PA VCF CONTRACEPTIVE FOAM T1 VIRT-PHOS 250 NEUTRAL T1 hcl 5.4 mg tablet T2 PA PHOSPHATE BINDERS

AURYXIA T2 PA calcium acetate 667 mg capsule T1 calcium acetate 667 mg tablet T1 CALPHRON T2 PA FOSRENOL (500 MG TABLET CHEW, 750 MG POWDER PACKET, 750 MG TABLET CHEW, 1,000 MG POWDER T2 PA PACK, 1,000 MG TABLET CHEW) carbonate (500 mg tab chew, 750 mg tab T1 chew) lanthanum carbonate 1000 mg tab chew T2 PA PHOSLYRA T2 PA

PAGE 279 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RENAGEL T2 PA RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER T2 PA PACKET, 800 MG TABLET) sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack) T2 PA sevelamer carbonate 800 mg tablet T1 sevelamer hcl T2 PA VELPHORO T2 PA HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

A-HYDROCORT T2 PA ANUCORT-HC T2 PA ANUSOL-HC 25 MG SUPPOSITORY T2 PA ARISTOSPAN T2 PA /betamethasone sodium T2 PA phosphate CELESTONE T2 PA CORTEF T2 PA 25 mg tablet T2 PA DECADRON 0.5 MG/5 ML ELIXIR T2 PA DECADRON (0.5 MG TABLET, 0.75 MG TABLET, 4 MG T1 TABLET, 6 MG TABLET) DEPO-MEDROL T2 PA 0.5 mg/5ml elixir T1 dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds T2 PA pk)

PAGE 280 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dexamethasone (0.5 mg tablet, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg T1 tablet, 6 mg tablet) DEXAMETHASONE INTENSOL T1 dexamethasone sodium phosphate T2 PA dexamethasone sodium phosphate in 0.9 % sodium T2 PA chloride dexamethasone sodium phosp/pf 10 mg/ml vial T1 DEXPAK T2 PA acetate 0.1 mg tablet T1 HEMMOREX-HC T2 PA HIDEX T2 PA hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) T1 hydrocortisone acetate (25 mg supp.rect, 30 mg T2 PA supp.rect) KENALOG-10 T2 PA KENALOG-40 T2 PA KORLYM T2 PA MEDROL (2 MG TABLET, 4 MG DOSEPAK, 4 MG TABLET, 8 T2 PA MG TABLET, 16 MG TABLET, 32 MG TABLET) (4 mg tab ds pk, 4 mg tablet) T1 methylprednisolone (8 mg tablet, 16 mg tablet, 32 mg T2 PA tablet) methylprednisolone acetate T2 PA methylprednisolone sodium succinate T2 PA MICORT-HC 2.5% CREAM T2 PA

PAGE 281 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MIFEPREX T2 PA T2 PA MILLIPRED T2 PA MILLIPRED DP T2 PA ORAPRED ODT T2 PA 15 mg/5 ml solution T1 prednisolone sodium phosphate (5 mg/5 ml solution, 15 T1 mg/5 ml solution, 25 mg/5 ml solution) prednisolone sodium phosphate (10 mg tab rapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 20 mg/5 ml solution, T2 PA 30 mg tab rapdis) (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mg T1 tablet, 20 mg tablet, 50 mg tablet) PREDNISONE INTENSOL T1 PROCTOCORT 30 MG SUPPOSITORY T2 PA RAYOS T2 PA

AL At least 18 yrs SERNIVO T2 old PA SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250 MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 1,000 MG ACT-O- T2 PA VL) SOLU-MEDROL (1 GRAM VIAL, 40 MG VIAL, 125 MG VIAL, T2 PA 500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) TAPERDEX 6 DAY 1.5 MG TABLET T2 PA triamcinolone acetonide (10 mg/ml vial, 40 mg/ml vial) T2 PA

PAGE 282 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ULTRAVATE 0.05% LOTION T2 PA VERIPRED 20 T2 PA HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

ACTHAR T2 PA CORTROSYN T2 PA cosyntropin T2 PA DDAVP (0.01% NASAL SPRAY, 0.1 MG TABLET, 0.2 MG TABLET, 4 MCG/ML AMPUL, 4 MCG/ML VIAL, 10 MCG/0.1 T2 PA ML SOLUTION) desmopressin acetate (0.1 mg tablet, 0.2 mg tablet) T1 desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial, T2 PA 10/spray spray/pump) desmopressin acetate (non-refrigerated) T2 PA GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 S MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK T1 PS 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG PA CARTRIDGE, 12 MG CARTRIDGE) S HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG T2 PS CARTRIDGE, 24 MG CARTRIDGE) PA INCRELEX T2 PA S NORDITROPIN FLEXPRO T1 PS PA S NUTROPIN AQ NUSPIN T2 PS PA

PAGE 283 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 T2 PS MG/1.5 ML CRTG) PA S SAIZEN T2 PS PA S SAIZEN-SAIZENPREP T2 PS PA S SEROSTIM T2 PS PA S STIMATE T1 PS T2 PA vasopressin in 0.9 % sodium chloride (in 0.9 % 100/100 ml plast. bag, in 0.9 % 100/250 ml plast. bag, in 0.9 % 40/100 T2 PA ml plast. bag, in 0.9 % 50/250 ml plast. bag) vasopressin in dextrose 5 % in water (in 5 % 100/100 ml T2 PA plast. bag, in 5 % 60/100 ml plast. bag) S ZOMACTON T2 PS PA S ZORBTIVE T2 PS PA

PAGE 284 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX /MODIFIERS)

ANADROL-50 T2 PA QL 1 / day ANDRODERM T2 AL At least 18 yrs old PA QL 5 / day ANDROGEL (1% (50 MG/5 G) PKT, 1.62% GEL PUMP, T2 AL At least 18 yrs 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) old PA QL 2.5 / day ANDROGEL 1% (25 MG/2.5 G) PKT T2 AL At least 18 yrs old PA ANDROID T2 PA AVEED T2 PA QL 6 / day AXIRON T2 AL At least 18 yrs old PA (50 mg capsule, 100 mg capsule, 200 mg capsule) T2 PA DEPO- T2 PA QL 4 / day FORTESTA T2 AL At least 18 yrs old PA METHITEST T2 PA

PAGE 285 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 10 mg capsule T2 PA QL 3 / day NATESTO T2 AL At least 18 yrs old PA OXANDRIN T2 PA (2.5 mg tablet, 10 mg tablet) T2 PA STRIANT T2 PA QL 300 / 30 days TESTIM T2 AL At least 18 yrs old PA S TESTOPEL T2 PS PA QL 10 / DAY testosterone 50 mg (1%) gel (gram) T2 AL At least 18 yrs old PA QL 4 / day testosterone 10 mg (2%) gel md pmp T2 AL At least 18 yrs old PA QL 10 / day testosterone 12.5/1.25g gel md pmp T2 AL At least 18 yrs old PA QL 5 / day testosterone 20.25/1.25 gel md pmp T1 AL At least 18 yrs old PA

PAGE 286 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 5 / day testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel T2 AL At least 18 yrs packet, 50 mg (1%) gel packet) old PA QL 2.5 / day testosterone 25mg(1%) gel packet T2 AL At least 18 yrs old PA QL 6 / day testosterone 30mg/1.5ml sol md pmp T2 AL At least 18 yrs old PA T1 T2 PA TESTRED T2 PA QL 10 / day VOGELXO 50 MG/5 GRAM GEL T2 PA QL 10 / day VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL PACKT) T2 AL At least 18 yrs old PA

QL 1 / day ACTIVELLA T2 PA AFIRMELLE T1 QL 2 / 30 days AFTERA T2 PA QL 0.29 / day ALORA T2 PA

PAGE 287 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day ALTAVERA T2 PA ALYACEN T2 PA QL 1 / day AMABELZ T2 PA AMETHIA T2 PA AMETHIA LO T2 PA QL 1 / day AMETHYST T2 PA QL 1 / day ANGELIQ T2 PA APRI T2 PA ARANELLE T2 PA ASHLYNA T2 PA QL 1 / day AUBRA T2 PA AUBRA EQ T2 PA AUROVELA 1 MG-20 MCG TABLET T1 AUROVELA 21 1.5-30 TABLET T2 PA AUROVELA 24 FE T2 PA AUROVELA FE T1 QL 1 / day AVIANE T2 PA AYUNA T1 AZURETTE T2 PA

PAGE 288 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BALZIVA T2 PA BEKYREE T2 PA BEYAZ T2 PA BLISOVI 24 FE T2 PA BLISOVI FE T1 BRIELLYN T2 PA CAMRESE T2 PA CAMRESE LO T2 PA CAZIANT T2 PA QL 1 / day CHATEAL T2 PA CHATEAL EQ T2 PA QL 0.15 / day CLIMARA T2 PA QL 0.15 / day CLIMARA PRO T2 PA QL 0.29 / day COMBIPATCH T2 PA COVARYX T2 PA COVARYX H.S. T2 PA CRYSELLE T2 PA CYCLAFEM T2 PA CYRED T2 PA CYRED EQ T2 PA

PAGE 289 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DASETTA T2 PA DAYSEE T2 PA DELESTROGEN T2 PA DEPO- T2 PA -ethinyl estradiol T2 PA desogestrel-ethinyl estradiol/ethinyl estradiol T2 PA DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75 MG GEL PACKET, 1 MG GEL PACKET, 1.25 MG GEL T2 PA PACKET) /ethinyl estradiol/levomefolate calcium T2 PA DUAVEE T2 PA QL 2 / 30 days ECONTRA EZ T2 PA QL 0.067 / DAY ECONTRA ONE-STEP T2 PA EEMT T2 PA EEMT H.S. T2 PA ELESTRIN T2 PA ELINEST T2 PA ELURYNG T1 QL 0.04 / DAY EMOQUETTE T2 PA ENPRESSE T2 PA ENSKYCE T2 PA ESTARYLLA T2 PA

PAGE 290 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day ESTRACE 0.01% CREAM T2 PA QL 1 / day ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) T2 PA estradiol 0.01 % cream/appl T1 QL 4 / day estradiol (.025mg/24h patch tdsw, .0375mg/24 patch QL 0.29 / day tdsw, 0.05mg/24h patch tdsw, .075mg/24h patch tdsw, T2 0.1mg/24hr patch tdsw) PA estradiol (.025mg/24h patch tdwk, .0375mg/24 patch QL 0.15 / day tdwk, 0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk, T2 .075mg/24h patch tdwk, 0.1mg/24hr patch tdwk) PA estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet) T1 QL 1 / day estradiol 10 mcg tablet T1 QL 1 / day (20 mg/ml vial, 40 mg/ml vial) T1 QL 1 / day estradiol/norethindrone acetate T2 PA ESTRING T2 PA QL 1.667 / day ESTROGEL T2 PA estrogens,esterified/methyltestosterone T2 PA ESTROSTEP FE T2 PA ethinyl estradiol/drospirenone 0.02-3(28) tablet T2 PA ethinyl estradiol/drospirenone 0.03mg-3mg tablet T1 ethynodiol diacetate-ethinyl estradiol T2 PA /ethinyl estradiol T1 QL 0.04 / DAY QL 0.54 / day EVAMIST T2 PA

PAGE 291 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day FALMINA T2 PA FAYOSIM T2 PA QL 1 / day FEMHRT T2 PA QL 0.02 / day FEMRING T2 PA FEMYNOR T1 QL 1 / day FYAVOLV T2 PA GENERESS FE T2 PA GIANVI T2 PA HAILEY T2 PA HAILEY 24 FE T2 PA HAILEY FE 1-20 TABLET T1 HAILEY FE 1.5-30 TABLET T1 QL 1 / day INTROVALE T2 PA ISIBLOOM T2 PA JAIMIESS T2 PA JASMIEL T2 PA QL 1 / day JINTELI T2 PA JOLESSA T2 PA JULEBER T2 PA

PAGE 292 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS JUNEL T2 PA JUNEL FE T2 PA JUNEL FE 24 T2 PA KAITLIB FE T2 PA KALLIGA T2 PA KARIVA T2 PA KELNOR 1-35 T2 PA KELNOR 1-50 T2 PA KURVELO T1 QL 1 / day LARIN 1.5 MG-30 MCG TABLET T2 PA LARIN 21 1-20 TABLET T1 LARIN 24 FE T2 PA LARIN FE T2 PA LARISSIA T1 LAYOLIS FE T2 PA LEENA T2 PA QL 1 / day LESSINA T2 PA LEVONEST T2 PA QL 0.067 / DAY T2 PA levonorgestrel/ethin.estradiol 0.1-0.02mg tablet T1 QL 1 / day levonorgestrel/ethin.estradiol 6-5-10 tablet T2 PA QL 1 / day levonorgestrel/ethin.estradiol 90-20 mcg tablet T2 PA

PAGE 293 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levonorgestrel/ethinyl estradiol (levonorgestrel/ethin.estradiol 0.15-0.03 tablet, T1 levonorgestrel/ethin.estradiol 0.15-0.03 tbdspk 3mo) l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo T2 PA levonorgestrel/ethinyl estradiol and ethinyl estradiol (l- norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l- T2 PA norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo) LEVORA-28 T2 PA LILLOW T1 LO LOESTRIN FE T2 PA

LO-ZUMANDIMINE T2 PA LOESTRIN T2 PA LOESTRIN FE T2 PA LOJAIMIESS T1 QL 1 / day LOPREEZA T2 PA LORYNA T2 PA LOSEASONIQUE T2 PA LOW-OGESTREL T2 PA LUTERA T2 PA QL 1 / day MARLISSA T2 PA MELODETTA 24 FE T2 PA

MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MG QL 1 / day T2 TABLET) PA QL 0.15 / day MENOSTAR T2 PA

PAGE 294 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MIBELAS 24 FE T2 PA MICROGESTIN T2 PA MICROGESTIN 24 FE T2 PA MICROGESTIN FE T2 PA MILI T1 MIMVEY T1 QL 1 / day MIMVEY LO T2 PA MINASTRIN 24 FE T2 PA QL 0.29 / day MINIVELLE T2 PA MIRCETTE T2 PA MONO-LINYAH T2 PA MONONESSA T2 PA QL 0.067 / DAY MY CHOICE T2 PA MY WAY T2 PA MYZILRA T2 PA NATAZIA T2 PA NECON T2 PA QL 0.067 / DAY NEW DAY T2 PA NIKKI T2 PA norethindrone ac-eth estradiol 1.5-0.03mg tablet T2 PA norethindrone ac-eth estradiol 1mg-20mcg tablet T1 QL 1 / day

PAGE 295 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, QL 1 / day T2 1mg-5mcg tablet) PA norethindrone-e.estradiol- 1mg-20(24) tab chew T2 PA norethindrone acetate-ethinyl estradiol/ferrous fumarate T1 (1mg-20(21) tablet, 1.5-30(21) tablet) norethindrone-e.estradiol-iron 1mg-20(24) tablet T2 PA noreth-ethinyl estradiol/iron 0.4-35(21) tab chew T2 PA noreth-ethinyl estradiol/iron 0.8-25(24) tab chew T2 PA -ethinyl estradiol (0.25-0.035 tablet, 7daysx3 T1 28 tablet, 7daysx3 lo tablet) NORTREL T2 PA NUVARING T2 PA OCELLA T2 PA QL 1 / day OGESTREL T2 PA QL 0.067 / DAY OPCICON ONE-STEP T2 PA QL 0.067 / DAY OPTION 2 T2 PA QL 1 / day ORSYTHIA T2 PA ORTHO TRI-CYCLEN T2 PA ORTHO TRI-CYCLEN LO T2 PA ORTHO-CYCLEN T2 PA ORTHO-NOVUM T2 PA

PAGE 296 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHILITH T2 PA PIMTREA T2 PA PIRMELLA T2 PA QL 0.067 / DAY PLAN B ONE-STEP T2 PA QL 1 / day PORTIA T2 PA QL 1 / day PREFEST T2 PA PREMARIN VAGINAL CREAM-APPL T1 QL 2 / day

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG QL 1 / day T2 TABLET, 0.9 MG TABLET, 1.25 MG TABLET) PA PREMARIN 25 MG VIAL T2 PA QL 1 / day PREMPHASE T2 PA QL 1 / day PREMPRO T2 PA PREVIFEM T1 QUARTETTE T2 PA QUASENSE T2 PA RECLIPSEN T2 PA RIVELSA T2 PA SAFYRAL T2 PA SEASONIQUE T2 PA

PAGE 297 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SETLAKIN T2 PA SIMLIYA T2 PA SIMPESSE T2 PA SPRINTEC T2 PA SRONYX T1 SYEDA T1 TAKE ACTION T2 PA TARINA 24 FE T2 PA TARINA FE T2 PA TARINA FE 1-20 EQ T2 PA TAYTULLA T2 PA TILIA FE T2 PA TRI FEMYNOR T1 TRI-ESTARYLLA T2 PA TRI-LEGEST FE T2 PA TRI-LINYAH T2 PA TRI-LO-ESTARYLLA T2 PA TRI-LO-MARZIA T1 TRI-LO-MILI T1 TRI-LO-SPRINTEC T1 TRI-MILI T1 TRI-NORINYL T2 PA TRI-PREVIFEM T1

PAGE 298 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRI-SPRINTEC T2 PA TRI-VYLIBRA T2 PA TRI-VYLIBRA LO T2 PA TRIVORA-28 T2 PA TYDEMY T2 PA VAGIFEM T1 QL 1 / day VELIVET T2 PA VIENVA T2 PA VIORELE T2 PA QL 0.29 / day VIVELLE-DOT T2 PA VOLNEA T2 PA VYFEMLA T2 PA VYLIBRA T2 PA WERA T2 PA WYMZYA FE T2 PA XULANE T1 QL 0.12 / day YASMIN 28 T2 PA YAZ T2 PA YUVAFEM T1 QL 1 / day ZARAH T2 PA ZOVIA 1-35E T2 PA ZUMANDIMINE T1

PAGE 299 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AGONISTS/ANTAGONISTS

QL 1 / day ELLA T2 PA PROGESTINS

AYGESTIN T2 PA CAMILA T2 PA CRINONE 4% GEL T2 PA QL 2.5 / day CRINONE 8% GEL T2 PA DEBLITANE T2 PA DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL, T2 PA 400 MG/ML VIAL) DEPO-SUBQ PROVERA 104 T2 PA QL 3 / day ENDOMETRIN T2 PA ERRIN T2 PA HEATHER T2 PA S hydroxyprogesterone caproate T2 PS PA S hydroxyprogesterone caproate/pf T1 PS INCASSIA T1 JENCYCLA T2 PA JOLIVETTE T2 PA

PAGE 300 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S KYLEENA T1 PS S LILETTA T1 PS LYZA T2 PA S MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) T2 PS PA acetate (150 mg/ml syringe, 150 T1 QL 0.04 / day mg/ml vial) medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, T1 10 mg tablet) MEGACE ES T2 PA acetate 625mg/5ml oral susp T2 PA (20 mg tablet, 40 mg tablet, T1 400mg/10ml oral susp) S MIRENA T1 PS S NEXPLANON T1 PS NORA-BE T2 PA norethindrone 0.35 mg tablet T1 norethindrone acetate 5 mg tablet T1 NORLYDA T1 ORTHO MICRONOR T2 PA progesterone 50 mg/ml vial T1

PAGE 301 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS progesterone, micronized (100 mg capsule, 200 mg T1 capsule) PROMETRIUM T2 PA PROVERA T2 PA SHAROBEL T2 PA S SKYLA T1 PS TULANA T2 PA SELECTIVE RECEPTOR MODIFYING AGENTS

QL 1 / day EVISTA T2 PA OSPHENA T1 QL 1 / day hcl T1 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING () ARMOUR THYROID (120 MG TABLET, 180 MG TABLET, T1 240 MG TABLET, 300 MG TABLET) ARMOUR THYROID (15 MG TABLET, 30 MG TABLET, 60 T2 PA MG TABLET, 90 MG TABLET) CYTOMEL T2 PA LEVO-T T2 PA sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg T1 tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) levothyroxine sodium (100 mcg vial, 200 mcg vial, 500 T2 PA mcg vial)

PAGE 302 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVOXYL T1 sodium (5 mcg tablet, 25 mcg tablet, 50 mcg T1 tablet) liothyronine sodium 10 mcg/ml vial T2 PA NATURE-THROID T2 PA NP THYROID T1 SYNTHROID T2 PA THYROID T1 thyroid, (15 mg tablet, 120 mg tablet) T1 THYROLAR-1 T2 PA THYROLAR-1/2 T2 PA THYROLAR-1/4 T2 PA THYROLAR-2 T2 PA THYROLAR-3 T2 PA TIROSINT (13 MCG CAPSULE, 25 MCG CAPSULE, 50 MCG CAPSULE, 75 MCG CAPSULE, 88 MCG CAPSULE, 100 MCG QL 1 / day T2 CAPSULE, 112 MCG CAPSULE, 125 MCG CAPSULE, 137 PA MCG CAPSULE, 150 MCG CAPSULE) TRIOSTAT T2 PA UNITHROID T1 WESTHROID T2 PA WP THYROID T2 PA HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

QL 2 / day S cinacalcet hcl T1 PS PA

PAGE 303 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day S SENSIPAR (30 MG TABLET, 60 MG TABLET) T2 PS PA QL 4 / day S SENSIPAR 90 MG TABLET T2 PS PA HORMONAL AGENTS, SUPPRESSANT (PITUITARY) T1 QL 2 / day S EGRIFTA SV T2 PS PA S ELIGARD T2 PS PA S FIRMAGON T2 PS PA S leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial) T2 PS PA S LUPANETA PACK T2 PS PA S LUPRON DEPOT T2 PS PA

PAGE 304 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S LUPRON DEPOT (LUPANETA) T2 PS PA S LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 T2 PS MG KIT, 15 MG KIT, 30 MG 3MO KIT) PA acetate (50 mcg/ml ampul, 50 mcg/ml syringe, S 100 mcg/ml ampul, 100 mcg/ml syringe, 500 mcg/ml T1 PS ampul, 500 mcg/ml syringe, 500 mcg/ml vial) PA S octreotide acetate (50 mcg/ml vial, 100 mcg/ml vial, 200 T2 PS mcg/ml vial, 1000mcg/ml vial) PA QL 30 / day S SANDOSTATIN 0.05 MG/ML AMPUL T2 PS PA QL 15 / day S SANDOSTATIN 0.1 MG/ML AMPUL T2 PS PA QL 3 / day S SANDOSTATIN 0.5 MG/ML AMPUL T2 PS PA QL 0.04 / day SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG S T2 KT, 30 MG VL) PS PA

PAGE 305 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.07 / day S SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) T2 PS PA SIGNIFOR T2 PA QL 0.1 / DAY SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) T2 PS PA QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) T2 PS PA QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) T2 PS PA QL 0.02 / day S SOMATULINE DEPOT T2 PS PA SOMAVERT T2 PA S SUPPRELIN LA T2 PS PA S SYNAREL T2 PS PA S TRELSTAR T2 PS PA

PAGE 306 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S VANTAS T2 PS PA S ZOLADEX T2 PS PA HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole (5 mg tablet, 10 mg tablet) T1 50 mg tablet T1 TAPAZOLE T2 PA IMMUNOLOGICAL AGENTS ANGIOEDEMA (HAE) AGENTS

AL At least 6 yrs BERINERT 500 UNIT KIT T1 old PA

AL At least 13 yrs BERINERT 500 UNIT VIAL T1 old PA

AL At least 13 yrs CINRYZE T1 old PA S FIRAZYR T2 PS PA PS acetate T2 PA

PAGE 307 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 16 yrs KALBITOR T1 old PA QL 0.87 / day RUCONEST T2 PA IMMUNE SUPPRESSANTS

QL 15 / day S ASTAGRAF XL 0.5 MG CAPSULE T2 PS PA QL 30 / day S ASTAGRAF XL 1 MG CAPSULE T2 PS PA QL 6 / day S ASTAGRAF XL 5 MG CAPSULE T2 PS PA AZASAN T2 PA azathioprine 50 mg tablet T1 azathioprine sodium T2 PA S CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 T2 PS MG TABLET, 500 MG VIAL) PA S CIMZIA (2X200 MG/ML SYRINGE KIT, 2X200 T2 PS MG/ML(X3)START KT, 200 MG VIAL KIT) PA

PAGE 308 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S cyclosporine (25 mg capsule, 100 mg capsule, 250 mg/5ml T2 PS ampul) PA cyclosporine, modified (25 mg capsule, 100 mg capsule, S T1 100 mg/ml solution) PS S cyclosporine, modified 50 mg capsule T2 PS PA QL 0.144 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML AL At least 2 yrs T1 old SYRINGE) S PS QL 0.144 / day AL At least 2 yrs ENBREL MINI T1 old S PS QL 0.144 / day AL At least 2 yrs ENBREL SURECLICK T1 old S PS S ENTYVIO T2 PS PA QL 1 / day S ENVARSUS XR T2 PS PA

PAGE 309 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) T2 PS PA

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100 S T1 MG/ML SOLUTION) PS QL 0.08 / day AL At least 2 yrs HUMIRA T1 old S PS QL 0.08 / day AL At least 2 yrs HUMIRA PEDIATRIC CROHN'S T1 old S PS QL 0.08 / day AL At least 2 yrs HUMIRA PEN T1 old S PS QL 0.08 / day AL At least 2 yrs HUMIRA PEN CROHN'S-UC-HS T1 old S PS QL 0.08 / day AL At least 2 yrs HUMIRA PEN PSOR-UVEITS-ADOL HS T1 old S PS

PAGE 310 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.08 / day AL At least 2 yrs HUMIRA(CF) 20 MG/0.2 ML SYRING T1 old S PS IMURAN T2 PA QL 0.5 / day S INFLECTRA T2 PS PA KINERET T2 PA sodium (2.5 mg tablet, 25 mg/ml vial) T1 methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 T1 mg/ml vial) mycophenolate mofetil (200 mg/ml susp recon, 250 mg S T1 capsule, 500 mg tablet) PS S mycophenolate mofetil hcl T2 PS PA S mycophenolate sodium T1 PS S MYFORTIC T2 PS PA S NEORAL (25 MG CAPSULE, 100 MG GELATIN T2 PS CAPSULE, 100 MG/ML SOLUTION) PA S NULOJIX T2 PS PA

PAGE 311 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL) T2 PS PA S ORENCIA CLICKJECT T2 PS PA OTREXUP T2 PA S PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG T2 PS CAPSULE, 5 MG/ML AMPULE) PA S RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML T2 PS ORAL SOLN, 2 MG TABLET) PA RASUVO T2 PA S REMICADE T2 PS PA S RENFLEXIS T2 PS PA S SANDIMMUNE (25 MG CAPSULE, 50 MG/ML AMPUL, 100 T2 PS MG CAPSULE, 100 MG/ML SOLN) PA

SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML S SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML T2 PS SYRINGE) PA S SIMPONI ARIA T2 PS PA

PAGE 312 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2 S T1 mg tablet) PS QL 2 / day tacrolimus 0.5 mg capsule T1 S PS QL 8 / day tacrolimus 1 mg capsule T1 S PS QL 4 / day tacrolimus 5 mg capsule T1 S PS TREXALL T2 PA S XELJANZ 5 MG TABLET T2 PS PA S XELJANZ XR 11 MG TABLET T2 PS PA S ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG T2 PS TABLET) PA IMMUNIZING AGENTS, PASSIVE

ANASCORP T2 PA antivenin,latrodectus mactans T2 PA antivenin,micrurus fulvius T2 PA S ATGAM T2 PS PA

PAGE 313 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S BIVIGAM T2 PS PA CROFAB T2 PA CUVITRU (1 GRAM/5 ML VIAL, 2 GRAM/10 ML VIAL, 4 T2 PA GRAM/20 ML VIAL, 8 GRAM/ 40 ML VIAL) S CYTOGAM T2 PS PA S FLEBOGAMMA DIF T2 PS PA S GAMASTAN T2 PS PA S GAMASTAN S-D T2 PS PA S GAMMAGARD LIQUID T2 PS PA S GAMMAGARD S-D T2 PS PA S GAMMAKED T2 PS PA

PAGE 314 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S GAMMAPLEX (5 GRAM/100 ML VIAL, 10 GRAM/200 ML T2 PS VIAL, 20 GRAM/400 ML VIAL) PA S GAMUNEX-C T2 PS PA S HEPAGAM B T2 PS PA S HIZENTRA (1 GRAM/5 ML VIAL, 2 GRAM/10 ML VIAL, 4 T2 PS GRAM/20 ML VIAL, 10 GRAM/50 ML VIAL) PA S HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) T2 PS PA S HYPERRAB S-D T2 PS PA S HYPERRHO S-D T2 PS PA S HYPERTET S-D T2 PS PA HYQVIA T2 PA HYQVIA IG COMPONENT T2 PA S IMOGAM RABIES-HT T2 PS PA

PAGE 315 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S KEDRAB T2 PS PA S MICRHOGAM ULTRA-FILTERED PLUS T2 PS PA S NABI-HB T2 PS PA S OCTAGAM T2 PS PA S PRIVIGEN T2 PS PA S RHOGAM ULTRA-FILTERED PLUS T2 PS PA S RHOPHYLAC T2 PS PA THYMOGLOBULIN T2 PA S VARIZIG T2 PS PA S WINRHO SDF T2 PS PA

PAGE 316 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS IMMUNOMODULATORS

S ACTEMRA (80 MG/4 ML VIAL, 162 MG/0.9 ML SYRINGE, T2 PS 200 MG/10 ML VIAL, 400 MG/20 ML VIAL) PA ACTIMMUNE T2 PA ARAVA T2 PA ARCALYST T2 PA S BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML T2 PS SYRINGE) PA QL 0.25 / day S BENLYSTA 120 MG VIAL T2 PS PA QL 0.334 / day S BENLYSTA 400 MG VIAL T2 PS PA ILARIS T2 PA leflunomide T1 S OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER T2 PS PACK) PA RIDAURA T2 PA SIMULECT T2 PA S SYNAGIS T2 PS PA

PAGE 317 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ACTHIB T1 ADACEL TDAP (SYRINGE, VIAL) T1 bcg , live/pf T2 PA BEXSERO T1 BIOTHRAX T1 BOOSTRIX TDAP (SYRINGE, VIAL) T1 DAPTACEL DTAP T1 ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) T1 ENGERIX-B PEDIATRIC-ADOLESCENT T1 GARDASIL 9 (9 SYRINGE, 9 VIAL) T1 HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML T1 VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) HIBERIX VACCINE VIAL T1 HIBERIX VACCINE WITH DILUENT T1 IMOVAX RABIES VACCINE T1 INFANRIX DTAP (SYRINGE, VIAL) T1 IPOL (SINGLE DOSE SYRINGE, VIAL) T1 IXIARO T1 KINRIX (TIP-LOK SYRINGE, VIAL) T1 M-M-R II VACCINE T1 MENACTRA T1 MENVEO A-C-Y-W-135-DIP T1 MENVEO MENA COMPONENT T1 MENVEO MENCYW-135 COMPONENT T1

PAGE 318 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PEDIARIX T1 PEDVAXHIB T1 PENTACEL T1 PENTACEL ACTHIB COMPONENT T1 PENTACEL DTAP-IPV COMPONENT T1 PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) T1 PREVNAR 13 T1 PROQUAD T1 QUADRACEL DTAP-IPV T1 RABAVERT T1 RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, T1 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) ROTARIX T1 ROTATEQ T1 TENIVAC (SYRINGE, VIAL) T1 tetanus and toxoids, adult T1 tetanus,diphtheria toxoid ped/pf T1 TRUMENBA T1 TWINRIX T1 TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) T1 VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML T1 VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) VARIVAX VACCINE T1 VAXCHORA ACTIVE COMPONENT T1 VAXCHORA VACCINE T1

PAGE 319 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIVOTIF T1 YF-VAX T1 ZOSTAVAX T1 INFLAMMATORY BOWEL DISEASE AGENTS

APRISO T1 ASACOL HD T2 PA disodium T1 CANASA T2 PA COLAZAL T2 PA DELZICOL T2 PA DIPENTUM T2 PA LIALDA T2 PA mesalamine 0.375g cap er 24h T1 mesalamine (4 g/60 ml enema, 1000 mg supp.rect) T1 mesalamine (1.2 g tablet dr, 400 mg cap(drtab), 800 mg T2 PA tablet dr) mesalamine with cleansing wipes T2 PA PENTASA T1 ROWASA (4 GM/60 ML ENEMA, 4 GM/60 ML ENEMA KIT) T2 PA SFROWASA T2 PA

ANUSOL-HC 2.5% CREAM T1 3 mg capdr - er T1

PAGE 320 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS budesonide 9 mg tabdr - er T2 PA COLOCORT T2 PA CORTENEMA T2 PA CORTIFOAM T2 PA ENTOCORT EC T2 PA hydrocortisone 100mg/60ml enema T2 PA PROCTO-PAK T1 PROCTOCORT 1% CREAM T1 PROCTOSOL-HC T1 PROCTOZONE-HC T1 UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) T2 PA SULFONAMIDES

AZULFIDINE (500 MG TABLET, ENTAB 500 MG) T2 PA (500 mg tablet, 500 mg tablet dr) T1 METABOLIC BONE DISEASE AGENTS

QL 0.04 / day ACTONEL 150 MG TABLET T2 PA QL 0.15 / day ACTONEL 35 MG TABLET T2 PA QL 1 / day ACTONEL 5 MG TABLET T2 PA QL 12.5 / day alendronate sodium 70 mg/75ml solution T2 PA alendronate sodium (35 mg tablet, 40 mg tablet, 70 mg T1 QL 0.15 / day tablet)

PAGE 321 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS alendronate sodium (5 mg tablet, 10 mg tablet) T1 QL 1 / day QL 0.15 / day ATELVIA T2 PA QL 0.15 / day BINOSTO T2 PA S BONIVA 3 MG/3 ML SYRINGE T2 PS PA QL 0.04 / day BONIVA 150 MG TABLET T2 PA ,salmon,synthetic T1 QL 0.13 / day calcitriol (1 mcg/ml ampul, 1 mcg/ml solution) T2 PA calcitriol (0.25 mcg capsule, 0.5 mcg capsule) T1 S doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg T2 PS capsule, 4mcg/2ml vial) PA etidronate disodium T2 PA S FORTEO T2 PS PA QL 0.15 / day FOSAMAX T2 PA QL 0.15 / day FOSAMAX PLUS D T2 PA S HECTOROL T2 PS PA

PAGE 322 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ibandronate sodium (3 mg/3 ml syringe, 3 mg/3 ml vial) T2 PS PA ibandronate sodium 150 mg tablet T1 QL 0.04 / day S MIACALCIN T2 PS PA NATPARA T2 PA S pamidronate disodium (30 mg vial, 30mg/10ml vial, 60 T2 PS mg/10ml vial, 90 mg vial, 90 mg/10ml vial) PA S paricalcitol (1 mcg capsule, 2 mcg capsule, 2 mcg/ml vial, T2 PS 4 mcg capsule, 5 mcg/ml vial) PA QL 0.13 / day S PROLIA T2 PS PA S RAYALDEE T2 PS PA S RECLAST T2 PS PA QL 0.04 / day risedronate sodium 150 mg tablet T2 PA QL 0.15 / day risedronate sodium 35 mg tablet T2 PA

PAGE 323 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day risedronate sodium 5 mg tablet T2 PA risedronate sodium (30 mg tablet, 35 mg tablet dr) T2 PA ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 T2 PA MCG/ML ORAL SOLN) QL 0.07 / day S XGEVA T2 PS PA S ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE, 2 MCG/ML T2 PS VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML VIAL) PA S zoledronic acid (4 mg vial, 4 mg/5 ml vial) T2 PS PA S zoledronic acid in mannitol and 0.9 % sodium chloride T2 PS PA zoledronic acid in mannitol and water for injection S (acid/mannitol-water 4 mg/100ml pggybk btl, T2 PS acid/mannitol-water 5 mg/100ml pggybk btl, acid/mannitol-water 5 mg/100ml piggyback) PA S ZOMETA (4 MG/100 ML INJECTION, 4 MG/5 ML VIAL) T2 PS PA MISCELLANEOUS THERAPEUTIC AGENTS

(d)-limonene flavor T2 PA 1,2-pentanediol T2 PA

PAGE 324 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 1,3-butanediol T2 PA 1,4-benzoquinone T2 PA 12 HOUR DECONGESTANT T1 12 HOUR NASAL DECONGESTANT T1 12 HOUR NASAL RELIEF T1 12 HOUR NASAL SPRAY (12 HOUR NASAL SPRAY, EQL 12HR NASAL SPRAY, RA 12HR NASAL SPRAY, SM 12HR T1 NASAL SPRAY) 2-deoxy-d-glucose T2 PA 2-methoxyestradiol T2 PA 2-methoxyethanol T2 PA 3,5-diiodothyronine T2 PA 4 WAY T0 5-hydroxy-l- (oxitriptan) T2 PA 7-oxodehydroepiandrosterone T2 PA 7-oxodehydroepiandrosterone, micronized T2 PA acacia T2 PA acebutolol hcl powder T2 PA acepromazine maleate T2 PA T2 PA ACETADOTE T2 PA acetaminophen 100 % powder T2 PA T2 PA acetazolamide powder T2 PA

PAGE 325 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS acetic acid (3 % liquid, 5 % liquid, 100 % liquid) T2 PA liquid T1 acetyl hexapeptide-8 (100 % powder, solution) T2 PA hcl T2 PA chloride T2 PA powder T2 PA acetylglucosamine T2 PA acid green 50 T2 PA acrylamide/sod acryloyldimethyl taurat copoly isohex poly T2 PA 80 S ACTHREL T2 PS PA activated charcoal powder T2 PA acyclovir 100 % powder T2 PA adapter cap for bottle each T1 PA adenosine powder T2 PA disodium trihydrate T2 PA adhesive bandage (bandage bandage, bandage 4" x 5" T2 PA bandage) adhesive tape (tape 0.125"x3" strip, tape 0.25"x1.5" strip, T2 PA tape 0.25"x3" strip, tape 0.25"x4" strip, tape 0.5"x4" strip) ADREVIEW T2 PA ADULT NASAL DECONGESTANT T1 T2 PA

PAGE 326 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS albendazole 100 % powder T2 PA ALBUKED-25 T2 PA ALBUKED-5 T2 PA albumin human T2 PA ALBUMINAR-5 T2 PA ALBURX T2 PA ALBUTEIN T2 PA albuterol sulfate powder T2 PA alcohol T1 alcohol antiseptic pads med. pad T0 T2 PA alginic acid T2 PA alkyl (c12-15) benzoate T2 PA alkyl acrylate crosspolymer T2 PA powder T2 PA allergenic tree -american elm T2 PA allergenic extract, grass pollen-bermuda, standard T2 PA allergenic extract, grass pollen-orchard grass, standard T2 PA allergenic extract, mite-d.farinae- T2 PA d.pteronyssinus,standard allergenic extract,grass pollen-june(kentucky T2 PA blue),standard allergenic extract,grass pollen-redtop, standard T2 PA QL 1 / day grass pollen-timothy, standard 100k/ml vial T2 PA

PAGE 327 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS grass pollen-timothy, standard 10k unit/1 vial T2 PA allergenic extract,mite-dermatophagoides pteronyssinus, T2 PA std allergenic extract-american cockroach T2 PA allergenic extract-cattle epithelium T2 PA allergenic extract-cockroach (american and german) T2 PA allergenic extract-corn smut T2 PA allergenic extract-cultivated crop pollen-corn T2 PA allergenic extract-dog epithelium T2 PA allergenic extract-fire ant T2 PA allergenic extract-german cockroach T2 PA allergenic extract-grass pollen-bahia T2 PA allergenic extract-grass pollen-johnson T2 PA allergenic extract-grass pollen-meadow fescue, T2 PA standardized allergenic extract-grass pollen-perennial rye, standard T2 PA allergenic extract-grass pollen-quack T2 PA allergenic extract-grass pollen-smooth brome T2 PA allergenic extract-horse epithelium T2 PA allergenic extract-mixed feathers, chicken, duck, goose T2 PA allergenic extract-mixed weed pollen-short and tall T2 PA ragweed allergenic extract-mosquito T2 PA allergenic extract-mouse epithelium T2 PA

PAGE 328 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-rabbit epithelium T2 PA allergenic extract-sweet vernal, standardized T2 PA allergenic extract-tree pollen-acacia T2 PA allergenic extract-tree pollen-alder white T2 PA allergenic extract-tree pollen-american beech T2 PA allergenic extract-tree pollen-american sycamore T2 PA allergenic extract-tree pollen-arizona cypress T2 PA allergenic extract-tree pollen-australian pine T2 PA allergenic extract-tree pollen-bald cypress T2 PA allergenic extract-tree pollen-bayberry T2 PA allergenic extract-tree pollen-black walnut T2 PA allergenic extract-tree pollen-black T2 PA allergenic extract-tree pollen-box elder T2 PA allergenic extract-tree pollen-eastern cottonwood T2 PA allergenic extract-tree pollen-elm, cedar T2 PA allergenic extract-tree pollen-hackberry T2 PA allergenic extract-tree pollen-juniper, western T2 PA allergenic extract-tree pollen-kapok T2 PA allergenic extract-tree pollen-melaleuca T2 PA allergenic extract-tree pollen-mesquite T2 PA allergenic extract-tree pollen-mountain cedar T2 PA allergenic extract-tree pollen-mulberry, red T2 PA allergenic extract-tree pollen-mulberry, white T2 PA

PAGE 329 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-tree pollen-olive T2 PA allergenic extract-tree pollen-palm, queen T2 PA allergenic extract-tree pollen-pecan T2 PA allergenic extract-tree pollen-pepper tree, california T2 PA allergenic extract-tree pollen-pine, white T2 PA allergenic extract-tree pollen-privet T2 PA allergenic extract-tree pollen-red birch T2 PA allergenic extract-tree pollen-red cedar T2 PA allergenic extract-tree pollen-red maple T2 PA allergenic extract-tree pollen-red T2 PA allergenic extract-tree pollen-shagbark T2 PA allergenic extract-tree pollen-sweet gum T2 PA allergenic extract-tree pollen-virginia live oak T2 PA allergenic extract-tree pollen-white ash T2 PA allergenic extract-tree pollen-white birch T2 PA allergenic extract-tree pollen-white oak T2 PA allergenic extract-venom- bee T2 PA venom-mixed vespid 1650mcg vial T2 PA allergenic extract-venom-wasp protein T2 PA venom-white-faced hornet prot 120 mcg vial T2 PA allergenic extract-venom-yellow hornet protein T2 PA allergenic extract-venom-yellow jacket protein T2 PA allergenic extract-weed pollen-carelessweed T2 PA

PAGE 330 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS allergenic extract-weed pollen-cocklebur T2 PA allergenic extract-weed pollen-dog T2 PA allergenic extract-weed pollen-english plantain T2 PA allergenic extract-weed pollen-giant (tall) ragweed T2 PA allergenic extract-weed pollen-goldenrod T2 PA allergenic extract-weed pollen-kochia (firebush) T2 PA allergenic extract-weed pollen-lambsquarters T2 PA allergenic extract-weed pollen- T2 PA allergenic extract-weed pollen-rough pigweed T2 PA allergenic extract-weed pollen-russian thistle T2 PA allergenic extract-weed pollen-sagebrush T2 PA allergenic extract-weed pollen-sheep T2 PA allergenic extract-weed pollen-sheep sorrel,yellow dock T2 PA allergenic extract-weed pollen-short ragweed T2 PA allergenic extract-weed pollen-spiny pigweed T2 PA allergenic extract-weed pollen-true marsh elder T2 PA allergenic extract-weed pollen-western ragweed T2 PA allergenic extract-weed pollen-yellow dock T2 PA allopurinol powder T2 PA extract T2 PA almond oil oil T2 PA almond oil/silicic acid/ T2 PA aloe vera (oil, powder) T2 PA

PAGE 331 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS aloe vera leaf gel extract T2 PA 100 mg capsule T1 alpha lipoic acid (100 % powder, powder) T2 PA alpha pinene T2 PA alpha-ketoglutaric acid T2 PA alprazolam 100 % powder T2 PA alprostadil 100 % powder T2 PA ALTAMIST T1 aluminum chloride T2 PA aluminum chlorohydrate T2 PA aluminum hydroxide (100 % granules, powder) T2 PA aluminum sulfate T2 PA aluminum, (acetato-o)dihydroxy T2 PA amantadine hcl powder T2 PA american root T2 PA T2 PA aminobenzoic acid T2 PA aminocaproic acid 100 % powder T2 PA aminophylline powder T2 PA sodium T2 PA aminosalicylic acid T2 PA amitriptyline hcl powder T2 PA amlodipine besylate 100 % powder T2 PA

PAGE 332 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS solution, strong T2 PA ammonium alum T2 PA T2 PA T2 PA ammonium lactate 70 % solution T2 PA ammonium lauryl sulfate T2 PA ammonium sulfate T2 PA ammonium tetrathiomolybdate T2 PA amoxicillin 100 % powder T2 PA amphotericin b powder T2 PA AMYVID T2 PA anastrozole 100 % powder T2 PA T2 PA ANEFRIN T1 flavor extract T2 PA anise oil T1 anisindione T2 PA ANTACID 750 MG CHEWABLE TABLET T0 anthralin T2 PA trichloride T2 PA antimony trisulfide colloid T2 PA antipyrine T2 PA ANTISEPTIC T1

PAGE 333 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS APLIGRAF T2 PA APLISOL T2 PA hcl T2 PA extract T2 PA apple flavor (liquid, powder) T2 PA apricot flavor (liquid, powder) T2 PA (100 % crystals, 100 % powder, powder) T2 PA arginine hcl 100 % powder T2 PA arnica flower T2 PA arnica flower extract T2 PA aromatic cascara fluid extract T2 PA arrowroot starch T2 PA trioxide powder T2 PA ASCLERA T2 PA ascorbate calcium powder T2 PA ascorbate sodium T2 PA ascorbic acid 100 % powder T2 PA ascorbyl palmitate T2 PA monohydrate 100 % crystals T2 PA aspartame T2 PA T2 PA aspirin 100 % powder T2 PA astragalus root T2 PA

PAGE 334 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS atenolol 100 % powder T2 PA ATOPADERM T2 PA atropine sulfate powder T2 PA attapulgite T2 PA AVITENE (FLOUR, SHEET 35MMX35MM, SHEET T2 PA 70MMX35MM, SHEET 70MMX70MM) avocado extract T2 PA avocado oil T2 PA AYR & SINUS NASAL MIST T1 AYR SALINE NASAL GEL SPRAY T0 AYR SALINE (DROPS, SPRAY) T1 azathioprine powder T2 PA azelaic acid (85 % flakes, 88 % flakes, 100 % flakes, 100 % T2 PA powder) hcl 100 % powder T2 PA azithromycin 100 % powder T2 PA BABY AYR SALINE T0 bacitracin 5mm unit powder(ea) T2 PA bacitracin zinc micronized T2 PA bacitracin, micronized (75.7/mg powder, 100 % powder) T2 PA 100 % powder T2 PA BAL IN OIL T2 PA balsam canada T2 PA balsam peru T2 PA

PAGE 335 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS banana creme flavor T2 PA banana extract T2 PA banana flavor liquid T2 PA sulfate T2 PA pod extract T2 PA beclomethasone dipropionate T2 PA beef extract T2 PA beeswax 100 % T1 belladonna alkaloids T2 PA belladonna alkaloids leaf extract T2 PA benactyzine hcl T2 PA benazepril hcl 100 % powder T2 PA bentonite T2 PA (0.1 % adh. patch, 50 % solution) T2 PA T2 PA T2 PA benzocaine micronized T2 PA (crystals, powder) T2 PA benzoin T2 PA benzoin gum T2 PA AL Up to 18 yrs old benzoyl peroxide 65% to 82% powder T2 PA T2 PA

PAGE 336 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS benzyl benzoate T2 PA beta 1,3 glucan T2 PA beta-carotene 10 % beads T2 PA beta-glucan, (1-3) (1-4) T2 PA betadex T2 PA hcl 100 % powder T2 PA betaine T2 PA betaine hcl powder T2 PA betamethasone acetate, micronized T2 PA betamethasone dipropionate powder T2 PA betamethasone sodium phosphate T2 PA betamethasone valerate powder T2 PA betanaphthol T2 PA bethanechol chloride powder T2 PA bioflavonoid, lemon T2 PA bioflavonoids, citrus (13 % powder, 100 % powder) T2 PA biotin 100 % powder T2 PA bisabolol T2 PA bisacodyl powder T2 PA bismuth citrate T2 PA bismuth subcarbonate T2 PA bismuth subgallate T2 PA bismuth subnitrate T2 PA

PAGE 337 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bismuth subsalicylate powder T2 PA bismuth tribromophenate/petrolatum,white (tribromoph/petrolatum 1"x8" bandage, tribromoph/petrolatum 2" x 2" bandage, T2 PA tribromoph/petrolatum 4" x 4" bandage, tribromoph/petrolatum 4"x108" bandage, tribromoph/petrolatum 5"x9" bandage) bitter almond oil T2 PA bitter mask flavor combination no.2 T2 PA bitter mask flavoring T2 PA black (food color) T2 PA blackberry flavor T2 PA blade lancet, safety (0.8 mmx2mm each, 1.2 mm each, T1 1.5 mmx2mm each) blood collection set (blood set 23gx3/4" each, blood set T2 PA 25gx3/4" blood set) blood glucose and control, normal T2 PA blood glucose calibration control high and low T1 blood glucose calibration control solution, high T2 PA blood glucose calibration control solution, high and T2 PA normal blood glucose calibration control solution, low T2 PA blood glucose calibration control solution, normal T1 blood glucose calibration control T2 PA high,normal,low blood ketone test, strips T2 PA blood pressure kit-extra large T0

PAGE 338 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS blood pressure test kit T0 blood pressure kit med,large kit T0 blood pressure test kit-large kit T0 blood pressure test kit-medium kit T0 blood pressure test kit-small T0 blood pressure test kit-wrist T0 QL 10 / day blood sugar diagnostic T2 PA blood-glucose calib. control T2 PA blood-glucose meter each T2 PA blood-glucose meter kit T1 QL 10 / day blood-gluc.meter, wrist bp mon kit T2 PA blood-glucose meter,continuous each T2 PA blood-glucose sensor T2 PA blood-glucose transmitter T2 PA blood-glucose transmitter/blood-glucose sensor T2 PA blue (food color) (liquid, powder) T2 PA blue agave extract T2 PA blue royal (food color) T2 PA blue-green algae powder T2 PA flavor T2 PA blunt needle, disposable (22gx1 1/2" dis needle, 23gx1" T2 PA dis needle) (granules, powder) T2 PA

PAGE 339 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA boron citrate T2 PA boswellia serrata extract T2 PA brilliant green (100 % powder, crystals) T2 PA tartrate 100 % powder T2 PA bromelains (1200/g powder, powder) T2 PA sodium 100 % powder T2 PA bromhexine hcl T2 PA bromocriptine mesylate powder T2 PA maleate T2 PA brown (food color) T2 PA bubblegum flavor liquid T2 PA budesonide, micronized T2 PA hcl T2 PA BUMINATE T2 PA bupivacaine hcl 100 % powder T2 PA buprenorphine hcl powder T2 PA bupropion hcl 100 % powder T2 PA buspirone hcl 100 % powder T2 PA butalbital T2 PA butorphanol tartrate 100 % powder T2 PA butter flavor T2 PA butter rum flavor T2 PA

PAGE 340 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS flavor T2 PA butyl alcohol T2 PA T2 PA butylated hydroxytoluene granules T1 butylated hydroxytoluene powder T2 PA butylparaben T2 PA c10-18 triglycerides wax T2 PA calamine T2 PA calcipotriene 100 % powder T2 PA calcitriol (100 % crystals, 100 % powder) T2 PA calcitriol/almond oil T2 PA calcium acetate powder T2 PA 100 % powder T2 PA calcium alginate/honey (alginate/honey 4" 5" bandage, T2 PA alginate/honey bandage) calcium amino acid chelate 30 % granules T2 PA calcium carbonate (100 % powder, 800 mg/2 g powder, T2 PA powder) (95 % powder, granules, powder) T2 PA calcium citrate 100 % powder T2 PA calcium glubionate T2 PA calcium glucarate T2 PA powder T2 PA calcium gluconate monohydrate T2 PA

PAGE 341 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS calcium hydroxide T2 PA calcium lactate 100 % powder T2 PA calcium levulinate dihydrate T2 PA calcium pantothenate powder T2 PA calcium phosphate T2 PA calcium phosphate, tribasic T2 PA calcium pyruvate T2 PA calcium sulfate T2 PA calcium thioglycolate trihydrate T2 PA camphor crystals T2 PA cananga oil T2 PA CANDIN T2 PA cantaloupe extract T2 PA cantharidin T2 PA caprylic/capric triglyceride T2 PA capsaicin powder T2 PA capsaicin palmitate T2 PA T2 PA capsule base no.138 T2 PA captopril 100 % powder T2 PA caramel flavor T2 PA T2 PA carbamazepine powder T2 PA

PAGE 342 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carbamide peroxide T2 PA T2 PA carbidopa powder T2 PA T2 PA carbitol T2 PA carbomer 934 56% to 68% powder T2 PA carbomer 940 T2 PA carbomer homopolymer type c T2 PA carboxymethylcellulose T1 carboxymethylcellulose sodium T2 PA carboxymethylcellulose sodium, low substituted T2 PA CARDIOLITE T2 PA carisoprodol powder T2 PA T2 PA carnosine T2 PA T2 PA carrageenan T2 PA extract T2 PA cat standardized allergenic extract T2 PA

PAGE 343 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS catheter (1" each, 6fr-16" each, 8 fr each, 8fr-16" each, 10 fr each, 10fr-16" each, 12 fr each, 12fr-16" each, 14 fr-16 " each, 16 fr each, 16fr-16" each, 18 fr each, 18fr-16" T2 PA each, 20 fr each, 22 fr each, 24 fr each, 26 fr each, 28 fr each, 30 fr each, kit) catheter 14 fr each T2 PA catheterization tray (tray tray, tray 16 fr tray, tray 18 fr T2 PA tray) cedar leaf oil T2 PA ceftazidime 100 % powder T2 PA ceftriaxone sodium powder T2 PA celecoxib 100 % powder T2 PA cellulase T2 PA cellulose T2 PA cellulose/carboxymethylcellulose sodium T2 PA cellulose/silica gel/magnesium stearate T2 PA cellulose/silica gel/mannitol/magnesium stearate T2 PA cellulose/silica/mannit/sodium lauryl sulf/sod starch glyc T2 PA CERAVE MOISTURIZING CREAM T1 CERAVE MOISTURIZING T1 ceresin T2 PA CERETEC INJECTION KIT T2 PA cervical cap T2 PA cesium chloride T2 PA CETAPHIL CLEANSING BAR T1

PAGE 344 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cetostearyl alcohol/ceteareth-20 T2 PA cetyl alcohol (100 % flakes, 100 % granules) T2 PA cetyl T2 PA cetyl myristoleate (20 % powder, 40 % oil, 40 % wax) T2 PA T2 PA flower T2 PA CHARCOCAPS T1 flavor T2 PA cherry flavor syrup T2 PA cherry-ade flavor T2 PA chicken extract T2 PA CHILDREN MULTIVITAMIN GUMMIES T0 CHILDREN'S SALINE NASAL SPRAY T0 CHILDREN'S SILFEDRINE T1 CHIRHOSTIM T2 PA hydrate T2 PA chlorambucil T2 PA chloramphenicol T2 PA chloramphenicol palmitate T2 PA chlorhexidine T2 PA chlorhexidine acetate T2 PA chlorhexidine gluconate 20 % solution T2 PA chloroallyl methenamine chloride T2 PA

PAGE 345 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA chlorophyllin complex T2 PA chloroquine phosphate powder T2 PA T2 PA T2 PA chlorpheniramine maleate powder T2 PA chlorpromazine hcl 100 % powder T2 PA flavor T2 PA chocolate flavor T2 PA (vitamin d3) (1mm unit/g liquid, 2400/ml T2 PA liquid, 100000/g powder, crystals) T2 PA cholesterol and blood glucose meter T2 PA cholestyramine T2 PA choline bitartrate 100 % powder T2 PA choline chloride (100 % crystals, 100 % powder) T2 PA choline salicyl/mag salicylate powder T2 PA chondroitin sulfate a sodium T2 PA chorionic , human 1mm unit powder(ea) T2 PA picolinate 12 % powder T2 PA chromium polynicotinate T2 PA chromium potassium sulfate dodecahydrate T2 PA T2 PA

PAGE 346 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS chymotrypsin T2 PA ciclopirox olamine powder T2 PA cidofovir 100 % powder T2 PA cimetidine powder T2 PA bark powder T2 PA ciprofloxacin hcl (100 % crystals, 100 % powder) T2 PA citric acid (100 % granules, powder) T2 PA citric acid monohydrate T2 PA T2 PA clarithromycin 100 % powder T2 PA fumarate powder T2 PA clemizole hcl T2 PA clidinium bromide T2 PA clindamycin hcl powder T2 PA clindamycin phosphate (crystals, powder) T2 PA T2 PA clobetasol propionate powder T2 PA clofazimine T2 PA clomiphene citrate 100 % powder T2 PA clomipramine hcl 100 % powder T2 PA clonazepam 100 % powder T2 PA clonidine hcl powder T2 PA clopidogrel bisulfate 100 % powder T2 PA

PAGE 347 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clotrimazole powder T2 PA oil T2 PA CLOVERINE T1 tar (tar tar, tar 20 % solution) T2 PA cobamamide T2 PA hcl 100 % crystals T2 PA cocamide dea T2 PA cocoa butter (100 % oint. (g), oint. (g)) T2 PA cocoa extract T2 PA flavor T2 PA coconut oil oil T2 PA coconut oil/beeswax/safflower oil T2 PA codeine phosphate T2 PA flavor T2 PA flavor T2 PA colchicine powder T2 PA colistin (colistimethate na) 390 mcg/mg powder T2 PA colistin sulfate T2 PA , hydrolysate (bovine) T2 PA T2 PA collodion T2 PA collodion, flexible liquid T2 PA

PAGE 348 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS colostomy bag, non-sterile (1 1/2"(12) each, 1 1/4"(12) each, 1 1/8"(12) each, 1 3/16"(7) each, 1 3/16"(8) each, 1 3/16"(9) each, 1 3/16(12) each, 1 3/4"(12) each, 1 3/4"(14) each, 1 3/4"(7") each, 1 3/8"(12) each, 1 3/8"(7") each, 1 3/8"(8") each, 1 3/8"(9") each, 1 7/8"(12) each, 1 9/16"(7) each, 1 9/16"(8) each, 1 9/16(11) each, 1 9/16(12) each, 1" (12") each, 1" (8") each, 1"(7") each, 2 1/2"(9") each, 2 1/4"(12) each, 2 1/4"(14) each, 2 1/4"(7") T2 PA each, 2 1/8"(12) each, 2 1/8"(9") each, 2 3/4"(12) each, 2 3/4"(14) each, 2 3/4"(7") each, 2 3/8" each, 2 3/8"(12) each, 2 3/8"(8") each, 2" (8") each, 3/4" (12") each, 4 1/3"(12) each, 4" (12") each, 7/8" (12") each, 13/16"(12) each, 13/16"(6") each, 13/16"(8") each, 470-10 1/4 each, 485-10 1/2 each, 600-11 1/4 each, 655-11 1/2 each, 760- 11 1/4 each) colostomy bags (1 1/2" each, 1 1/4" each, 1 3/4" each, 1" each, 2 1/4" each, 2 1/8"(7") each, 2 3/4" each, 3/4" each, T2 PA 4 1/3"(12) each, 655-11 1/2 each, each) colostomy belt T2 PA colostomy washer 7/8" miscell T2 PA colostomy-ileost.sets, sterile 4" (12") each T2 PA compound solution sugar-free no.1 T2 PA compound vehicle suspension no.7 T1 compound vehicle suspension sugar-free no.1 T2 PA compound vehicle suspension sugar-free no.12 T2 PA compounding vehicle no.8 T1 compounding vehicle sugar-free no.9 T2 PA compounding vehicle suspension no.17 T2 PA compounding vehicle suspension no.19 T2 PA compounding vehicle suspension sugar-free no.18 T2 PA

PAGE 349 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS compound vehicle susp sf no.20 oral susp T2 PA compounding vehicle syrup no.10 T2 PA compounding vehicle syrup no.13 T2 PA compounding vehicle syrup no.23 T2 PA compression stocking, knee high, regular length, medium T2 PA compression stocking, knee high, regular length, small T2 PA compression stocking,knee high,long length, large T2 PA circumfer. compression stocking,knee high,long length, x-large T2 PA circumf. compression stocking,knee high,long length,medium T2 PA circumfer. compression stocking,knee high,long length,small T2 PA circumferen compression stocking,knee high,regular length,large T2 PA circumf. compression stocking,knee high,regular length,x-large T2 PA circum compression stocking,thigh high,long length,extra-large T2 PA circ compression stocking,thigh high,long length,large T2 PA circumfer. compression stocking,thigh high,long length,medium T2 PA circumfer compression stocking,thigh high,long length,small T2 PA circumfer. compression stocking,thigh high,long length,x-small T2 PA circumf.

PAGE 350 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS compression stocking,thigh high,reg length,x-large T2 PA circumfer compression stocking,thigh high,regular length,large T2 PA circumf compression stocking,thigh high,regular length,medium T2 PA circum compression stocking,thigh high,regular length,small T2 PA circumf compression stocking,thigh high,regular length,x-small T2 PA circ. compression stocking,thigh high,short length,large T2 PA circumfer compression stocking,thigh high,short length,medium T2 PA circumf. compression stocking,thigh high,short length,small T2 PA circumfer compressor, for nebulizer T2 PA conception assistance supplies combination no.1 T2 PA condoms, , lubricated T1 CONRAY T2 PA CONRAY-30 T2 PA CONRAY-43 BOTTLE T2 PA container,empty T1 copper gluconate 100 % powder T2 PA copper glycinate T2 PA corn oil T2 PA corn starch powder T2 PA

PAGE 351 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS / T2 PA corticotropin T2 PA cortisone acetate powder T2 PA COSAMIN DS TABLET T1 cotton candy flavor T2 PA cottonseed oil T2 PA T2 PA crab extract T2 PA cran-raspberry flavor T2 PA cranberry extract (extract 12:1 powder, extract 50 T2 PA mg tab chew) cream base no. 9 T2 PA cream base no.103 T2 PA cream base no.105 T2 PA cream base no.108 T2 PA cream base no.109 T2 PA cream base no.110 T2 PA cream base no.111 T2 PA cream base no.115 T2 PA cream base no.127 T2 PA cream base no.128 T2 PA cream base no.130 T2 PA cream base no.135 T2 PA

PAGE 352 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cream base no.142 T2 PA cream base no.148 T2 PA cream base no.157 T2 PA cream base no.159 T2 PA cream base no.161 T2 PA cream base no.165 T2 PA cream base no.170 T2 PA cream base no.171 T2 PA cream base no.174 T2 PA cream base no.175 T2 PA cream base no.176 T2 PA cream base no.177 T2 PA cream base no.181 T2 PA cream base no.185 T2 PA cream base no.186 T2 PA cream base no.189 T2 PA cream base no.190 T2 PA cream base no.191 T2 PA cream base no.192 T2 PA cream base no.193 T2 PA cream base no.195 T2 PA cream base no.201 T2 PA cream base no.208 T2 PA

PAGE 353 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cream base no.210 T2 PA cream base no.29 T2 PA cream base no.31 T2 PA cream base no.34 T2 PA cream base no.37 T2 PA cream base no.39 T2 PA cream base no.40 T2 PA cream base no.42 T2 PA cream base no.43 T2 PA cream base no.47 T2 PA cream base no.49 T2 PA cream base no.52 T2 PA cream base no.56 T2 PA cream base no.58 T2 PA cream base no.64 T2 PA cream base no.68 T2 PA cream base no.69 T2 PA cream base no.70 T2 PA cream base no.73 T2 PA cream base no.77 T2 PA cream base no.78 T2 PA cream base no.81 T2 PA cream base no.82 T2 PA

PAGE 354 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cream base no.83 T2 PA cream base no.84 T2 PA cream base no.87 T2 PA cream base no.88 T2 PA cream base no.96 T2 PA cream base no.97 T2 PA cream base no.98 T2 PA cream de menthe T2 PA cream or lotion base no.74 T2 PA T2 PA creatine monohydrate 100 % powder T2 PA T2 PA cromolyn sodium powder T2 PA cromolyn sodium 5.2 mg spray/pump T1 crotamiton T2 PA croton oil T2 PA cupric sulfate T2 PA cupric sulfate pentahydrate T2 PA CURITY STERILE WATER,IRRIGATIO T1 CUTTER BACKWOODS T1 CUTTER BACKWOODS DRY T1 CUTTER SKINSATIONS T1 cyanocobalamin (vitamin b-12) powder T2 PA

PAGE 355 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYANOKIT T2 PA T2 PA hcl 100 % powder T2 PA hcl 100 % powder T2 PA cyclophosphamide 100 % powder T2 PA cycloserine powder T2 PA cyclosporine powder T2 PA hcl 100 % powder T2 PA cysteamine hcl T2 PA (100 % crystals, 100 % powder) T2 PA cysteine hcl powder T2 PA CYSTEX CRANBERRY T2 PA cystine 100 % powder T2 PA CYSTO-CONRAY II T2 PA CYSTOGRAFIN T2 PA CYSTOGRAFIN-DILUTE T2 PA d and c green no.6 T2 PA d-mannose 99 % powder T2 PA d-xylose T2 PA dalfampridine powder T2 PA danazol powder T2 PA dantrolene sodium powder T2 PA hcl T2 PA

PAGE 356 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dapsone 98 % powder T2 PA DATSCAN T2 PA deanol T2 PA deanol bitartrate T2 PA deanol/ T2 PA decamethylcyclopentasiloxane T2 PA DEEP SEA T1 deferoxamine mesylate T2 PA T2 PA deoxycholic acid T2 PA DERMAGRAFT T2 PA DESFERAL T2 PA DESFERAL MESYLATE T2 PA desipramine hcl powder T2 PA desmopressin acetate powder T2 PA desonide, micronized T2 PA desoximetasone, micronized T2 PA desoxycorticosterone acetate T2 PA devil's claw extract T2 PA T2 PA dexamethasone acetate, micronized T2 PA dexamethasone isonicotinate T2 PA dexamethasone, micronized T2 PA

PAGE 357 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hcl T2 PA dexmedetomidine in 0.9 % nacl 80mcg/20ml vial T2 PA dexpanthenol (100 % liquid, 100 % powder) T2 PA hbr T2 PA dextrose (granules, powder) T2 PA diabetic supplies,miscell (each, kit, miscell) T2 PA DIALYVITE 800 PLUS D T1 diaper,brief,adult, disposable each T2 PA diaper/brief,infant-toddler, disposable T2 PA diaphragms, wide seal T2 PA diazepam 100 % powder T2 PA /iodopropynyl butylcarbamate T2 PA diazoxide 100 % powder T2 PA dibucaine hcl T2 PA T2 PA dichloroacetic acid T2 PA diclofenac sodium 100 % powder T2 PA diclofenac sodium, micronized T2 PA dicumarol T2 PA dicyclomine hcl 100 % powder T2 PA diethanolamine T2 PA citrate T2 PA diethylpropion hcl 100 % powder T2 PA

PAGE 358 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA diethyltoluamide T2 PA DIGESTIVE ADVANTAGE INT BOWEL T0 DIGESTIVE ADVANTAGE LACTOS DEF T0 digoxin 100 % powder T2 PA dihydrocodeine bitartrate T2 PA dihydroergotamine mesylate powder T2 PA (1,3) T2 PA diindolylmethane T2 PA diltiazem hcl powder T2 PA diluent for epoprostenol sodium (glycine) T2 PA S DILUENT FOR FLOLAN T2 PS PA DILUENT FOR ROTARIX T2 PA diluent for treprostinil (glycine) T2 PA DILUENT-MERCK LIVE VIRUS VACC T2 PA DILUTING MEDIUM FOR NOVOLOG T2 PA dimenhydrinate 100 % powder T2 PA dimethyl fumarate crystals T2 PA dimethyl (99 % liquid, 99 % vial, 99.99 % liquid) T2 PA dimethylacetamide T2 PA hcl T2 PA dinitrochlorobenzene (2,4) T2 PA

PAGE 359 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA T2 PA dioxybenzone T2 PA diphencyprone T2 PA hcl powder T2 PA diphenidol hcl T2 PA dipyridamole 100 % powder T2 PA disulfiram 100 % powder T2 PA dl- T2 PA DMSA T2 PA docosanol 100 % powder T2 PA docusate sodium (85 % powder, powder) T2 PA dopamine hcl powder T2 PA DOTAREM (5 MMOL/10 ML SYRINGE, 5 MMOL/10 ML VIAL, 7.5 MMOL/15 ML SYRINGE, 7.5 MMOL/15 ML VIAL, T2 PA 10 MMOL/20 ML SYRINGE, 10 MMOL/20 ML VIAL, 50 MMOL/100 ML VIAL) doxazosin mesylate 100 % powder T2 PA doxepin hcl powder T2 PA doxycycline hyclate powder T2 PA doxycycline monohydrate 100 % powder T2 PA doxylamine succinate T2 PA drainage bag 2000ml each T2 PA DRAXIMAGE DTPA T2 PA

PAGE 360 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS , collagen/sodium T2 PA alginate/carboxymethylcellulose dressing,collagen/silver/sod T2 PA alginate/carboxymethylcellulose droperidol powder T2 PA duloxetine hcl 100 % powder T2 PA DUODOTE T2 PA dyclonine hcl T2 PA dyphylline T2 PA E-Z DISK T2 PA E-Z-HD T2 PA E-Z-PAQUE T2 PA E-Z-PASTE T2 PA econazole nitrate powder T2 PA edetate calcium disodium (100 % powder, 200 mg/ml T2 PA ampul) edetate disodium 100 % powder T2 PA edetate tetrasodium tetrahydrate T2 PA edetic acid T2 PA chloride T2 PA egg extract T2 PA egg extract T2 PA emollient combination no. 15 T2 PA emollient combination no. 2 T2 PA

PAGE 361 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS emollient combination no.112 T2 PA emollient combination no.37 T2 PA emollient combination no.59 T2 PA emollient combination no.64 T2 PA emollient combination no.79 T2 PA emu oil (oil oil, oil 100 % liquid) T2 PA emulsifying wax T2 PA emulsion base no.54 T2 PA enalapril maleate 100 % powder T2 PA ENDO-AVITENE T2 PA ENDOFORM (4" 5" TEMPLATE, FENESTRATED, T2 PA FENESTRATED 4" 5", TEMPLATE) FLEET ENEMA EXTRA T1 ENTERO VU T2 PA ENTTY T2 PA EOVIST T2 PA ephedrine hcl T2 PA ephedrine sulfate powder T2 PA EPHRINE NOSE DROPS T0 T2 PA epinephrine powder T2 PA epinephrine bitartrate powder T2 PA ergocalciferol (vitamin d2) powder T2 PA ergoloid mesylates 100 % powder T2 PA

PAGE 362 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ergotamine tartrate T2 PA erythromycin base powder T2 PA erythromycin estolate T2 PA erythromycin ethylsuccinate powder T2 PA sodium T2 PA estradiol 100 % powder T2 PA T2 PA T2 PA estradiol hemihydrate, micronized T2 PA estradiol micronized T2 PA estradiol valerate powder T2 PA T2 PA estriol micronized T2 PA (100 % powder, crystals) T2 PA ETHAMOLIN T2 PA ethanolamine T2 PA T2 PA ethinyl estradiol T2 PA ethosuximide 100 % powder T2 PA ethoxydiglycol T2 PA ethyl acetate T2 PA ethyl alcohol (95 % liquid, 100 % liquid) T2 PA ethyl oleate T2 PA

PAGE 363 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA eucalyptol T1 oil 100 % oil T1 S EUFLEXXA T2 PS PA T2 PA T2 PA EVARREST T2 PA EVICEL FIBRIN 2X5 ML SEALANT T2 PA S EXONDYS-51 T2 PS PA EYESCRUB T1 facial mask T2 PA famotidine 100 % powder T2 PA fd and c blue no.1 T2 PA fd and c green no.3 T2 PA fd and c no.2 (indigotine) T2 PA fd and c no.5 (tartrazine) T2 PA fd and c red no.40 T2 PA fd and c yellow no.6 (sunset yellow fcf) T2 PA feeder container T2 PA feeder container with gravity set T2 PA

PAGE 364 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS feeder container with pump set T2 PA feeder irrigation kit T2 PA fenoprofen calcium, dihydrate T2 PA fentanyl citrate 100 % powder T2 PA ferric ammonium citrate T2 PA ferric chloride T2 PA ferric subsulfate (20-22g/100 solution, powder) T2 PA ferric sulfate T2 PA ferrous fumarate 100 % powder T2 PA ferrous gluconate 100 % powder T2 PA ferrous sulfate 100 % granules T2 PA ferrous sulfate, dried 100 % powder T2 PA ferulic acid T2 PA feverfew extract T2 PA hcl 100 % powder T2 PA finasteride 100 % powder T2 PA EQ FIRST AID ANTISEPTIC SOLN T1 flavoring agent (liquid, oil, powder) T2 PA flaxseed oil oil T1 FLEXBUMIN T2 PA T2 PA floxuridine 100 % powder T2 PA fluconazole 100 % powder T2 PA

PAGE 365 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS flucytosine 100 % powder T2 PA fludrocortisone acetate powder T2 PA (0.1 mg/ml vial, 100 % powder) T2 PA 100 % powder T2 PA fluocinolone acetonide powder T2 PA fluocinonide, micronized T2 PA fluorescein sodium T2 PA fluoride (sodium) powder T2 PA fluorouracil 100 % powder T2 PA fluoxetine T2 PA fluphenazine decanoate (2.5 %(w/w) oil, 100 % liquid) T2 PA flurbiprofen powder T2 PA fluticasone propionate 100 % powder T2 PA fluticasone propionate, micronized T2 PA foam bandage (foam bandage 2" x 2" bandage, foam bandage 3" x 3" bandage, foam bandage 4" x 4" bandage, foam bandage 4.5" x5.5" bandage, foam bandage 5 1/16"sqr bandage, foam bandage 5"x5" bandage, foam bandage 6 1/16"sqr bandage, foam T2 PA bandage 6" x 6" bandage, foam bandage 6.75x6.75" bandage, foam bandage 7"x7" bandage, foam bandage 8" x 8" bandage, foam bandage 8.25x8.25" bandage, foam bandage 9"x9" bandage) foam base no.129 T2 PA foam base no.99 T2 PA folic acid 100 % powder T2 PA

PAGE 366 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FOLIC ACID-VIT B-6-VIT B-12 T1 (1 g/ml vial, 100 % liquid) T2 PA FORMADON T1 (10 % solution, 37 % solution) T2 PA fumarate T2 PA formoterol fumarate dihydrate, micronized T2 PA granules T2 PA fuchsin,basic T2 PA fuller's earth T2 PA T2 PA furosemide powder T2 PA gabapentin 100 % powder T2 PA GADAVIST (1 MMOL/ML BULK VIAL, 2 MMOL/2 ML VIAL, 7.5 MMOL/7.5 ML SYR, 7.5 MMOL/7.5 ML VIAL, 10 T2 PA MMOL/10 ML SYRINGE, 10 MMOL/10 ML VIAL, 15 MMOL/15 ML SYRINGE, 15 MMOL/15 ML VIAL) T2 PA gamma-aminobutyric acid T2 PA gardenia fragrance T2 PA GASTROGRAFIN T2 PA GASTROMARK T2 PA gatifloxacin 100 % powder T2 PA gauze bandage (bandage 0.25"x36" bandage, bandage 1" T2 PA x 5yard bandage) gel base no.102 T2 PA

PAGE 367 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gel base no.107 T2 PA gel base no.117 T2 PA gel base no.120 T2 PA gel base no.133 T2 PA gel base no.137 T2 PA gel base no.153 T2 PA gel base no.162 T2 PA gel base no.180 T2 PA gel base no.184 T2 PA gel base no.197 T2 PA gel base no.225 T2 PA gel base no.30 T2 PA gel base no.41 T2 PA gel base no.46 T2 PA gel base no.72 T2 PA gel base no.79 T2 PA gel base no.80 T2 PA gel base no.86 T2 PA gel base no.92 T2 PA gel dressing (gel gel (gram), gel gel (ml), gel 4.75" T2 PA bandage) S GEL-ONE T2 PS PA

PAGE 368 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gelatin (each, gel (gram), powder) T2 PA gelatin capsules (empty) T1 gelatin troche base no.53 T2 PA GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE, POWDER, SIZE 50 SPONGE, SIZE 100 SPONGE, SIZE 200 T2 PA SPONGE) GELFOAM COMPRESSED T2 PA gemfibrozil powder T2 PA GENICIN T1 T2 PA gentamicin sulfate 590mcg/mg powder T2 PA gentian violet crystals T2 PA S GENVISC 850 T2 PS PA geranium oil T2 PA root powder T2 PA glipizide 100 % powder T2 PA gloves each T1 PA gloves, latex T1 gluconolactone T2 PA glucosamine hcl powder T2 PA glucosamine hcl/chondroitin sulfate a T1

PAGE 369 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glucosamine hcl/chondroitin sulfate a sodium (glucosmine/chondr su 167-133 mg cpsule, glucosmine/chondr su 250-200 mg tblet, T1 glucosmine/chondr su 500-400 mg tblet, glucosmine/chondr su 750-600 mg tblet) glucosamine hcl/msm/chondroitin sulfate a/hyaluronic T1 acid glucosamine sulfate 500 mg capsule T1 glucosamine sulfate dipot chlr 100 % powder T2 PA glucosamine sulfate dipotassium chlor/chondroitin sulfate a (su 2kcl/chondroitin su 250-200 mg capsule, su 2kcl/chondroitin su 500-400 mg capsule, su T1 2kcl/chondroitin su 500-400 mg tablet, su 2kcl/chondroitin su 750-600 mg tablet) glucosamine sulfate sodium cl T2 PA GLUCOSAMINE-CHONDROITIN T1 GLUCOSAMINE-CHONDROITIN CAP T1 GLUCOSAMINE-MSM COMPLEX TAB T1 glucosamine/chondroit-msm no.1/c//boswellia serrata (glucosam/chon- T1 msm1/c/mang/bosw 500-416.6 tablet, glucosam/chon- msm1/c/mang/bosw 750-625mg tablet) glucosamine/chondro su a 500-400 mg tablet T1 T2 PA powder T2 PA (25 % solution, 50 % solution) T2 PA T2 PA glyburide powder T2 PA

PAGE 370 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glycerides c12-18 T2 PA glycerin 100 % liquid T2 PA formal T2 PA glyceryl oleate T2 PA glycine powder T2 PA glycine carbonate sodium T2 PA GLYCINE SOYA PROTEIN T1 T2 PA glycofurol T2 PA glycolic acid (70 % solution, crystals) T2 PA glycopyrrolate 100 % powder T2 PA glycosaminoglycans,mixed T2 PA T2 PA gold sodium thiomalate T2 PA gramicidin d T2 PA grape flavor T2 PA grape seed oil T2 PA green (food color) (liquid, powder) T2 PA green soap powder T2 PA green extract T2 PA oil T2 PA griseofulvin T2 PA T2 PA

PAGE 371 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS guaifenesin 100 % powder T2 PA acetate T2 PA sulfate T2 PA guar gum T2 PA guarana seed extract T2 PA guava flavor T2 PA gymnema leaf T2 PA haloperidol powder T2 PA 100 % powder T2 PA hawthorn powder T2 PA hematoxylin, c.i. 75290 T2 PA T2 PA T2 PA HESPAN T2 PA hetastarch in 0.9 % sodium chloride T2 PA HEXTEND LACTATED ELECTROLYTE T2 PA HICON T2 PA phosphate T2 PA hcl T2 PA methylbromide T2 PA FORMULA T1 honey almond fragrance T2 PA honey flavor T2 PA

PAGE 372 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HPR PLUS CREAM T2 PA huperzine serrate a T2 PA S HYALGAN (20 MG/2 ML SYRINGE, 20 MG/2 ML VIAL) T2 PS PA hyaluronate sodium (94 % powder, 100 % powder) T2 PA hyaluronidase, bovine T2 PA hydralazine hcl powder T2 PA sulfate T2 PA 10 % liquid T1 hydrochloric acid 37 % liquid T2 PA hydrochlorothiazide 100 % powder T2 PA hydrocodone bitartrate (100 % powder, crystals) T2 PA hydrocolloid dressing (4" x 4" bandage, 6" x 6" bandage, T2 PA 7"x8" bandage, 8" x 8" bandage) hydrocortisone powder T2 PA hydrocortisone acetate powder T2 PA fluoride T2 PA 30 % solution T2 PA hydrogenated T2 PA hydromorphone hcl 100 % powder T2 PA hydroxocobalamin powder T2 PA hydroxyamphetamine hydrobromide T2 PA hydroxyapatite T2 PA

PAGE 373 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydroxychloroquine sulfate powder T2 PA hydroxyethyl acrylate/sod acryloyldimethyl taurate T2 PA copolymer hydroxyethyl methacrylate T2 PA hydroxyethylcellulose T2 PA hydroxypropyl betadex T2 PA hydroxypropyl cellulose T2 PA hydroxyurea 100 % powder T2 PA hcl powder T2 PA hydroxyzine pamoate powder T2 PA HYLAGUARD T2 PA HYLATOPICPLUS CREAM T2 PA HYLENEX T2 PA S HYMOVIS T2 PS PA hyoscyamine sulfate powder T2 PA hypromellose (23 % &10 % powder, powder) T2 PA HYQVIA HY COMPONENT T2 PA ibuprofen 100 % powder T2 PA IC GREEN T2 PA ichthammol (100 % liquid, powder) T2 PA idebenone T2 PA idoxuridine T2 PA

PAGE 374 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS imidurea T2 PA imipramine hcl 100 % powder T2 PA imiquimod 100 % powder T2 PA INAVIX T2 PA INDICLOR T2 PA T2 PA INDIUM IN-111 DTPA T2 PA indium in-111 oxyquinoline T2 PA indocyanine green (25 mg vial, 100 % powder) T2 PA -3-carbinol T2 PA indomethacin powder T2 PA INFLAMMACIN T2 PA inhaler, assist devices T2 PA inhaler,assist device,accesory each T1 PA inhaler,assist device with large mask T1 inhaler,assist device with medium mask T1 inhaler,assist device with small mask T1 inositol powder T2 PA inositol niacinate T2 PA insulin syringe-needle,safety,disposal unit,0.5 ml T1 iodine (100 % granules, crystals) T2 PA iodine/ 5 %-10 % solution T2 PA iodine/ tincture T1

PAGE 375 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS IODOFLEX T2 PA (1" x 5yard bandage, 1/2"x5yd bandage, T2 PA 1/4"x180" bandage, 2"x180" bandage, 100 % powder) iodoquinol T2 PA IODOSORB T2 PA T2 PA powder T2 PA IRO-PLEX CAPLET T2 PA irrigation set irrig set T2 PA (100 % crystals, powder) T2 PA isomalt T2 PA mucate T2 PA isoniazid powder T2 PA iodide T2 PA (70 % solution, 91 % solution, 99 % T2 PA solution) isopropyl alcohol 70 % towelette T1 isopropyl myristate T2 PA isopropyl palmitate T2 PA isoproterenol hcl powder T2 PA isosorbide T2 PA isosulfan blue 100 % powder T2 PA isotretinoin 100 % powder T2 PA ISOVUE-200 (INFUS BOTTLE, VIAL) T2 PA

PAGE 376 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ISOVUE-250 (BULK, INFUS BOTTLE, VIAL) T2 PA ISOVUE-300 (BULK, INFUS BOTTLE, VIAL) T2 PA ISOVUE-370 (BULK, INFUS BOTTLE, VIAL) T2 PA ISOVUE-M 200 T2 PA ISOVUE-M 300 T2 PA isoxsuprine hcl 100 % powder T2 PA itraconazole powder T2 PA itraconazole, micronized T2 PA ivermectin powder T2 PA jasmine fragrance T2 PA jojoba oil T2 PA juniper tar T2 PA kahlua flavor T2 PA kanamycin sulfate T2 PA kaolin powder T2 PA karaya gum powder T2 PA ketamine hcl 100 % powder T2 PA ketoconazole powder T2 PA ketoconazole, micronized T2 PA ketoprofen 100 % powder T2 PA ketoprofen, micronized T2 PA ketorolac tromethamine 100 % powder T2 PA fumarate 100 % powder T2 PA

PAGE 377 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS kinetin T2 PA KINEVAC T2 PA kiwi fragrance T2 PA kojic acid T2 PA krill/omega-3/dha/epa/ 300mg-90mg capsule T1 root T2 PA labetalol hcl powder T2 PA lactase 5k unit/g powder T2 PA T2 PA lactobacillus acidophilus (1b unit/g powder, powder) T2 PA lactose powder T2 PA lamotrigine 100 % powder T2 PA lancets (17 gauge each, 18 gauge each, 21 gauge each, 23 gauge each, 25 gauge each, 26 gauge each, 28 gauge T1 each, 31 gauge each, 32 gauge each, 33 gauge each, each) lancets 30 gauge each T1 lancing device each T1 lanolin 72 % oint. (g) T1 lanolin (100 % oil, wax) T2 PA lanolin T2 PA lanolin,anhydrous T1 lansoprazole 100 % powder T2 PA 100 % oil T2 PA laureth 9 T2 PA

PAGE 378 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS laureth-23 T2 PA lauric acid T2 PA lead acetate trihydrate T2 PA lead tetroxide T2 PA granules T2 PA lecithin, soy powder T2 PA lecithin/isopropyl palmitate T2 PA lecithin/sorbic acid/isopropyl palmitate T2 PA lemon flavor extract liquid T1 lemon oil oil T2 PA lemonade flavor oil T2 PA letrozole 100 % powder T2 PA leucine (100 % crystals, powder) T2 PA leucovorin calcium powder T2 PA leuprolide acetate 100 % powder T2 PA hcl T2 PA levetiracetam 100 % powder T2 PA levocarnitine powder T2 PA levocarnitine 1 g/10 ml solution T1 levocarnitine hcl T2 PA dihydrochloride powder T2 PA levodopa T2 PA levofloxacin 100 % powder T2 PA

PAGE 379 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levomefolate calcium 100 % powder T2 PA levorphanol tartrate 100 % powder T2 PA levothyroxine sodium (1 mg/g powder, 100 % powder) T2 PA licorice flavor T2 PA licorice root extract T2 PA licorice,deglycyrrhizinated T2 PA lidocaine powder T2 PA lidocaine hcl 100 % powder T2 PA lime green (food color) T2 PA lime oil T2 PA linoleic acid T2 PA liothyronine sodium (1 mg/g powder, 100 % powder) T2 PA liquid base no.154 T2 PA liquid base no.178 T2 PA liquid base no.57 T2 PA liquid base no.71 T2 PA LIQUID E-Z PAQUE T2 PA LIQUID POLIBAR PLUS T2 PA lisinopril 100 % powder T2 PA 99 % powder T2 PA lithium citrate tetrahydrate T2 PA LITTLE REMEDIES T0 LITTLE REMEDIES STUFFY NOSE T0

PAGE 380 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LMD 10% WITH 0.9% SOD CHLORIDE T2 PA LMD 10% WITH 5% DEXTROSE T2 PA LONG ACTING NASAL DECONGESTANT T1 loperamide hcl powder T2 PA 100 % powder T2 PA loratadine, micronized T2 PA lorazepam 100 % powder T2 PA lotion base no.203 T2 PA lotion base no.48 T2 PA LUGOL'S T1 lutein (5 % beads, 90 % powder) T2 PA LYMPHAZURIN T2 PA lysine hcl 100 % powder T2 PA m-cresol acetate T2 PA maca T2 PA magnesium aluminum silicate (100 % powder, granules) T2 PA magnesium amino acid chelate 20 % powder T2 PA magnesium ascorbate T2 PA magnesium aspartate dihydrate T2 PA magnesium carbonate T2 PA magnesium chloride crystals T2 PA magnesium citrate powder T2 PA magnesium gluconate powder T2 PA

PAGE 381 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS magnesium glycinate (15 % powder, 20 % powder) T2 PA magnesium hydroxide 100 % powder T2 PA magnesium malate T2 PA magnesium oxide 100 % powder T2 PA magnesium phosphate T2 PA magnesium stearate T2 PA (100 % crystals, 100 % powder) T2 PA MAGNEVIST (BULK VIAL, SYRINGE, VIAL) T2 PA maleic acid T2 PA malic acid T2 PA maltodextrin T2 PA mandelic acid T2 PA manganese chloride 100 % powder T2 PA manganese gluconate T2 PA manganese sulfate powder T2 PA mango flavor T2 PA mannitol powder T2 PA maple flavor T2 PA marshmallow flavor T2 PA masterwort extract T2 PA MD-76 R (R 66-10 INFUSION BOTTLE, R 66-10 VIAL) T2 PA MD-GASTROVIEW T2 PA T2 PA

PAGE 382 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS mecamylamine hcl T2 PA mechlorethamine hcl T2 PA meclizine hcl powder T2 PA meclofenamate sodium powder T2 PA hcl T2 PA mecobalamin (96 % powder, 100 % powder) T2 PA medical supply, miscellaneous (each, miscell, pad, tray) T2 PA medium chain triglycerides T2 PA medroxyprogesterone acetate, micronized T2 PA 100 % powder T2 PA MEGA PROBIOTIC T0 megestrol acetate,micronized T2 PA MELATIN T1 100 % powder T2 PA melatonin (1 mg tablet, 3 mg tab rapdis, 3 mg tablet, 5 T1 mg tablet) melatonin/chamomile flower T1 melatonin/pyridoxine T1 melatonin/pyridoxine hcl (vit b6) (melatonin/pyridoxine 1mg-10mg tablet, melatonin/pyridoxine 3 mg-10 mg T1 tablet, melatonin/pyridoxine 5 mg-10 mg tablet) meloxicam 100 % powder T2 PA memantine hcl 100 % powder T2 PA menadione T2 PA menadione sodium bisulfite T2 PA

PAGE 383 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS menthol crystals T2 PA meperidine hcl 100 % powder T2 PA mequinol T2 PA mercaptopurine 100 % powder T2 PA mesalamine powder T2 PA meta-cresol T2 PA metaproterenol sulfate powder T2 PA metformin hcl 100 % powder T2 PA chloride 100 % powder T2 PA copolymer type a T2 PA methadone hcl 100 % powder T2 PA methanesulfonic acid T2 PA T1 powder T2 PA methenamine T2 PA methenamine mandelate powder T2 PA METHERGINE T1 QL 6 / day methimazole 100 % powder T2 PA T2 PA methocarbamol 100 % powder T2 PA methotrexate T2 PA methscopolamine bromide powder T2 PA methyl aminolevulinate hcl T2 PA

PAGE 384 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylcellulose T2 PA methylcellulose 1500cps T2 PA methylcellulose 4000cps T2 PA (1 % ampul, 1 % vial, powder) T2 PA methylene blue/gentian violet/foam bandage T2 PA methylergonovine maleate (.2mg/ml(1) ampul, T2 PA .2mg/ml(1) vial) QL 6 / day methylergonovine maleate 0.2 mg tablet T2 PA methylparaben T2 PA methylphenidate hcl powder T2 PA methylprednisolone acetate, micronized T2 PA methylprednisolone, micronized T2 PA methylscopolamine nitrate T2 PA methylsulfonylmethane (100 % crystals, 100 % powder, T2 PA 1000 mg tablet) methyltestosterone powder T2 PA methyltestosterone, micronized T2 PA methyltetrahydrofolate glucosamine T2 PA maleate T2 PA metoclopramide hcl powder T2 PA METOPIRONE T2 PA metoprolol tartrate 100 % powder T2 PA metronidazole powder T2 PA

PAGE 385 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS metronidazole benzoate T2 PA mexiletine hcl 100 % powder T2 PA miconazole T2 PA miconazole nitrate powder T2 PA midazolam T2 PA middle ear inflation device T2 PA MIDNITE PM T2 PA milk thistle 100 % powder T2 PA mineral oil oil T2 PA MINERAL OIL HEAVY T2 PA mineral oil, light sterile T2 PA mineral oil, light/petrolatum,white/cetyl alc/stearyl alc T2 PA mineral oil/petrolatum/emulsifying wax T2 PA mineral oil/polyethylene glycol T2 PA mineral oil/polyethylene/butylated hydroxytoluene (oil/polyethylene/bhtol gel (gram), oil/polyethylene/bhtol T2 PA oint. (g)) minocycline hcl powder T2 PA minoxidil powder T2 PA mint chocolate chip flavor T2 PA misoprostol 1 % powder T2 PA mite-dermatophagoides farinae, standardized T2 PA mitomycin powder T2 PA T2 PA

PAGE 386 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS molybdenum T2 PA mometasone furoate 100 % powder T2 PA T2 PA monochloroacetic acid T2 PA , monohydrate T2 PA S MONOVISC T2 PS PA montelukast sodium powder T2 PA morphine sulfate 100 % powder T2 PA moxifloxacin hcl 100 % powder T2 PA hcl T2 PA mucus clearing device T2 PA MULTIHANCE T2 PA MULTIHANCE MULTIPACK T2 PA mupirocin 100 % powder T2 PA MYALEPT T2 PA S MYOBLOC T2 PS PA nabumetone 100 % powder T2 PA nabumetone, micronized T2 PA nadide T2 PA nadolol powder T2 PA

PAGE 387 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nalbuphine hcl 100 % powder T2 PA nalidixic acid T2 PA naloxone hcl powder T2 PA naltrexone hcl 100 % powder T2 PA naltrexone hydrochloride dihydrate T2 PA decanoate 100 % powder T2 PA naproxen powder T2 PA naproxen sodium powder T2 PA NASAL ALLERGY SPRAY T1 NASAL DECON () T1 NASAL DECONGESTANT (CVS NASAL DECONGEST 30 MG TAB, HM NASAL DECONGEST 30 MG TAB, HM NASAL DECONGEST ER 120 MG, KRO NASAL DECONGEST 30 MG TAB, NASAL DECONGESTANT 0.05% SPRAY, NASAL T1 DECONGESTANT 30 MG TAB, PUB NASAL DECONGEST ER 120 MG, QC NASAL DECONGEST 30 MG TAB, SM NASAL DECONGEST 30 MG TAB, SM NASAL DECONGEST ER 120 MG) NASAL DECONGESTANT (EQL NASAL DECONGEST 30 MG TAB, GNP NASAL DECONGEST 30 MG TAB, PUB NASAL T0 DECONGEST 30 MG TAB, SW NASAL DECONGESTANT 30 MG TB) NASAL DECONGESTANT PE T1 nasal exhalation resistance device T2 PA NASAL FOUR T0 CVS NO DRIP NASAL MIST 0.05% T2 PA NASAL MIST 0.9% SPRAY T0

PAGE 388 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GNP NASAL MOIST 0.65% SPRAY T0 NASAL MOISTURIZING (GS NASAL MOIST SPRAY, NASAL T1 MOISTURIZING SPRAY) NASAL RELIEF T1 NASAL SPRAY (CVS NASAL SPRAY 0.05%, EQ NASAL 0.05% SPRAY, EQL NASAL SPRAY 0.05%, GS NASAL SPRAY 0.05%, T1 NASAL SPRAY 0.05%, RA NASAL SPRAY, RA NASAL SPRAY 0.05%, SM NASAL 0.05% SPRAY, SM NASAL SPRAY 0.05%) NASAL SPRAY (EQ NASAL 0.65% SPRAY, EQ NASAL SPRAY 1%, EQL NASAL SPRAY 1%, GNP NASAL SPRAY 1%, KRO T0 NASAL SPRAY 1%, NASAL 0.65% SPRAY, NASAL SPRAY 1%) NASAL SPRAY EXTRA MOISTURIZING T1 NASAL SPRAY ORIGINAL T1 NASAL SPRAY SINUS T1 nasogastric tube 10 fr-43" each T2 PA nebulizer T2 PA nebulizer accessories T2 PA nebulizer and compressor T2 PA needle clipping and storage device T2 PA needles, blood collection (blood 20gx1" dis needle, blood T1 PA 21 g x 1" dis needle, blood 22gx1" dis needle) needles, blood collection 20gx1 1/2" dis needle T2 PA

PAGE 389 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS needles, disposable (14gx1" dis needle, 14gx1.5" dis needle, 14gx2" dis needle, 15gx1.5" dis needle, 16 g x 1" dis needle, 16gx0.625" dis needle, 16gx1.5" dis needle, 16gx3/4" dis needle, 18gx1 1/2" dis needle, 18gx1 1/4" dis needle, 18gx1" dis needle, 19gx1 1/2" dis needle, 19gx1" dis needle, 20gx1 1/2" dis needle, 20gx1" dis needle, 20gx3/4" dis needle, 21 g x 1" dis needle, 21g x1.25" dis needle, 21gx1 1/2" dis needle, 21gx2" dis needle, T1 22gx3/4" dis needle, 23gx1 1/2" dis needle, 23gx1.25" dis needle, 23gx3/4" dis needle, 24 gx1.25" dis needle, 24gx1" dis needle, 25gx0.875" dis needle, 25gx1.25" dis needle, 25gx2" dis needle, 25gx3/4" dis needle, 26 g x5/8" dis needle, 26gx1/2" dis needle, 26gx3/8" dis needle, 27gx1.25" dis needle, 27gx1.5" dis needle, 30gx1" dis needle, 30gx1/2" dis needle, 31 gx5/16" dis needle, 32 gx5/16" dis needle, dis needle) needles, disposable (22gx1 1/2" dis needle, 22gx1" dis needle, 23gx1" dis needle, 25gx1 1/2" dis needle, 25gx1" T1 PA dis needle, 25gx5/8" dis needle, 26gx1.5" dis needle, 27gx1/2" dis needle, 30gx3/4" dis needle) needles, filter (18gx1 1/2" dis needle, 18gx3" dis needle, T1 19gx1" dis needle, 20gx1 1/2" dis needle) needles, filter 19gx1 1/2" dis needle T2 PA needles, huber disposable T1 needles, pharmacy compound T1 needles, reusable T1 needles, safety (18gx1 1/2" dis needle, 23gx1" dis needle, T2 PA 25gx5/8" dis needle, 27gx1/2" dis needle)

PAGE 390 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS needles, safety (18gx1" dis needle, 19gx1 1/2" dis needle, 19gx1" dis needle, 20gx1 1/2" dis needle, 20gx1" dis needle, 21 g x 1" dis needle, 21gx1 1/2" dis needle, 22gx1 T1 PA 1/2" dis needle, 22gx1" dis needle, 23gx1 1/2" dis needle, 25gx1 1/2" dis needle, 25gx1" dis needle, 26gx1/2" dis needle) needles, safety (22gx3/4" dis needle, 23gx5/8" dis needle, 26gx1" dis needle, 27gx1" dis needle, 27gx5/8" dis needle, T1 28gx1/2" dis needle, 29 g x1/2" dis needle, 30 gx5/16" dis needle, 30gx1/2" dis needle, 31 gx5/16" dis needle) needles, safety 30gx1 1/2" dis needle T2 PA needles, safety huber, disposable T1 needles, spinal- (15gx1.5" dis needle, 16gx1.5" dis needle, 17gx1.5" dis needle, 18gx1" dis needle, 19gx1 T2 PA 1/2" dis needle, 20gx1 1/2" dis needle, 21 g x 1" dis needle) NEO- 1% SPRAY T0 neomycin sulfate powder T2 PA neostigmine methylsulfate 100 % powder T2 PA nettle leaf T2 PA NEXAFED T0 NEXAVIR T2 PA niacin powder T2 PA niacinamide (100 % powder, crystals) T2 PA niaouli oil T2 PA T2 PA -adenine dinucleotide, reduced, disodium T2 PA nicotine bitartrate T2 PA

PAGE 391 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 24 / day nicotine polacrilex (15 % powder, 20 % powder) T2 PA nifedipine powder T2 PA NITHIODOTE T2 PA T2 PA nitrofurantoin powder T2 PA nitrofurantoin macrocrystal 100 % powder T2 PA T2 PA NIVATOPIC PLUS T2 PA NO DRIP T1 NO DRIP NASAL SPRAY T1 norepinephrine bitartrate 100 % powder T2 PA norethindrone 100 % powder T2 PA norethindrone acetate powder T2 PA nortriptyline hcl powder T2 PA NOSE DROPS T0 nylidrin hcl T2 PA nystatin (1b unit powder(ea), 1mm unit powder(ea), 2b unit powder(ea), 5b unit powder(ea), 10b unit powder(ea), 15b unit powder(ea), 50mm unit powder(ea), T2 PA 100mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea)) octanoic acid T2 PA OCTAPLAS (BLOOD A IV BAG, BLOOD AB IV BAG, BLOOD B T2 PA IV BAG, BLOOD O IV BAG) octinoxate T2 PA

PAGE 392 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS octoxynol 9 T2 PA OCTREOSCAN T2 PA OFF ACTIVE T0 OFF DEEP T1 OFF DEEP WOODS DRY T0 OFF DEEP WOODS SPORTSMEN (25% SPR, 30% SPR, T0 98.25%) OFF FAMILYCARE INSCT RPLNT III T0 OFF FAMILYCARE INSECT RPLNT T1 OFF FAMILYCARE INSECT RPLNT II T0 ointment base no.104 T2 PA ointment base no.198 T2 PA ointment base no.75 T2 PA oleic acid T1 T1 PA olive oil/macadamia oil ethoxy/peg-6 caprylic-capric T2 PA gly OMEGA 3-6-9 FATTY T1 omega-3 fatty acids/fish oil 360-1200mg capsule T1 omeprazole 100 % powder T2 PA OMNIPAQUE (140 MG/ML BOTTLE, 180 MG/ML VIAL, 240 MG/ML BOTTLE, 240 MG/ML INFU BTL, 240 MG/ML VIAL, 300 MG/ML BOTTLE, 300 MG/ML INFU BTL, 300 MG/ML T2 PA PLUSPAK, 300 MG/ML PLUSPAK BT, 300 MG/ML VIAL, 350 MG/ML INFU BTL, 350 MG/ML PLUSPAK) OMNISCAN (287 MG/ML SYRINGE, 287 MG/ML VIAL) T2 PA

PAGE 393 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OMNISCAN PREFILL PLUS T2 PA ondansetron hcl 100 % powder T2 PA OPTIRAY 300 (300 MG/ML) SYRN, 300 MG/ML) VIAL) T2 PA OPTIRAY 320 (320 MG/ML) SYRN, 320 MG/ML) VIAL) T2 PA OPTIRAY 350 (350 MG/ML) SYRN, 350 MG/ML) VIAL) T2 PA oral dosing devices disp syrin T2 PA ORALAIR 100-300 IR CHILD SAMPL T2 PA orange (food color) T2 PA orange cream flavor T2 PA orange flavor liquid T2 PA orange oil oil T1 origanum oil T2 PA ORIGINAL NASAL SPRAY T1 hcl T2 PA citrate powder T2 PA S ORTHOVISC T2 PS PA ostomy barrier seal T2 PA ostomy kit T2 PA

PAGE 394 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ostomy supply (1 1/2" each, 1 1/4" each, 1 1/8" each, 1 3/4" each, 1 3/8" each, 1" each, 1" miscell, 1/2" each, 1.625" each, 1.875" each, 2 1/2" each, 2 1/4" each, 2 3/4" each, 2" each, 3 1/2" each, 3/4" each, 4" each, 4" x 4" T2 PA bandage, 4" x 4" each, 4" x 4" wafer, 4" x 8" wafer, 5/8" each, 6" x 6" each, 7/8" each, 8" x 8" each, 8" x 8" wafer, 8.5" each, 12" each, box, each, liquid, miscell, paste (g), powder, spray, swab) oxalic acid T2 PA oxandrolone 100 % powder T2 PA oxybenzone T2 PA oxybutynin chloride powder T2 PA oxycodone hcl 100 % powder T2 PA hcl 100 % powder T2 PA oxymetazoline hcl 0.05 % spray T1 oxyquinoline sulfate T2 PA hcl T2 PA (10 unit/ml vial, powder) T2 PA oxytocin in 0.9 % sodium chloride (oxytocin/0.9 % 10/500ml plast. bag, oxytocin/0.9 % 20/500ml plast. bag, T2 PA oxytocin/0.9 % 30/500 ml plast. bag, oxytocin/0.9 % 80/1000 ml plast. bag) oxytocin in 5 % dextrose 30/500 ml plast. bag T2 PA oxytocin/ringer's lactate 30/500 ml plast. bag T2 PA palmarosa oil T2 PA palmitoyl pentapeptide-4 T2 PA panax ginseng root powder T2 PA

PAGE 395 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pancreatin T2 PA T2 PA papain powder T2 PA papaverine hcl powder T2 PA parachlorophenol T2 PA paraffin 100 % beads T2 PA T1 S PARAGARD T 380-A T1 PS paromomycin sulfate 675 mcg/mg powder T2 PA passion fruit flavor T2 PA peach flavor T2 PA peak flow meter T0 peak flow meter/inhaler, assist devices T2 PA butter flavor T2 PA peanut oil T1 pectin powder T2 PA PEDIA RELIEF INFANT T0 pediatric multivitamin no.136 T0 peg 100 stearate/glyceryl monostearate T2 PA peg 3350/mannitol/sodium bicarbonate/citric T2 PA acid/sucrose peg 400 monostearate T2 PA peg-40 castor oil T2 PA

PAGE 396 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS pen needle, diabetic (pen 29 g x1/2" dis needle, pen 29 gauge dis needle, pen 29g x 3/8" dis needle, pen 30 gx5/16" dis needle, pen 31 g x1/3" dis needle, pen 31 g x1/4" dis needle, pen 31 g x1/6" dis needle, pen 31 gx3/16" dis needle, pen 31 gx5/16" dis needle, pen 32 gx T1 1/4" dis needle, pen 32 gx 1/5" dis needle, pen 32 gx 1/6" dis needle, pen 32 gx3/16" dis needle, pen 32 gx5/16" dis needle, pen 32gx 5/32" dis needle, pen 33 g x1/4" dis needle, pen 33 gx3/16" dis needle, pen 33 gx5/16" dis needle, pen 33 gx5/32" dis needle) pen needle,dual safety,diabetc 30 gx3/16" dis needle T1 pen needle, diabetic, safety (pen 29 g x1/2" dis needle, T1 pen 30 gx 1/3" dis needle) penicillamine powder T2 PA pennyroyal oil T2 PA pentetate calcium trisodium T2 PA pentetate zinc trisodium T2 PA sodium T2 PA pentoxifylline 100 % powder T2 PA T2 PA T2 PA perfluorodecalin T2 PA permethrin 92 % liquid T2 PA perphenazine 100 % powder T2 PA petrolatum, yellow T1 petrolatum,white jelly (g) T2 PA petrolatum,white 100 % jelly (g) T2 PA

PAGE 397 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS petrolatum,white (oint pack, oint. (g)) T1 petrolatum,white/carboxymethylcellulose T2 PA S PH 12 DILUENT FOR FLOLAN T2 PS PA phenazopyridine hcl 100 % powder T2 PA phenelzine sulfate 100 % powder T2 PA hcl T2 PA phenindione T2 PA phenobarbital powder T2 PA phenol (89 % liquid, 100 % crystals, liquid) T2 PA phenolsulfonic acid T2 PA phenoxybenzamine hcl powder T2 PA phenoxyethanol T2 PA phentermine hcl 100 % powder T2 PA phentolamine mesylate powder T2 PA phenyl salicylate T2 PA 100 % powder T2 PA phenylalanine,dl- 100 % crystals T2 PA T2 PA phenylephrine hcl 100 % powder T2 PA phenylmercuric acetate T2 PA T2 PA

PAGE 398 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS phenytoin powder T2 PA phenytoin sodium powder T2 PA phosphatidyl (20 % powder, 40 % powder) T2 PA T2 PA phosphoric acid,diluted T2 PA salicylate T2 PA phytic acid T2 PA phytonadione (vit k1) (1 % powder, 100 % liquid) T2 PA pilocarpine hcl powder T2 PA pilocarpine nitrate powder T2 PA pina colada flavor T2 PA pine needle oil T1 pine oil T2 PA pineapple flavor T2 PA pineapple fruit extract T2 PA pink (food color) T2 PA T2 PA piroxicam 100 % powder T2 PA PITOCIN T2 PA PLASBUMIN-25 T2 PA PLASBUMIN-5 T2 PA PLASMANATE T2 PA podofilox 100 % powder T2 PA

PAGE 399 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS podophyllum T2 PA POLIBAR ACB T2 PA poloxalene 100 % powder T2 PA poloxamer (20 % gel (gram), 20 % gel (ml), 30 % gel (ml), T2 PA liquid, powder) poloxamer 188/poloxamer 407/xylitol T2 PA polyethylene glycol T2 PA polyethylene glycol 1000 T2 PA polyethylene glycol 1450 powder T2 PA polyethylene glycol 300 T2 PA polyethylene glycol 3350 granules T0 PA polyethylene glycol 3350/polyethylene glycol 400 (3350/peg 400 1.3gm/3ml oint. (g), 3350/peg 400 40 %- T2 PA 60 % oint. (g)) polyethylene glycol 400 T2 PA polyethylene glycol 400/peg 8000/polysorbate 80 T2 PA polyethylene glycol 600 T2 PA polyethylene glycol 8000 (8000 powder, 8000 100 % T2 PA powder, 8000 100 % wax) polyhexamethylene T2 PA polyhexamethylene biguanide/gauze bandage (biguan/gauze bandage 0.2%-1/2x3 strip, biguan/gauze bandage 0.2%-2"x2" sponge, biguan/gauze bandage T2 PA 0.2%-4"x4" sponge, biguan/gauze bandage 0.2-6x6.75 sponge, biguan/gauze bandage .2-4.5x4.1 bandage) polymyxin b sulfate,micronized T2 PA

PAGE 400 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS polyoxyl (100) stearyl ether T2 PA polyoxyl 10 oleyl ether T2 PA polyoxyl 40 stearate 100 % wax T2 PA polyquaternium-6/gauze bandage 0.3 %-1"x5 strip T2 PA polysorbate 20 solution T2 PA polysorbate 40 T2 PA polysorbate 60 T1 polysorbate 80 solution T2 PA 100 % powder T2 PA polyvinyl alcohol/gentian violet/methylene blue T2 PA porcine acell submucosa,meshed T2 PA porcine acellular small intestine submucosa, fenestrated T2 PA 100 % powder T2 PA potassium alum (100 % crystals, 100 % granules) T2 PA potassium aminobenzoate T2 PA potassium aspartate T2 PA potassium azeloyl diglycinate T2 PA potassium bicarbonate (100 % granules, 100 % powder) T2 PA potassium bitartrate T2 PA (100 % pellet (g), 100 % powder, T2 PA crystals) potassium chloride (granules, powder) T2 PA potassium citrate 100 % granules T2 PA

PAGE 401 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium citrate monohydrate (100 % granules, 100 % T2 PA powder) potassium gluconate powder T2 PA (10 % solution, 20 % solution, 45 % T2 PA (w/w) solution, pellet (g)) potassium iodide (100 % crystals, granules, powder) T2 PA potassium iodide/iodine T2 PA potassium metabisulfite T2 PA potassium nitrate (granules, powder) T2 PA potassium T2 PA potassium (crystals, granules) T2 PA potassium phosphate, dibasic crystals T2 PA potassium phosphate,monobasic T2 PA potassium sorbate (crystals, powder) T2 PA potassium sulfate T2 PA povidone T2 PA povidone-iodine 100 % powder T2 PA povidone-iodine (10 % liquid pkt, 10 % oint. (g), 10 % T1 solution, 10 % spray) powder base no.200 T2 PA powder scent fragrance T2 PA chloride T2 PA pralines and cream flavor T2 PA pramoxine hcl powder T2 PA

PAGE 402 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (dhea) 100 % powder T2 PA prasterone (dhea), micronized T2 PA 98.5%-101% powder T2 PA prazosin hcl powder T2 PA PRE-PEN T2 PA PRECEDEX (80 MCG/20 ML VIAL, 200 MCG/2 ML VIAL, 200 T2 PA MCG/50 ML INJECT, 400 MCG/100 ML INJECT) prednisolone powder T2 PA , micronized T2 PA prednisolone sodium phosphate powder T2 PA prednisolone, micronized T2 PA prednisone powder T2 PA prednisone micronized T2 PA T2 PA pregnenolone, micronized T2 PA PRENATAL ONE T0 prezatide copper T2 PA S PRIALT T2 PS PA prilocaine hcl T2 PA primidone 100 % powder T2 PA PRISMASOL (B22GK 4/0, BGK 0/2.5, BGK 2/0, BGK 2/3.5, T2 PA BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2)

PAGE 403 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS procainamide hcl powder T2 PA procaine hcl T2 PA hcl T2 PA prochlorperazine edisylate 100 % powder T2 PA prochlorperazine maleate powder T2 PA progesterone 100 % powder T2 PA progesterone, micronized 100 % powder T2 PA PROHANCE (279.3 MG/ML SYRINGE, 279.3 MG/ML VIAL) T2 PA PROHANCE MULTIPACK T2 PA T2 PA promethazine hcl 100 % powder T2 PA propantheline bromide powder T2 PA proparacaine hcl 100 % powder T2 PA propranolol hcl powder T2 PA T2 PA propylene glycol T2 PA propylene glycol monostearate T2 PA propylene glycol/carbomer 940 T2 PA propylparaben (100 % powder, crystals) T2 PA propylthiouracil 100 % powder T2 PA protamine sulfate 100 % powder T2 PA PROTECTIVE OINTMENT T1 prothrombin time/inr test meter T2 PA

PAGE 404 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS protirelin T2 PA PROTOPAM CHLORIDE T2 PA PROVOCHOLINE T2 PA pseudoephedrine hcl 100 % powder T2 PA pseudoephedrine hcl 60 mg tablet T0 pseudoephedrine hcl (30 mg tablet, 30 mg/5 ml liquid, T1 120 mg tablet er) psyllium husk 100 % powder T2 PA pumice T2 PA pump set T2 PA pamoate T2 PA pyrazinamide 100 % powder T2 PA pyridostigmine bromide 100 % powder T2 PA T2 PA pyridoxine hcl (vitamin b6) (100 % powder, crystals) T2 PA pyrilamine maleate T2 PA pyrimethamine powder T2 PA pyrithione zinc T2 PA pyrogallol T2 PA T2 PA QUADRAMET T2 PA dihydrate T2 PA quinacrine hcl T2 PA

PAGE 405 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS quinidine sulfate (100 % powder, crystals) T2 PA quinine hcl dihydrate T2 PA quinine sulfate powder T2 PA R-GENE 10 T2 PA racemethionine T2 PA racepinephrine hcl T2 PA ranitidine hcl powder T2 PA rapeseed oil T2 PA rasagiline mesylate 100 % powder T2 PA raspberry flavor (liquid, powder) T2 PA raspberry flavor syrup T1 raspberry flavor, artificial solution T1 rauwolfia serpentina T2 PA READI-CAT 2 T2 PA rectal, vaginal applicator tip T1 red (food color) (liquid, powder) T2 PA red algae T2 PA red rice extract T2 PA REPEL HUNTER'S T1 REPEL SPORTSMEN T1 REPEL SPORTSMEN DRY T1 REPEL SPORTSMEN MAX (LOTION, SPRAY) T0 T2 PA

PAGE 406 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (crystals, powder) T2 PA >98 % powder T2 PA retinal T2 PA riboflavin (vitamin b2) powder T2 PA riboflavin 5-phosphate sodium (b2) T2 PA ribose T2 PA rifampin powder T2 PA T2 PA rocuronium bromide 100 % powder T2 PA flavor T2 PA ropivacaine hcl T2 PA T2 PA rose oil T1 oil T1 100 % lump T2 PA T2 PA rutin powder T2 PA s-adenosylmethionine sul tosyl 100 % powder T2 PA T2 PA saccharin sodium (100 % granules, 100 % powder) T2 PA safety syringe with needle, disposable kit-tray, 1 ml (1 ml T1 25gx1" tray, 1 ml 26gx3/8" tray, 1 ml 27gx1/2" tray) safflower oil T2 PA sage leaf T1

PAGE 407 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS salicylic acid (crystals, powder) T2 PA salicylic acid/resorcinol/lactic acid/ethyl alcohol T2 PA SALINE NASAL MIST T0 salsalate 100 % powder T2 PA sapropterin dihydrochloride (100 % powder, powder) T2 PA sarracenia flava T2 PA T1 saturated fa glycerides c12-18 T2 PA saw palmetto powder T2 PA scarlet red T2 PA SCLEROSOL T2 PA scopolamine hydrobromide T2 PA SCRUB CARE POVIDONE IODINE T1 acetate (human) T2 PA SECURA PROTECTIVE OINTMENT T1 selegiline hcl powder T2 PA selenium sulfide 52 %-55.5% powder T2 PA selenium yeast T2 PA selenomethionine 0.5 % powder T2 PA serine T2 PA sermorelin acetate T2 PA serotonin hcl T2 PA sertraline hcl 100 % powder T2 PA

PAGE 408 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS oil T1 shampoo base no.50 T2 PA shampoo base no.89 T2 PA shark cartilage T2 PA T2 PA shower fresh fragrance T2 PA siberian ginseng T2 PA citrate 100 % powder T2 PA silica gel, amorphous synthetic micronized T2 PA silicon dioxide T2 PA silicon,colloidal T2 PA silver (1" x 24" bandage, 2" x 2" bandage, 4" x 4" bandage, 4" x 5" bandage, 4" x 8" bandage, 4"x48" T2 PA bandage, 5"x5" bandage, 6" x 6" bandage, 8"x16" bandage, 16"x16" bandage) silver nitrate crystals T2 PA silver protein,mild T2 PA silver sulfadiazine 100 % powder T2 PA silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5 %-2"x 2" bandage, sulfadiaz/foam bandage 5 %-3" x3" bandage, sulfadiaz/foam bandage 5 %-4"x 4" bandage, sulfadiaz/foam bandage 5 %-5" x5" bandage, T2 PA sulfadiaz/foam bandage 5 %-6"x 6" bandage, sulfadiaz/foam bandage 5 %-7" x7" bandage, sulfadiaz/foam bandage 5 %-8"x 8" bandage) silver sulfate/foam bandage (sulfate/foam bandage 6" 8" T2 PA bandage, sulfate/foam bandage bandage)

PAGE 409 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS silver sulfate/non-adherent bandage T2 PA silver/calcium alginate (silver/calcium 1"x12" bandage, silver/calcium 2" x 2" bandage, silver/calcium 3/4"x12" T2 PA bandage, silver/calcium 4"x4 3/4" bandage) silver/foam bandage (silver/foam bandage 1" bandage, silver/foam bandage 2" x 2" bandage, silver/foam bandage 4" x 8" bandage, silver/foam bandage 4"x10" T2 PA bandage, silver/foam bandage 4"x13 3/4" bandage, silver/foam bandage 4"x4 3/4" bandage) simethicone liquid T2 PA simple syrup T1 simvastatin 100 % powder T2 PA SINOGRAFIN T2 PA SINUS 12 HOUR T1 SINUS 12-HOUR T1 SINUS DECONGESTANT T1 SINUS NASAL T1 SINUS NASAL SPRAY T1 SINUS PE DECONGESTANT T1 SINUS RELIEF NASAL SPRAY 0.05% T1 sirolimus 100 % powder T2 PA SITZMARKS T2 PA sodium acetate powder T2 PA sodium acetate trihydrate (crystals, granules) T2 PA sodium alginate T2 PA sodium ascorbyl phosphate dihydrate T2 PA

PAGE 410 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium benzoate T2 PA sodium bicarbonate powder T2 PA sodium bisulfite T1 sodium borate T2 PA T2 PA T2 PA sodium cacodylate T2 PA T2 PA sodium chloride (6"x6 3/4" bandage, granules, powder) T2 PA sodium chloride 0.65 % spray T0 T2 PA sodium citrate 100 % powder T2 PA sodium citrate dihydrate (100 % powder, granules) T2 PA sodium decanoate T2 PA sodium desoxycholate T2 PA sodium dichloroacetate T2 PA sodium gluconate T2 PA (10 % solution, 100 % pellet (g), 100 % T2 PA powder, flakes, granules) sodium iodide T2 PA sodium lactate 60 % solution T2 PA sodium laureth sulfate T2 PA sodium lauryl sulfate T2 PA sodium metabisulfite (100 % granules, powder) T2 PA

PAGE 411 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium monofluorophosphate T2 PA sodium nitrate T2 PA sodium nitrite (30 mg/ml vial, granules) T2 PA sodium oleate T2 PA (100 % powder, crystals) T2 PA sodium phosphate dibasic, heptahydrate T2 PA sodium phosphate,dibasic (100 % granules, powder) T2 PA sodium phosphate,monobasic T2 PA sodium propionate T2 PA sodium pyroglutamate T2 PA sodium pyruvate T2 PA sodium salicylate T2 PA sodium selenite T2 PA sodium silicate T1 sodium stearate T2 PA sodium stearyl fumarate T2 PA sodium succinate T2 PA sodium sulfate T2 PA sodium T2 PA sodium tartrate dihydrate T2 PA sodium tetradecyl sulfate (3 % vial, 27 % solution, T2 PA powder) sodium thiosalicylate T2 PA

PAGE 412 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS (12.5g/50ml vial, 100 % crystals, 100 % T2 PA powder) SOLESTA T2 PA S SOLIRIS T2 PS PA sorbic acid T2 PA sorbitan monolaurate T2 PA sorbitan monooleate T2 PA sorbitan monopalmitate T2 PA sorbitol (flakes, pellet (g)) T2 PA sorbitol powder T1 SOTRADECOL T2 PA oil T2 PA oil T1 SPHERUSOL T2 PA spirometers and accessories T2 PA spironolactone 100 % powder T2 PA spironolactone, micronized T2 PA squalane 100 % oil T2 PA squaric acid T2 PA squaric acid dibutylester (100 % liquid, powder) T2 PA squaric acid dibutylester in butyl alcohol T2 PA st. john's wort powder T2 PA

PAGE 413 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS stannous chloride dihydrate T2 PA T2 PA stanozolol micronized T2 PA stearic acid 90 % flakes T2 PA stearic acid powder T1 stearyl alcohol T1 STERILE WATER DILUENT-CABLIVI T2 PA STERILE WATER FOR KCENTRA T2 PA steviol T2 PA 90 % powder T2 PA stevioside/glycerin 15 % liquid T2 PA STRAVIX 3CM X 6CM MATRIX T2 PA strawberry flavor liquid T2 PA streptomycin sulfate powder T2 PA strontium chloride hexahydrate T2 PA strontium nitrate T2 PA succimer T2 PA succinic acid T2 PA succinylcholine chloride 100 % powder T2 PA sucralfate powder T2 PA sucrose powder T2 PA sucrose octaacetate T2 PA SUDAFED 12 HOUR T1

PAGE 414 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SUDAFED 24-HOUR T0 SUDOGEST (12 HOUR 120 MG CAPLET, 30 MG TABLET, 60 T1 MG TABLET) SUDOGEST PE T1 sufentanil citrate powder T2 PA sulfacetamide T2 PA sulfacetamide sodium powder T2 PA sulfacetamide sodium, monohydrate T2 PA sulfadiazine powder T2 PA sulfadiazine sodium T2 PA sulfamerazine T2 PA sulfamethoxazole T2 PA sulfanilamide powder T2 PA sulfapyridine T2 PA sulfasalazine powder T2 PA sulfathiazole T2 PA sulfisoxazole T2 PA sulfosalicylic acid dihydrate T2 PA sulfur T2 PA sulfur sublimed T2 PA sulfurated potash T2 PA T2 PA sulindac powder T2 PA sumatriptan 100 % powder T2 PA

PAGE 415 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sumatriptan succinate 100 % powder T2 PA S SUPARTZ FX T2 PS PA SUPER GINSENG MULTIVITAMIN T1 super synersweet flavor T2 PA dismutase T2 PA SUPHEDRIN (30 MG TABLET, GNP LIQUID, LIQUID) T1 GNP SUPHEDRIN 30 MG TABLET T0 QC SUPHEDRINE 30 MG TABLET T1 RA SUPHEDRINE 30 MG TABLET T0 SUPHEDRINE 12-HOUR T1 SUPHEDRINE PE T1 SUPHEDRINE SINUS CONGESTION T1 suppository base no.119 T2 PA suppository base no.55 T2 PA suppository base no.85 T2 PA suppository container, empty T1 suppository mold each T2 PA sweetleaf/polyethylene glycol 1450 T2 PA SYNOVACIN T1 S SYNVISC T2 PS PA S SYNVISC-ONE T2 PS PA

PAGE 416 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syring w-needl 0.5 ml,kit-tray (syring 0.5 27gx1/2" tray, T2 PA syring 0.5 28gx1/2" tray) syringe accessory T2 PA SYRINGE AVITENE T2 PA syringe filter (syringe 25 each, syringe 50 each) T2 PA syringe filter 25 mm-0.2 each T1 syringe w-needle 0.3 ml,insulin,safety w-self-cont.dis.unit T1 syringe with cannula, disposable, 1 ml T1 syringe with cannula, 10 ml 17 gauge disp syrin T2 PA syringe with cannula, 3 ml 18gx1" disp syrin T1 syringe with cannula, 3 ml syringe T2 PA syringe with cannula, disposable, 5 ml T2 PA syringe with cannula, disposable, 6 ml T2 PA syringe with cannula,disposable 12 ml T2 PA syringe with needle 1 ml, disposable kit-tray (syringe 1 T1 27gx1/2" tray, syringe 1 28gx1/2" tray) syringe with needle 1 ml,insulin,safety w-self-con.disp.unit T1 syringe with needle and cannula, disposable, 10 ml T1 syringe with needle, insulin, safety, 0.3 ml (29 g x1/2" disp T1 syrin, 30 gx5/16" disp syrin) syringe,needle,insuln,sf 0.5ml 29 g x1/2" disp syrin T2 PA syringe,needle,insuln,sf 0.5ml 30 gx5/16" disp syrin T1 syringe with needle, insulin, safety, 1 ml (30 gx5/16" disp T1 syrin, 30gx1/2" disp syrin, 31 gx5/16" disp syrin) syringe,needle,insuln,safe,1ml 29 g x1/2" disp syrin T2 PA

PAGE 417 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe with needle,disposable T1 syringe with needle, 0.5 ml 27gx0.375" disp syrin T2 PA syringe with needle,disposable, 0.5 ml (syringe 0.5 ml T1 27gx1/2" disp syrin, syringe 0.5 ml 28gx1/2" disp syrin) syringe with needle, 1 ml 26gx1/2" disp syrin T2 PA syringe with needle, 1 ml 26gx3/8" disp syrin T2 PA syringe with needle,disposable, 1 ml (syringe 1 ml 20gx1" disp syrin, syringe 1 ml 21 g x 1" disp syrin, syringe 1 ml 26 T1 g x5/8" disp syrin, syringe 1 ml 28gx1/2" disp syrin) syringe with needle,disposable, 1 ml (syringe 1 ml 25gx1" disp syrin, syringe 1 ml 25gx5/8" disp syrin, syringe 1 ml T1 PA 27gx0.375" disp syrin, syringe 1 ml 27gx1/2" disp syrin) syringe with needle,disposable, 10 ml (syringe 10 ml 20gx1 1/2" disp syrin, syringe 10 ml 20gx1" disp syrin, syringe 10 ml 21 g x 1" disp syrin, syringe 10 ml 21gx1 T1 1/2" disp syrin, syringe 10 ml 22gx1 1/2" disp syrin, syringe 10 ml 22gx1" disp syrin, syringe 10 ml 23gx1.25" disp syrin) syringe with needle,disposable, 12 ml T1

PAGE 418 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe with needle,disposable, 3 ml (syringe ml 18gx1 1/2" disp syrin, syringe ml 20gx1 1/2" disp syrin, syringe ml 20gx1" disp syrin, syringe ml 20gx3/4" disp syrin, syringe ml 21 g x 1" disp syrin, syringe ml 21gx1 1/2" disp syrin, syringe ml 22gx1 1/2" disp syrin, syringe ml 22gx1" disp syrin, syringe ml 22gx3/4" disp syrin, syringe ml T1 23gx1 1/2" disp syrin, syringe ml 23gx1" disp syrin, syringe ml 25gx1 1/2" disp syrin, syringe ml 25gx1" disp syrin, syringe ml 25gx1.25" disp syrin, syringe ml 25gx5/8" disp syrin, syringe ml 26 g x5/8" disp syrin, syringe ml 27gx1.25" disp syrin) syringe with needle,disposable, 5 ml T1 syringe with needle,disposable, 6 ml (syringe 6 ml disp syrin, syringe 6 ml 20gx1 1/2" disp syrin, syringe 6 ml 21 g T2 PA x 1" disp syrin, syringe 6 ml 21gx1 1/2" disp syrin, syringe 6 ml 22gx1 1/2" disp syrin) syringe and needle,insulin,1ml 29 g x1/2" disp syrin T1 PA syringe with needle,disposable,insulin 1 ml (syringe disp syrin, syringe 25gx1" disp syrin, syringe 25gx5/8" disp syrin, syringe 26gx1/2" disp syrin, syringe 27gx1/2" disp syrin, syringe 27gx5/8" disp syrin, syringe 28 gauge disp syrin, syringe 28gx1/2" disp syrin, syringe 29 gauge disp T1 syrin, syringe 29gx7/16" disp syrin, syringe 30 g x3/8" disp syrin, syringe 30 gauge disp syrin, syringe 30 gx5/16" disp syrin, syringe 30gx1/2" disp syrin, syringe 31 g x1/4" disp syrin, syringe 31 gx5/16" disp syrin, syringe 31gx15/64" disp syrin, syringe 31gx3/8" disp syrin) syringe with needle,insulin 0.3 ml (half unit mark) (0.3 ml 29 g x1/2" disp syrin, 0.3 ml 30 gx5/16" disp syrin, 0.3 ml T1 31 g x1/4" disp syrin, 0.3 ml 31 gx5/16" disp syrin, 0.3 ml 31gx15/64" disp syrin) syringe with needle,insulin disposable T1

PAGE 419 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe with needle,insulin,0.3 ml (ml 29 g x1/2" disp syrin, ml 29 gauge disp syrin, ml 30 g x3/8" disp syrin, ml 30 gauge disp syrin, ml 30 gx5/16" disp syrin, ml 30gx1/2" T1 disp syrin, ml 31 g x1/4" disp syrin, ml 31 gx5/16" disp syrin, ml 31gx15/64" disp syrin, ml 31gx3/8" disp syrin) syringe with needle,insulin,0.5 ml (ml 27gx1/2" disp syrin, ml 28gx1/2" disp syrin, ml 29 gauge disp syrin, ml 30 g x3/8" disp syrin, ml 30 gauge disp syrin, ml 30 gx5/16" T1 disp syrin, ml 30gx1/2" disp syrin, ml 31 g x1/4" disp syrin, ml 31 gx5/16" disp syrin, ml 31gx15/64" disp syrin, ml 31gx3/8" disp syrin) syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin, T1 PA ml 29 g x1/2" disp syrin) syringe without needle,insulin disposible, 1 ml T1 syringe, disposable irrigation, 70 ml T2 PA syringe, disposable, 1 ml T1 syringe, disposable, 10 ml T1 syringe, disposable, 12 ml T2 PA syringe, disposable, 20 ml disp syrin T2 PA syringe, disposable, 3 ml disp syrin T2 PA syringe, disposable, 30 ml T1 syringe, disposable, 35 ml T2 PA syringe, disposable, 5 ml T2 PA syringe, disposable, 6 ml disp syrin T2 PA syringe, disposable, 60 ml disp syrin T2 PA syringe, insulin u-500 with needle, disposable, 0.5 ml T1 syringe,safety with needle,1ml 25gx5/8" disp syrin T2 PA

PAGE 420 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe,safety with needle,1ml 26 g x5/8" disp syrin T1 syringe,safety with needle,1 ml (25gx1" syringe, 26gx3/8" T1 PA disp syrin, 27gx1/2" disp syrin, 28gx1/2" disp syrin) syringe,safety with needle,10 ml (ml 18gx1 1/2" disp syrin, ml 18gx1" disp syrin, ml 21 g x 1" disp syrin, ml 22gx1 T1 1/2" disp syrin, ml 25gx1" disp syrin) syringe,safety with needle,10 ml (ml 20gx1 1/2" disp syrin, T1 PA ml 20gx1" disp syrin, ml 21gx1 1/2" disp syrin) syringe,safety with needle,12 ml (ml 20gx1 1/2" disp syrin, T1 ml 21gx1 1/2" disp syrin) syringe,safety with needle,3 ml (18gx1 1/2" disp syrin, 18gx1" disp syrin, 19gx1 1/2" disp syrin, 19gx1" disp syrin, T1 23gx1 1/2" disp syrin) syringe,safety with needle,3 ml (20gx1 1/2" disp syrin, 20gx1" disp syrin, 21gx1 1/2" disp syrin, 22gx1 1/2" disp T1 PA syrin, 23gx1" disp syrin, 25gx5/8" disp syrin) syringe,safety with needle,3 ml (21 g x 1" disp syrin, T2 PA 22gx1" disp syrin, 25gx1" disp syrin) syringe,safety with needle,5 ml (18gx1" disp syrin, 21 g x 1" disp syrin, 22gx1 1/2" disp syrin, 25gx1" disp syrin, T1 25gx5/8" disp syrin) syringe,safety with needle,5 ml (20gx1 1/2" disp syrin, T1 PA 20gx1" disp syrin, 21gx1 1/2" disp syrin) tablet rapid dissolve compounding base no. 163 T2 PA tablet rapid dissolve compounding base no.123 T2 PA TACHOSIL T2 PA tacrolimus 100 % powder T2 PA tacrolimus anhydrous T2 PA tacrolimus, micronized T2 PA

PAGE 421 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TAGITOL T2 PA talc (5 g vial, 100 % powder) T2 PA tamoxifen citrate powder T2 PA tangerine flavor T2 PA tangerine oil oil T2 PA tannic acid T2 PA (100 % crystals, granules) T2 PA 100 % powder T2 PA tazarotene 100 % powder T2 PA (tea oil oil, tea oil 100 % oil) T2 PA teaberry oil flavor T2 PA TENSION HEADACHE T1 TENSION HEADACHE PAIN RELIEVER T1 sulfate powder T2 PA terpin hydrate powder T2 PA testosterone powder T2 PA testosterone cypionate, micronized T2 PA testosterone micronized T2 PA powder T2 PA tetracaine 100 % wax T2 PA tetracaine hcl powder T2 PA tetracycline hcl powder T2 PA tetrahydrozoline hcl T2 PA

PAGE 422 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TETRIX T2 PA thallous chloride tl-201 37 mbq/ml vial T2 PA 99.1 % powder T2 PA theobromine T2 PA anhydrous powder T2 PA thermometer for the ear, electronic T2 PA thermometer, electronic,oral each T2 PA thermometer, temple electronic each T2 PA thiabendazole T2 PA thiamine hcl powder T2 PA thioguanine T2 PA thioridazine hcl 100 % powder T2 PA thiotepa 100 % powder T2 PA (crystals, powder) T2 PA THROMBI-GEL T2 PA THROMBI-PAD T2 PA T2 PA thymol iodide T2 PA S THYROGEN T2 PS PA thyroid,pork 100 % usp powder T2 PA ticarcillin disodium/potassium clavulanate T2 PA

PAGE 423 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS timolol maleate 100 % powder T2 PA tinidazole 100 % powder T2 PA T2 PA (30 % liquid, powder) T2 PA hcl 100 % powder T2 PA tobramycin 900 mcg/mg powder T2 PA tobramycin sulfate 634 mcg/mg powder T2 PA hcl T2 PA tolonium chloride T2 PA topical cream metered-dose device T2 PA topiramate 99.7 % powder T2 PA TOXICOLOGY SALIVA COLLECTION T2 PA tragacanth T1 tramadol hcl 100 % powder T2 PA tranexamic acid powder T2 PA tranilast T2 PA transcutaneous electrical nerve stimulators (tens units) T2 PA transfer device, closed system (13mm each, 20mm each, T2 PA 28mm each) trazodone hcl powder T2 PA tretinoin powder T2 PA triamcinolone T2 PA triamcinolone acetonide 100 % powder T2 PA

PAGE 424 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA triamcinolone diacetate, micronized T2 PA triamcinolone hexacetonide T2 PA triamterene powder T2 PA trichlormethiazide T2 PA trichloroacetic acid (20 % soln recon, crystals, powder) T2 PA T2 PA triethanolamine T2 PA triethanolamine lauryl sulfate T2 PA trifluridine 100 % powder T2 PA T2 PA S TRILURON T2 PA trimeprazine tartrate T2 PA trimethobenzamide hcl 100 % powder T2 PA trimethoprim 100 % powder T2 PA trimethoprim, micronized T2 PA trioxsalen T2 PA hcl T2 PA hcl 100 % powder T2 PA S TRIVISC T2 PS PA troche base no.131 T2 PA

PAGE 425 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS troche base no.168 T2 PA troche base no.66 T2 PA troche mold T2 PA tromethamine T2 PA TROPICAL LIQUID T0 tropical punch flavor T2 PA powder T2 PA T2 PA T2 PA tryptic soy broth T2 PA tryptophan powder T2 PA TUBERSOL T2 PA (95 % powder, 100 % powder) T2 PA T2 PA tutti-frutti flavor T2 PA (1 g-15/4 g packet, powder) T2 PA ubidecarenone (100 % powder, powder) T2 PA ubiquinol (32 % powder, 100 % powder) T2 PA ULTRAFOAM T2 PA ULTRATHON INSECT REPELLENT 8 T1 ULTRAVIST T2 PA T2 PA underpads (23" x 36" each, 30"x36" each) T2 PA

PAGE 426 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS unithiol (97 % powder, crystals) T2 PA urea (100 % beads, 100 % powder) T2 PA uridine T2 PA urinary bag (bag combo. pkg, bag each, bag kit, bag 9" T2 PA each, bag 10" each) urinary bag/catheter (bag/catheter 6 fr combo. pkg, T2 PA bag/catheter 8fr-14" combo. pkg) urinary bag/catheterization tray T2 PA QL 6.66 / day acetone test,strips T2 PA urine albumin test T2 PA urine bilirubin test T2 PA QL 10 / day urine glucose test strip T2 PA urine glucose-acet test strip T2 PA urine leukocyte test strips T2 PA QL 6.66 / day urine multiple test strips T2 PA urine phenaphthazine- test (15 feet each, strip) T2 PA urostomy pouch (1 1/2"(9") each, 1 3/4"(9") each, 2 1/2"(9") each, 2 1/4"(9") each, 2 3/4"(9") each, 4" (14") T2 PA combo. pkg, 9.2" each, 10.3" each, 456-10 1/2 each) ursodiol 100 % powder T2 PA vacuum erection device system T2 PA vaginal suppository applicator T1 valacyclovir hcl 100 % powder T2 PA

PAGE 427 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS root powder T2 PA powder T2 PA valproic acid 100 % liquid T2 PA valproic acid (as sodium salt) 100 % powder T2 PA VALU-TAPP DECONGESTANT T0 vanadium T2 PA vanadyl sulfate T2 PA vancomycin hcl 900 mcg/mg powder T2 PA butternut flavor T2 PA vanilla extract flavor T2 PA T2 PA VARIBAR HONEY T2 PA VARIBAR NECTAR T2 PA VARIBAR PUDDING T2 PA VARIBAR THIN HONEY T2 PA VARIBAR THIN LIQUID T2 PA VAXCHORA BUFFER COMPONENT T2 PA vecuronium bromide 100 % powder T2 PA vehicle base no.10 T2 PA vehicle base no.11 (20 % gel (gram), cmb gel lq) T2 PA vehicle base no.13 T2 PA vehicle base no.144 T2 PA vehicle base no.15 T2 PA

PAGE 428 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS vehicle base no.18 T2 PA vehicle base no.19 T2 PA vehicle base no.20 T2 PA vehicle base no.22 T2 PA vehicle base no.24 T2 PA vehicle base no.4 T2 PA vehicle base no.5 T2 PA vehicle base no.6 T2 PA vehicle base no.60 T2 PA vehicle base no.7 T2 PA vehicle gel base no.61 T2 PA vehicle gel base no.63 T2 PA vehicle lozenge base no.14 T2 PA verapamil hcl 100 % powder T2 PA vial,empty T1 VICKS SINEX 12 HOUR SPRAY T1 vidarabine T2 PA vidarabine monohydrate T2 PA vinpocetine T2 PA violet (food color) T2 PA S VISCO-3 T2 PS PA

PAGE 429 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VISIPAQUE (270 MG/ML BOTTLE, 270 MG/ML INFU BTL, 270 MG/ML VIAL, 320 MG/ML BOTTLE, 320 MG/ML INFU T2 PA BTL, 320 MG/ML INFUS BTL, 320 MG/ML PLUSPAK, 320 MG/ML VIAL) VISTOGARD T2 PA acetate 325k/g beads T2 PA vitamin a palmitate (plmitte 1.7mm/g liquid, plmitte 100 T2 PA % liquid, plmitte 18000/ml liquid) vitamin e (dl,tocopheryl acet) 100 % liquid T2 PA vitamin e acetate (actat50 % powdr, actat125/ml liquid) T2 PA vitamin e acid succinate 100 % powder T2 PA vitamin e mixed 30 % powder T2 PA vitamin e(dl-alpha ) T2 PA 0.2 % powder T2 PA VITRASE T2 PA VOLUMEN T2 PA VOLUVEN T2 PA voriconazole 100 % powder T2 PA WAL-FOUR T0 WAL-PHED 30 MG TABLET T0 WAL-PHED PE 10 MG TABLET T1 WAL-PHED 12 HOUR T1 WAL-PHED D ER T1 warfarin sodium 100 % powder T2 PA water T2 PA

PAGE 430 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS water for inj.,bacteriostatic T2 PA water for injection,sterile (ampul, iv soln) T2 PA S water for injection,sterile syringe T2 PS PA water for injection,sterile vial T2 PA water for irrigation,sterile T2 PA watermelon flavor T2 PA wax base no.116 T2 PA wax base no.28 T2 PA whey protein isolate T2 PA white (food color) T2 PA white willow bark/salicin T2 PA wild cherry flavor T2 PA witch hazel extract T2 PA WOMEN'S COMPLEX T1 xanthan gum powder T2 PA XCLAIR T2 PA XIAFLEX T2 PA XURIDEN T2 PA xylitol T2 PA hcl T2 PA y-port adapter-extension set (enteral) T2 PA

PAGE 431 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS T2 PA yellow (food color) (liquid, powder) T2 PA yohimbine hcl powder T2 PA zeaxanthin T2 PA ZEPHREX-D T0 zinc acetate dihydrate T2 PA zinc chloride 100 % granules T2 PA zinc citrate T2 PA zinc gluconate 100 % powder T2 PA zinc methionine sulfate T2 PA zinc oxide powder T2 PA zinc picolinate T2 PA zinc sulfate (100 % powder, powder) T2 PA zinc sulfate heptahydrate T2 PA zinc undecylenate T2 PA QL 0.2 / day zolmitriptan 100 % powder T2 PA zonisamide 100 % powder T2 PA OPHTHALMIC AGENTS OPHTHALMIC AGENTS, OTHER

QL 0.334 / DAY acetylcysteine in sterile water/pf T2 PA AK-FLUOR T2 PA

PAGE 432 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AK-POLY-BAC T1 QL 0.434 / day AKTEN T2 PA ALCAINE T2 PA ALTACAINE T2 PA ALTACHLORE (OINTMENT, OPHTH SOLN) T1 ALTAZINE T1 AMVISC T2 PA AMVISC PLUS T2 PA ARTIFICIAL TEARS (1.4% DROPS, DROPS, EYE OINTMENT, T1 GS EYE DROPS, QC DROPS) ARTIFICIAL TEARS (ARTIFICIAL, ARTIFICIAL EYE DROPS, T0 ARTIFICIALS DROPS) ASTRINGENT EYE DROPS T1 atropine sulfate (1 % drops, 1 % oint. (g)) T1 atropine sulfate/0.9 %sod chlr 0.01 % drops T2 PA QL 0.36/day AZASITE T2 PA bacitracin/polymyxin b sulfate T1 QL 0.434 / day balanced salt irrig soln no.2 T2 PA BETADINE 5% EYE SOLUTION T2 PA S bevacizumab (1mg/0.04ml syringe, 1.25mg/.05 syringe, T2 PS 2.5 mg/0.1 syringe) PA BIOGLO T2 PA QL 5 / fill BLEPH-10 T2 PA

PAGE 433 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 5 / fill BLEPHAMIDE T2 PA QL 4 / fill BLEPHAMIDE S.O.P. T2 PA BSS T2 PA BSS PLUS T2 PA CELLUGEL T2 PA QL 0.767 / day CILOXAN (EYE DROPS, OINTMENT) T2 PA ciprofloxacin hcl 0.3 % drops T1 QL 0.767 / day CYCLOGYL T2 PA CYCLOMYDRIL T2 PA cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) T1 cyclopentolate hcl/lidocaine T2 PA hcl/phenylephrine/tropicamide cyclopentolate hcl/tropicamide/phenylephrine hcl in T2 PA water QL 1 / day CYSTARAN T2 PA DISCOVISC T2 PA DRY EYE RELIEF (CVS DROPS, DROPS) T0 DRY EYE RELIEF (HM DROPS, SM DROPS) T1 DUOVISC T2 PA EQ GENTLE T0 erythromycin base 5 mg/gram oint. (g) T1 QL 0.54 / day

PAGE 434 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TEARS T0 EYE DROPS T1 EYE-STREAM T1 QL 0.04 / day EYLEA (2 MG/0.05 ML SYRINGE, 2 MG/0.05 ML VIAL) T2 PA FLUCAINE T2 PA FLUORESCITE T2 PA FRESHKOTE EYE DROP T2 PA FRESHKOTE EYE DROPS T1 FUL-GLO T2 PA QL 0.36 / day gatifloxacin 0.5 % drops T2 PA GELFILM T2 PA GENTAK T1 QL 0.54 / day gentamicin sulfate 0.3 % drops T1 QL 2.143 / day GENTEAL TEARS (0.1%-0.2%-0.3%, 0.1%-0.3% DROP) T1 GENTEAL TEARS SEVERE 0.3% GEL T1 GONIOTAIRE T1 GONIOVISC T1 HEALON T2 PA HEALON5 T2 PA HOMATROPAIRE T2 PA homatropine hbr T2 PA ISOPTO TEARS T1

PAGE 435 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LACRISERT T2 PA QL 0.767 / day levofloxacin 0.5 % drops T2 PA LIQUITEARS T1 LUBRICANT EYE (CVS LUBRICANT 0.4%-0.3%, CVS LUBRICANT DROPS, LUBRICANT 0.4%-0.3% DROP, T1 LUBRICANT 0.5-0.9% DROPS, LUBRICANT OINTMENT, SM LUBRICANT DROPS) LUBRICANT EYE (EQ LUBRICANT DROPS, GNP LUBRICANT T0 DROPS, RA LUBRICANT DROPS) LUBRICANT EYE DROP (CVS LUBRICANT 0.5% DROP, CVS LUBRICANT 0.6% DROP, GNP LUBRICANT 0.5% DROP, T1 LUBRICANT 0.5% DROP, LUBRICANT 0.6% DROP, RA LUBRICANT 0.5% DROP, RA LUBRICANT 0.6% DROP) LUBRICANT EYE DROPS T1 LUBRICANT GEL DROPS T0 LUBRICANT PM EYE OINTMENT T1 LUBRICATING EYE DROPS T1 LUBRICATING PLUS (GS LUBRICAT DRPS, HM LUBRICAT T1 DRPS, LUBRICATING DRPS, SM LUBRICAT DRPS) KRO LUBRICATING RLF 0.3-0.4% T0 LUBRICATING RELIEF (0.3-0.4% EYE, GNP 0.3-0.4%) T2 PA LUBRICATING TEARS T1 LUBRIFRESH PM T1 QL 0.04 / day LUCENTIS (0.3 MG/0.05 ML SYRING, 0.3 MG/0.05 ML S T2 VIAL, 0.5 MG/0.05 ML VIAL) PS PA

PAGE 436 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.0111 / day S MACUGEN T2 PS PA QL 5 / fill MAXITROL EYE DROPS T2 PA QL 4 / fill MAXITROL EYE OINTMENT T2 PA MEMBRANEBLUE T2 PA MIOCHOL-E T2 PA QL 0.434 / day MOXEZA T2 PA moxifloxacin hcl 0.5 % drops T2 QL 0.434 / day MURO-128 2% EYE DROPS T1 MYDRIACYL T2 PA NATURAL BALANCE TEARS T1 NATURAL TEARS T0 NATURE'S TEARS T1 QL 0.124 / day NEO-POLYCIN T2 PA QL 4 / fill NEO-POLYCIN HC T2 PA neomycin sulfate/bacitracin zinc/polymyxin QL 4 / fill T2 b/hydrocortisone PA QL 0.124 / day neomycin sulfate/bacitracin/polymyxin b T2 PA

PAGE 437 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1.47 / day neomycin sulfate/polymyxin b sulfate/gramicidin d T2 PA QL 10 / fill neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp T2 PA neomycin/polymyxin b/dexametha 0.1 % drops susp T1 QL 5 / fill neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g) T1 QL 4 / fill NIGHTTIME DRY-EYE RELIEF T2 PA OCUCOAT T2 PA QL 1.47 / day OCUFLOX T2 PA ofloxacin 0.3 % drops T1 QL 0.334 / DAY OMIDRIA T2 PA OPTI-CLEAR T1 PAREMYD T2 PA phenylephrine hcl (2.5 % drops, 10 % drops) T2 PA POLYCIN T1 QL 0.434 / day polymyxin b sulfate/trimethoprim T1 QL 1.47 / day QL 1.47 / day POLYTRIM T2 PA polyvinyl alcohol 1.4 % drops T1 povidone-iodine 5 % solution T2 PA QL 5 / fill PRED-G 1% EYE DROPS T2 PA QL 4 / fill PRED-G S.O.P. EYE OINTMENT T2 PA

PAGE 438 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS proparacaine hcl 0.5 % drops T1 proparacaine hcl/fluorescein sodium T2 PA PROVISC T2 PA PURALUBE T1 PURE & GENTLE EYE DROPS T0 REDNESS RELIEVER T1 REFRESH CELLUVISC T1 REFRESH CLASSIC T1 REFRESH LACRI-LUBE T1 REFRESH LIQUIGEL T1 REFRESH OPTIVE GEL EYE DROPS T1 REFRESH OPTIVE ADVANCED T1 REFRESH OPTIVE SENSITIVE T1 REFRESH P.M. T1 QL 2 / day RESTASIS T2 PA QL 0.2 / day RESTASIS MULTIDOSE T2 PA RETAINE HPMC T0 RETAINE PM T1 sodium chloride (5 % drops, 5 % oint. (g)) T0 SOOTHE HYDRATION T0 STERILE EYE DROPS T1 QL 21 / fill sulfacetamide sodium 10 % drops T2 PA

PAGE 439 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / fill sulfacetamide sodium 10 % oint. (g) T2 PA sulfacetamide sodium/prednisolone sodium phosphate T1 QL 5 / fill SYSTANE (0.3-0.4% DROPS, NIGHTTIME OINTMENT) T1 SYSTANE GEL (0.3% GEL, GEL DROPS) T1 TEARS AGAIN T1 TETCAINE T2 PA tetracaine hcl 0.5 % drops T2 PA tetracaine hcl/pf 0.5 % drops T2 PA TETRAVISC T2 PA TETRAVISC FORTE T2 PA TOBRADEX EYE DROPS T1 QL 5 / fill TOBRADEX EYE OINTMENT T1 QL 4 / fill QL 5 / fill TOBRADEX ST T2 PA tobramycin 0.3 % drops T1 QL 2.143 / day tobramycin/dexamethasone T1 QL 5 / fill QL 2.143 / day TOBREX 0.3% EYE DROP T2 PA QL 0.54 / day TOBREX 0.3% EYE OINTMENT T2 PA tropicamide (0.5 % drops, 1 % drops) T1 ULTRA FRESH T1 GNP ULTRA LUBRICANT EYE DROPS T0

PAGE 440 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ULTRA LUBRICANT EYE DROPS T1 QL 0.434 / day VIGAMOX T2 PA VISCOAT T2 PA TOTALITY T2 PA VISINE-A T1 S VISUDYNE T2 PS PA QL 5 / fill ZYLET T2 PA QL 0.36 / day ZYMAXID T2 PA OPHTHALMIC ANTI-ALLERGY AGENTS

ALAWAY T1 QL 0.167 / day ALLERGY EYE DROPS T1 QL 0.167 / DAY QL 5 / fill ALOCRIL T2 PA QL 10 / fill ALOMIDE T2 PA QL 0.267 / day azelastine hcl 0.05 % drops T2 PA QL 0.334 / day BEPREVE T2 PA CHILDREN'S ALAWAY T1 QL 0.167 / DAY

PAGE 441 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cromolyn sodium 4 % drops T1 QL 10 / fill QL 0.286 / day ELESTAT T2 PA QL 5 / fill EMADINE T2 PA QL 0.286 / day hcl T2 PA EYE ITCH RELIEF T1 QL 0.167 / DAY ITCHY EYE T1 QL 0.167 / DAY ketotifen fumarate 0.025 % drops T1 QL 0.167 / DAY QL 3 / 30 days LASTACAFT T2 PA hcl (0.1 % drops, 0.2 % drops) T1 QL 0.286 / day QL 0.286 / day PATADAY 0.2% EYE DROPS T2 PA QL 0.286 / day PATANOL T2 PA PAZEO T1 QL 0.286 / day WAL-ZYR 0.025% EYE DROPS T1 QL 0.167 / DAY ZADITOR T1 QL 0.167 / DAY OPHTHALMIC ANTI-INFLAMMATORIES

QL 15 / 30 days ACULAR T2 PA QL 5 / fill ACULAR LS T2 PA

PAGE 442 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day ACUVAIL T2 PA QL 0.5 / day ALREX T2 PA QL 8 / rx bromfenac sodium 0.09 % drops T2 PA QL 0.1 / DAY BROMSITE T2 PA diclofenac sodium 0.1 % drops T1 QL 5 / fill DUREZOL T1 QL 0.334 / DAY QL 10 / fill FLAREX T2 PA T1 QL 10 / fill flurbiprofen sodium T1 QL 3 / fill QL 10 / fill FML T2 PA QL 10 / fill FML FORTE T2 PA QL 4 / fill FML S.O.P. T2 PA QL 4 / fill ILEVRO T2 PA ILUVIEN T2 PA ketorolac tromethamine 0.4 % drops T1 QL 5 / fill ketorolac tromethamine 0.5 % drops T1 QL 0.5 / DAY

PAGE 443 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 10 / fill LOTEMAX 0.5% OPHTHALMIC GEL T2 PA QL 21 / fill LOTEMAX 0.5% EYE DROPS T2 PA QL 4 / fill LOTEMAX 0.5% EYE OINTMENT T2 PA QL 21 / fill etabonate T2 PA QL 10 / fill MAXIDEX T2 PA QL 3 / fill NEVANAC T2 PA QL 21 / fill OMNIPRED T2 PA QL 0.04 / day S OZURDEX T2 PS PA QL 21 / fill PRED FORTE T2 PA QL 21 / fill PRED MILD T2 PA prednisolone acetate T1 QL 21 / fill QL 0.667 / DAY prednisolone sodium phosphate 1 % drops T2 PA QL 3 / fill PROLENSA T2 PA

PAGE 444 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S RETISERT T2 PS PA QL 1 / day TRIESENCE T2 PA XIIDRA T1 QL 2 / day OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P T1 QL 0.4 / day QL 0.8 / DAY hcl T2 PA AZOPT T1 QL 0.334 / day betaxolol hcl 0.5 % drops T1 QL 0.54 / day QL 0.286 / day BETIMOL 0.25% EYE DROPS T2 PA QL 0.334 / day BETIMOL 0.5% EYE DROPS T2 PA QL 0.54 / day BETOPTIC S T2 PA QL 0.4 / day brimonidine tartrate 0.15 % drops T2 PA brimonidine tartrate 0.2 % drops T1 QL 0.4 / day hcl T1 QL 0.334 / day COMBIGAN T1 QL 0.334 / day QL 0.334 / day COSOPT T2 PA

PAGE 445 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day COSOPT PF T2 PA hcl T1 QL 0.4 / day dorzolamide hcl/timolol maleate T1 QL 0.334 / day dorzolamide/timolol/pf 2 %-0.5 % droperette T1 QL 2 / day QL 0.8 / day IOPIDINE 1% EYE DROPS T2 PA QL 0.8 / DAY IOPIDINE 0.5% EYE DROPS T2 PA QL 0.54 / day ISOPTO CARPINE T2 PA QL 0.286 / day ISTALOL T2 PA hcl T1 QL 0.4 / day methazolamide (25 mg tablet, 50 mg tablet) T2 PA T1 QL 0.334 / day MIOSTAT T2 PA PHOSPHOLINE IODIDE T2 PA pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) T1 QL 0.54 / day QL 0.4 / day SIMBRINZA T2 PA QL 0.334 / day timolol maleate 0.5 % drop daily T2 PA timolol maleate 0.5 % drops T1 QL 0.334 / day timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol- T1 QL 0.286 / day gel)

PAGE 446 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.286 / day TIMOPTIC 0.25% EYE DROP T2 PA QL 0.334 / day TIMOPTIC 0.5% EYE DROP T2 PA QL 2 / day TIMOPTIC OCUDOSE T2 PA QL 0.286 / day TIMOPTIC-XE T2 PA QL 0.4 / day TRUSOPT T2 PA OPHTHALMIC AND PROSTAMIDE ANALOGS

QL 0.13 / day 0.03 % drops T2 PA latanoprost 0.005 % drops T1 QL 0.13 / day QL 0.13 / day LUMIGAN T2 PA TRAVATAN Z T1 QL 0.167 / DAY T1 QL 0.167 / DAY QL 0.13 / day XALATAN T2 PA QL 1 / day ZIOPTAN T2 PA OTIC AGENTS acetic acid 2 % solution T1 CARBAMOXIDE T1

PAGE 447 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.434 / day CIPRO HC T2 PA CIPRODEX T1 QL 0.257 / day ciprofloxacin hcl/fluocinolone acetonide T2 PA QL 10 / fill COLY-MYCIN S T2 PA DERMOTIC T2 PA EAR DROPS (CVS DROPS, DROPS, GNP DROPS, RA DROPS, T1 SM DROPS) EAR SYSTEM T1 EAR WAX REMOVAL T1 FLAC OTIC OIL T2 PA fluocinolone acetonide oil T2 PA hydrocortisone/acetic acid T1 MURINE EAR DROPS T1 MURINE EAR WAX REMOVAL SYSTEM T1 neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin b/hydrocort 3.5-10k-1 drops susp, T1 QL 10 / fill neomycin/polymyxin b/hydrocort 3.5-10k-1 solution) OTOVEL T2 PA RESPIRATORY TRACT/PULMONARY AGENTS ANTI-INFLAMMATORIES, INHALED

ALLER-FLO T1 QL 0.54 / day ALLERGY RELIEF (50 MCG SPRAY, EQ 50 MCG SPRAY, HM T1 QL 0.54 / day 50 MCG SPRAY, QC 50 MCG SPRAY, SM 50 MCG SPRAY)

PAGE 448 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALVESCO T2 PA ARNUITY ELLIPTA (100 MCG, 200 MCG) T2 PA ASMANEX T1 ASMANEX HFA (HFA 100 MCG INHALER, HFA 200 MCG T2 PA INHALER) QL 1.667 / day BECONASE AQ T2 PA budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul- T1 neb, 1 mg/2 ml ampul-neb) QL 0.4 / day budesonide 32mcg spray/pump T2 PA CHILDREN 24 HR ALLERGY RELIEF T1 CLARISPRAY T1 QL 0.54 / day FLOVENT DISKUS T1 FLOVENT HFA T1 QL 0.834 / day flunisolide 25 mcg spray T2 PA fluticasone propionate 50 mcg spray susp T1 QL 0.54 / day QL 0.567 / day mometasone furoate 50 mcg spray/pump T2 PA NASAL ALLERGY (CVS NASAL 24HR SPRAY, KRO NASAL T0 QL 0.6 / day 24HR SPRAY, NASAL 24HR SPRAY) QL 0.567 / day NASONEX T2 PA QL 0.434 / day OMNARIS T2 PA

PAGE 449 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PULMICORT T2 PA PULMICORT FLEXHALER T1 QL 0.3 / day QNASL T2 PA QL 0.2 / day QNASL CHILDREN T2 PA QVAR REDIHALER T2 PA TICANASE T2 PA triamcinolone acetonide 55 mcg spray T1 QL 0.55 / day QL 0.22 / day ZETONNA T2 PA

24HOUR ALLERGY T1 QL 1 / day 24HR ALLERGY RELIEF T1 QL 1 / day ALAVERT 10 MG ODT T1 QL 1 / day ALER-CAPS T0 SM ALL DAY ALLERGY 1 MG/ML SYR T1 QL 10 / day ALL DAY ALLERGY (10 MG TABLET, EQL 10 MG TAB, GNP 10 MG TAB, GS 10 MG TAB, HM 10 MG TAB, KRO 10 MG T1 QL 1 / day TAB, QC 10 MG TAB, SM 10 MG TAB) ALL DAY ALLERGY RELIEF T1 QL 1 / day ALLER-CHLOR T1

ALLER-EASE (180 MG TABLET, EQL 180 MG TABLET, GS QL 1 / day T2 180 MG TABLET) PA QL 2 / day ALLER-EASE 60 MG TABLET T2 PA

PAGE 450 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALLER-FEX T1 QL 1 / day ALLER-G-TIME T1 ALLER-TEC T1 QL 1 / day ALLERCLEAR T0 QL 1 / day ALLERGY (4 MG TABLET, EQL 4 MG TABLET, KRO 4 MG TABLET, SM 4 MG TABLET, 25 MG CAPSULE, 25 MG T1 SOFTGEL, 25 MG TABLET, CVS 25 MG CAPSULE, EQL 25 MG TABLET, HM 25 MG CAPSULE, HM 25 MG TABLET) ALLERGY (CVS 25 MG SOFTGEL, CVS 25 MG TABLET, GNP 4 MG TABLET, GNP 25 MG CAPSULE, GNP 25 MG SOFTGEL, GNP 25 MG TABLET, KRO 25 MG CAPSULE, KRO T0 25 MG TABLET, PUB 12.5 MG/5 ML LIQ, PUB 25 MG CAPSULE, PUB 25 MG TABLET, RA 25 MG TABLET) ALLERGY (LORATADINE) 10 MG TAB T1 QL 1 / day ALLERGY 4-HOUR T1 ALLERGY MEDICATION (25 MG CAPSULE, CAPSULE) T0 RA ALLERGY MED 25 MG TABLET T1 ALLERGY MEDICINE 25 MG TABLET T0 ALLERGY RELIEF (25 MG SOFTGEL, EQ 25 MG TABLET) T0 ALLERGY RELIEF (CVS 50 MG/20 ML LIQ, CVS RELIEF 4 MG T0 TABLET, CVS RELIEF ER 12 MG TB, EQ RELIEF 25 MG CAP) ALLERGY RELIEF (CVS RELIEF 5 MG/5 ML, GNP RELF 5 T1 QL 5 / day MG/5 ML SLN, RELIEF 5 MG/5 ML SOLN) EQ ALLERGY RELIEF 1 MG/ML SOLN T1 QL 10 / day

PAGE 451 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALLERGY RELIEF (12.5 MG/5 ML, 25 MG CAPSULE, 25 MG TABLET, CVS 25 MG CAP, CVS 25 MG TAB, EQL 25 MG CAP, GNP 25 MG CAP, GS 4 MG TABLET, GS 25 MG CAP, T1 GS 25 MG TABLET, HM 25 MG CAP, HM 25 MG TABLET, RA 4 MG TABLET, RA 25 MG CAP, SM 4 MG TABLET, SM 12.5 MG/5 ML, SM 25 MG CAP, SM 25 MG TABLET) ALLERGY RELIEF (4 MG TABLET, HM 4 MG TABLET) T1 ALLERGY RELIEF (ALLERGY RELIEF 10 MG ODT, ALLERGY RELIEF 180 MG TABLET, ALLERGY RLF(CETRZN) 10 MG SFGL, CVS ALLERGY RELIEF 180 MG TAB, CVS ALLERGY(CETRZN) 10 MG SFGL, EQ ALLERGY RELIEF 180 QL 1 / day T2 MG TAB, GNP ALLERGY RELIEF 180 MG TAB, HM ALLERGY PA RELIEF 180 MG TAB, KRO ALLERGY RELIEF 180 MG TAB, PUB ALLERGY RELIEF 180 MG TAB, RA ALLERGY RELIEF 180 MG TAB, SM ALLERGY RELIEF 10 MG ODT) ALLERGY RELIEF (CVS (CETRZN) 10 MG TAB, CVS (LORAT) 10 MG TAB, EQ (LORAT) 10 MG TAB, EQ RELIEF 10 MG TABLET, GS RELIEF 10 MG TABLET, HM RELIEF 10 MG T1 QL 1 / day TABLET, PUB RELIEF 10 MG TAB, RA RELIEF 10 MG TABLET, RELIEF 10 MG TABLET, RLF (CETRZN) 10 MG TAB, SW RELIEF 10 MG TAB) ALLERGY RELIEF (CVS 60 MG TAB, KRO 60 MG TAB) T1 QL 2 / day ALLERGY RELIEF (EQL 10 MG TAB, KRO 10 MG TAB) T1 QL 1 / day QL 1 / day CVS ALLERGY RELIEF 5 MG TABLET T2 PA

SM ALLERGY RELIEF 1.34 MG TAB T1 AL At least 2 yrs old ALLERGY-TIME T1 azelastine hcl 137 mcg spray/pump T1 QL 2 / day QL 2 / day azelastine hcl 205.5 mcg spray/pump T2 PA

PAGE 452 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BANOPHEN (12.5 MG/5 ML SOLUTION, ALLERGY 12.5 MG/5 ML, 25 MG CAPSULE, 25 MG TABLET, 50 MG T1 CAPSULE) 25 MG LIQUI- T0 BENADRYL ALLERGY T1 maleate (4 mg tablet, 4 mg/5 ml liquid) T1 AL At least 2 yrs old hcl 1 mg/ml solution T1 QL 10 / day cetirizine hcl (5 mg tab chew, 5 mg/5 ml solution) T2 PA QL 1 / day cetirizine hcl 10 mg tab chew T2 PA cetirizine hcl 10 mg tablet T1 QL 1 / day cetirizine hcl 5 mg tablet T1 CHILDREN'S ALL DAY ALLERGY T1 QL 10 / day CHILD'S ALLERGY 12.5 MG/5 ML T1 CHILDREN'S ALLERGY (GNP 12.5 MG/5 ML, GS 12.5 MG/5 T1 ML, HM 12.5 MG/5 ML, QC 12.5 MG/5 ML) CHILDREN'S ALLERGY (5 MG/5 ML SOLN, EQ 5 MG/5 ML T1 QL 5 / day SOL, RA 5 MG/5 ML SOL, SM 5 MG/5 ML SOL) CHILDREN'S ALLERGY (PUB 1 MG/ML, QC 1 MG/ML) T1 QL 10 / day CHILDREN'S ALLERGY (12.5 MG/5 ML ELIXIR, CHILDREN'S T0 ODT, EQL CHILD 12.5 MG/5 ML) CHILDREN'S ALLERGY RELIEF (CVS 12.5 MG ODT, EQ 12.5 MG ODT, EQ 12.5 MG/5 ML, KRO 12.5 MG/5 ML, RA 12.5 T0 MG ODT, RA 12.5 MG/5 ML, REL 12.5 MG/5 ML) CHILDREN'S ALLERGY RELIEF (CVS 12.5 MG/5 ML, RLF 12.5 T1 MG/5 ML) CVS CHILD ALLERGY RLF 30 MG/5 T1 QL 10 / day

PAGE 453 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CHILDREN'S ALLERGY RELIEF (5 MG/5 ML, EQ SOLN, KRO T1 QL 5 / day SOLN) CHILDREN'S ALLERGY RELIEF (CVS RELF 1 MG/ML, EQ RELF T1 QL 10 / day 1 MG/ML, RA RELF 1 MG/ML, RELIEF 1 MG/ML) CHILDREN'S ALLERGY RELIEF (CVS 5 MG CHW, HM 5 MG T1 QL 2 / day CHEW, RA 5 MG CHEW) CHILD BENADRYL 12.5 MG TB CHEW T0 CHILD CLARITIN 5 MG/5 ML SOLN T1 QL 5 / day CHILDREN'S WAL-DRYL ALLERGY (12.5 MG/5 ML, ALLERGY T0 ODT) CHILDREN'S WAL-FEX T1 QL 10 / day CHILD WAL-ZYR 1 MG/ML SOLUTION T1 QL 10 / day CHILD'S WAL-ZYR 10 MG CHEW TAB T1 QL 1 / day CHLOR-TRIMETON T1 CHLORHIST T1 CHLORPHEN SR T1 chlorpheniramine maleate 4 mg tablet T1 chlorpheniramine maleate 12 mg tablet er T1 CHLORTABS T0 QL 10 / day CLARINEX 0.5 MG/ML (2.5 MG/5) T2 PA QL 1 / day CLARINEX 5 MG TABLET T2 PA clemastine fumarate 2.68 mg tablet T1 AL At least 2 yrs old COMPLETE ALLERGY (COMPLETE 25 MG CAPLET, COMPLT MED 25 MG CP, QC COMPLETE 25 MG CAP, QC T1 COMPLETE 25 MG CPLT)

PAGE 454 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RA COMPLETE ALLERGY 25 MG CPLT T0 cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 T1 AL At least 2 yrs mg/10 ml syrup) old

DAYHIST ALLERGY 1.34 MG TABLET T1 AL At least 2 yrs old (2.5 mg tab rapdis, 5 mg tab rapdis, 5 mg QL 1 / day T2 tablet) PA DIPHEDRYL (12.5 MG/5 ML ELIXIR, ALLERGY CAPSULE) T1 DIPHEDRYL (GNP 12.5 MG/5 ML ELX, GNP ALLERGY CAP, T0 RA 12.5 MG/5 ML ELIX) DIPHEDRYL ALLERGY T0 DIPHEN (12.5 MG/5 ML ELIXIR, 12.5 MG/5 ML SOLUTION) T2 PA DIPHEN 25 MG CAPLET T1 DIPHENHIST (12.5 MG/5 ML SOLN, 25 MG CAPSULE, 25 T1 MG CAPTAB) diphenhydramine hcl (12.5mg/5ml elixir, 12.5mg/5ml liquid, 12.5mg/5ml syrup, 25 mg capsule, 25 mg tablet, 50 T1 mg capsule, 50 mg/ml cartridge, 50 mg/ml syringe, 50 mg/ml vial) diphenhydramine hcl in 0.9 % sodium chloride T1 ED CHLORPED JR T0 QL 10 / day fexofenadine hcl 30 mg/5 ml oral susp T2 PA fexofenadine hcl 180 mg tablet T1 QL 1 / day QL 2 / day fexofenadine hcl 60 mg tablet T2 PA GERI-DRYL 25 MG TABLET T1

PAGE 455 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg T1 AL At least 2 yrs tablet, 50 mg tablet, 50 mg/25ml solution) old hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) T1 hydroxyzine pamoate (25 mg capsule, 50 mg capsule) T1 AL At least 2 yrs old hydroxyzine pamoate 100 mg capsule T1 KARBINAL ER T2 PA QL 30 / day levocetirizine dihydrochloride 2.5 mg/5ml solution T2 PA levocetirizine dihydrochloride 5 mg tablet T1 QL 1 / day LORADAMED T1 QL 1 / day loratadine 5 mg/5 ml solution T1 QL 5 / day QL 2 / day loratadine 5 mg tab chew T2 PA loratadine (10 mg tab rapdis, 10 mg tablet) T1 QL 1 / day MUCUS RELIEF COLD-SINUS MAX T1 NARAMIN T0 NIGHTTIME ALLERGY RELIEF T0 NON-DROWSY ALLERGY T1 QL 1 / day QL 31 / 30 days olopatadine hcl 0.6 % spray/pump T2 PA QL 31 / 30 days PATANASE T2 PA PHARBECHLOR T1 PHARBEDRYL T1

PAGE 456 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PHENADOZ T1 AL At least 2 yrs old PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50 T2 PA MG/ML AMPUL, 50 MG/ML VIAL) PRESSURE-PAIN PE PLUS MUCUS T1 promethazine hcl (25 mg/ml ampul, 25 mg/ml vial, 50 T1 mg/ml ampul, 50 mg/ml vial) promethazine hcl 50 mg supp.rect T1 AL At least 2 yrs old promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 25 mg tablet, 50 mg T1 AL At least 2 yrs old tablet)

PROMETHEGAN (12.5 MG SUPPOS, 25 MG SUPPOSITORY) T1 AL At least 2 yrs old

PROMETHEGAN 50 MG SUPPOSITORY T1 AL At least 2 yrs old SILADRYL T1 SINUS CONGESTION-PAIN SEVERE T1 CVS SINUS RLF PRESS-PAIN CPLT T1 SINUS SEVERE T1 TOTAL ALLERGY T0

AL At least 2 yrs VISTARIL T2 old PA WAL-DRYL ALLERGY 25 MG CAPSULE T1 WAL-DRYL ALLERGY 25 MG SOFTGEL T0 WAL-DRYL ALLERGY 12.5 MG/5 ML T1 WAL-DRYL ALLERGY 25 MG MINITAB T0 WAL-FEX ALLERGY 180 MG TABLET T1 QL 1 / day

PAGE 457 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS WAL-FEX ALLERGY 60 MG TABLET T1 QL 2 / day WAL-FINATE T1 WAL-ITIN (5 MG/5 ML SYRUP, CHILD 5 MG/5 ML SOLN, T1 QL 5 / day CHILD 5 MG/5 ML SYRUP) WAL-ITIN 10 MG TABLET T0 QL 1 / day WAL-ZYR SOLUTION T1 QL 10 / day WAL-ZYR 10 MG TABLET T1 QL 1 / day QL 30 / day XYZAL 2.5 MG/5 ML SOLUTION T2 PA ANTILEUKOTRIENES

QL 2 / day ACCOLATE T2 PA QL 1 / day montelukast sodium 4 mg gran pack T2 PA QL 1 / day montelukast sodium 4 mg tab chew T1 AL 2 to 5 yrs old QL 1 / day montelukast sodium 5 mg tab chew T1 AL Up to 14 yrs old montelukast sodium 10 mg tablet T1 QL 1 / day

SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG QL 1 / day T2 TABLET CHEW, 10 MG TABLET) PA QL 2 / day T2 PA QL 4 / day zileuton T2 PA

PAGE 458 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day ZYFLO T2 PA QL 4 / day ZYFLO CR T2 PA BRONCHODILATORS,

ATROVENT HFA T1 INCRUSE ELLIPTA T2 PA ipratropium bromide 0.2 mg/ml solution T1 ipratropium bromide (21 mcg spray, 42 mcg spray) T1 QL 2 / day SEEBRI NEOHALER T2 PA SPIRIVA T1 SPIRIVA RESPIMAT T2 PA TUDORZA PRESSAIR T2 PA BRONCHODILATORS, SYMPATHOMIMETIC

ADRENALIN 1 MG/ML VIAL T2 PA ADRENALIN 30 MG/30 ML VIAL T1 ADRENALIN CHLORIDE T2 PA ADYPHREN T2 PA ADYPHREN AMP T2 PA albuterol sulfate 90 mcg hfa aer ad T1 QL 0.8 / DAY albuterol sulfate 2 mg/5 ml syrup T1 albuterol sulfate (2 mg tablet, 4 mg tab er 12h, 4 mg T2 PA tablet, 8 mg tab er 12h)

PAGE 459 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial- neb, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 5 mg/ml T1 QL 18 / day solution) ARCAPTA NEOHALER T1 QL 1 / day ASTHMANEFRIN REFILL T1 QL 2 / fill AUVI-Q (0.15 MG, 0.3 MG) T2 PA BRONCHIAL MIST (MIST INH REFILL, MIST INHALER) T1 QL 4 / day BROVANA T2 AL At least 17 yrs old PA epinephrine 1 mg/ml(1) ampul T2 PA epinephrine (0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) T1 QL 4 / fill epinephrine 0.1 mg/ml syringe T1 epinephrine hcl in 0.9 % sodium chloride (in 0.9 % 0.16 mg/10 syringe, in 0.9 % 1 mg/10 ml syringe, in 0.9 % 1 mg/250ml plast. bag, in 0.9 % 100 mcg/10 syringe, in 0.9 T2 PA % 2mg/250ml plast. bag, in 0.9 % 4mg/250ml plast. bag, in 0.9 % 50mcg/5ml syringe, in 0.9 % 8 mg/250ml plast. bag, in 0.9 % 800 mcg/50 syringe) epinephrine hcl in dextrose 5 % in water (in 1 mg/250ml plast. bag, in 2mg/250ml plast. bag, in 4mg/250ml plast. T2 PA bag, in 8 mg/250ml plast. bag, in 16mg/250ml plast. bag) epinephrine hcl/pf T1 QL 2 / fill EPINEPHRINESNAP-EMS T2 PA QL 2 / fill EPINEPHRINESNAP-V T2 PA

PAGE 460 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EPIPEN T1 QL 4 / fill QL 4 / fill EPIPEN 2-PAK T2 PA EPIPEN JR T1 QL 4 / fill QL 4 / fill EPIPEN JR 2-PAK T2 PA EPISNAP T2 PA isoproterenol hcl (0.2 mg/ml ampul, 0.2 mg/ml vial) T2 PA ISUPREL T2 PA levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial- T2 PA neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb) QL 1.5 / day levalbuterol tartrate T2 PA metaproterenol sulfate 10 mg/5 ml syrup T1 metaproterenol sulfate (10 mg tablet, 20 mg tablet) T2 PA QL 4 / DAY PERFOROMIST T2 AL At least 17 yrs old PA QL 0.8 / DAY PROAIR DIGIHALER T2 PA PROAIR HFA T1 QL 0.8 / DAY QL 0.07 / day PROAIR RESPICLICK T2 AL At least 12 yrs old PA QL 0.6 / day PROVENTIL HFA T2 PA

PAGE 461 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day SEREVENT DISKUS T1 AL At least 4 yrs old STRIVERDI RESPIMAT T1 QL 0.144 / day terbutaline sulfate (1 mg/ml vial, 2.5 mg tablet, 5 mg T2 PA tablet) VENTOLIN HFA T1 QL 1.5 / day XOPENEX T2 PA XOPENEX CONCENTRATE T2 PA QL 1.5 / day XOPENEX HFA T2 PA CYSTIC FIBROSIS AGENTS

QL 8 / day AL At least 6 yrs BETHKIS T1 old S PS QL 84 / 28 Days CAYSTON T2 AL At least 7 yrs old PA

KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES QL 2 / day T2 PACKET, 150 MG TABLET) PA QL 10 / day AL At least 6 yrs KITABIS PAK T1 old S PS

PAGE 462 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day ORKAMBI (100 MG TABLET, 200 MG TABLET) T2 PA QL 280 / 28 Days AL At least 6 yrs old TOBI T2 S PS PA QL 224 / 28 Days AL At least 6 yrs old TOBI PODHALER T1 S PS PA QL 280 / 28 Days AL At least 6 yrs old tobramycin in 0.225 % sodium chloride T2 S PS PA QL 56 / 28 Days AL At least 6 yrs old tobramycin/nebulizer T2 S PS PA PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE aminophylline (250mg/10ml vial, 500mg/20ml ampul, T2 PA 500mg/20ml vial) CAFCIT T2 PA

PAGE 463 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS caffeine citrate 60 mg/3 ml solution T2 PA DALIRESP T2 PA ELIXOPHYLLIN T2 PA THEO-24 T2 PA theophylline anhydrous 80 mg/15ml solution T2 PA theophylline anhydrous (80 mg/15ml elixir, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er T2 PA 24h, 450 mg tab er 12h, 600 mg tab er 24h) theophylline in dextrose 5 % in water T2 PA PULMONARY ANTIHYPERTENSIVES

QL 2 / day AL At least 18 yrs old ADCIRCA T2 S PS PA QL 3 / day ADEMPAS T2 PA QL 2 / day S ALYQ T1 PS PA QL 1 / day T1 AL At least 18 yrs old PA QL 2 / day T1 PA

PAGE 464 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS epoprostenol sodium (glycine) T2 PA FLOLAN T2 PA QL 1 / day LETAIRIS T2 PA QL 1 / day OPSUMIT T2 PA

ORENITRAM ER (ER 0.125 MG TABLET, ER 0.25 MG QL 3 / day T2 TABLET, ER 1 MG TABLET, ER 2.5 MG TABLET) PA REMODULIN T2 PA QL 6 / day AL At least 18 yrs old REVATIO 10 MG/ML ORAL SUSP T1 S PS PA QL 3 / day AL At least 18 yrs old REVATIO 20 MG TABLET T2 S PS PA S REVATIO 10 MG/12.5 ML VIAL T2 PS PA QL 6 / day AL At least 18 yrs old sildenafil citrate 10 mg/ml susp recon T1 S PS PA

PAGE 465 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day AL At least 18 yrs old sildenafil citrate 20 mg tablet T1 S PS PA

AL At least 18 yrs old sildenafil citrate 10 mg/12.5 vial T2 S PS PA QL 0.2 / day AL At least 18 yrs old tadalafil 20 mg tablet T1 S PS PA QL 2 / day TRACLEER (62.5 MG TABLET, 125 MG TABLET) T1 PA S treprostinil sodium T2 PS PA QL 1 / day TYVASO T2 PA QL 1 / day TYVASO INSTITUTIONAL START KIT T2 PA QL 3 / day TYVASO REFILL KIT T2 PA QL 3 / day TYVASO STARTER KIT T2 PA

PAGE 466 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 18 yrs UPTRAVI 200-800 TITRATION PACK T2 old PA QL 2 / day UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 T2 AL At least 18 yrs old MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) PA VELETRI T2 PA QL 9 / day VENTAVIS T1 PA RESPIRATORY TRACT AGENTS, OTHER

12-HOUR COUGH RELIEF T1 ABATUSS DMX T1 ACETAMINOPHEN CONGESTION-PAIN T2 PA acetylcysteine (100 mg/ml vial, 200 mg/ml vial) T1 ACTICON (1 MG-30 MG/5 ML SOLN, 2-60 MG TABLET) T0 ADLT WAL-TUSSIN COUGH-COLD CF T1 ADULT COUGH FORMULA DM MAX T1 ADULT DM MAXIMUM T1 ADULT TUSSIN CHEST CONGESTION T1 ADULT TUSSIN COUGH CONGEST DM T1 ADULT TUSSIN DM T1 ADULT TUSSIN MULTI-SYMP COLD T1 ADULT WAL-TUSSIN T1 ADULT WAL-TUSSIN DM T1 ADULT WAL-TUSSIN DM MAX T1

PAGE 467 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADVAIR 100-50 DISKUS T1 AL At least 4 yrs old

ADVAIR DISKUS (250-50, 500-50) T1 AL At least 12 yrs old

ADVAIR HFA T1 AL At least 12 yrs old ALA-HIST PE T0 ALAVERT D-12 ALLERGY-SINUS TAB T1 QL 2 / day ALKA-SELTZER PLUS DAY T1 ALKA-SELTZER PLUS SINUS-COUGH T1 QL 2 / day ALL DAY ALLERGY-D T2 PA ALLER-TEC D T1 QL 2 / day ALLERCLEAR D-12HR T1 QL 2 / day ALLERCLEAR D-24HR T1 QL 1 / day QL 2 / day ALLERGY COMPLETE-D T1 PA ALLERGY D-12 T1 QL 2 / day ALLERGY RELIEF D T1 QL 2 / day QL 2 / day ALLERGY RELIEF D-12 T2 PA QL 1 / day ALLERGY RELIEF D-24HR T2 PA ALLERGY RELIEF-D (CVS RLF-D 60-120 MG TB, KRO RLF-D T1 QL 2 / day 60-120 MG TB, RELIEF-D 12 HOUR TAB)

ALLERGY RELIEF-D (CVS TABLET, PUB TABLET, SW TABLET, QL 2 / day T2 TABLET) PA

PAGE 468 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day ALLERGY RELIEF-D12 T2 PA QL 1 / day ALLERGY RELIEF-NASAL DECONGEST T2 PA ALLERGY+CONGESTION RELIEF-D T1 QL 2 / day ALLERGY-CONGEST 12HR 60-120 MG T1 QL 2 / day QL 2 / day HM ALLERGY-CONGESTION 12HR TAB T2 PA ALLERGY-CONGESTION ER T1 QL 2 / day QL 1 / day ALLERGY-CONGESTION RELIEF T2 PA QL 2 / day ALLERGY-CONGESTION RELIEF 12HR T2 PA ALLERGY-CONGESTION RELIEF-D T1 QL 1 / day ALTIPRES T1

ANORO ELLIPTA T1 AL At least 18 yrs old ANTITUSSIVE DM T1 AP-HIST DM T1 APRODINE T1 S ARALAST NP T2 PS PA QL 0.8 / DAY azelastine hcl/fluticasone propionate T2 PA QL 6 / day benzonatate 100 mg capsule T1 AL At least 6 yrs old

PAGE 469 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 6 yrs benzonatate 150 mg capsule T2 old PA QL 2 / day benzonatate 200 mg capsule T1 AL At least 6 yrs old

BEVESPI AEROSPHERE T1 AL At least 18 yrs old BIO T PRES T1 BIO-B KIDS T1 BIOCOTRON T1

AL At least 18 yrs BREO ELLIPTA T2 old PA

AL At least 2 yrs BROMFED DM T2 old PA brompheniramine maleate/pseudoephedrine T1 AL At least 2 yrs hcl/dextromethorphan old BROTAPP DM T1

AL At least 12 yrs budesonide/formoterol fumarate 160-4.5mcg hfa aer ad T2 old PA

AL At least 6 yrs budesonide/formoterol fumarate 80-4.5 mcg hfa aer ad T2 old PA CAPCOF T2 PA CETIRI-D T1 QL 2 / day QL 2 / day cetirizine hcl/pseudoephedrine hcl T2 PA

PAGE 470 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 60 / day CHERATUSSIN AC T1 AL At least 6 yrs old CHEST CONGESTION RELIEF (CVS RLF TAB, RELIEF TABLET) T1 CHEST CONGESTION RELIEF DM (CONGESTION RELIEF TAB, CVS CONGEST RELIEF TB, HM CONGEST RLF CAPLET, T1 SM CONGEST RLF CAPLET) CHEST CONGESTION-COUGH RELIEF T1 CHILD CHEST CONGESTION-COUGH T1 CHILD COUGH-COLD-SORE THROAT T1 CHILD COUGH-SORE THROAT T1 CHILD MUCINEX CHEST MINI-MELTS T1 CHILD MUCINEX COUGH MINI-MELTS T1 CHILD MUCUS RELIEF COUGH T1 CHILD MUCUS-COUGH RELIEF T1 CHILD MULTI-SYMPTOM COLD-FEVER T1 CHILD TRIAMINIC COLD-ALLERGY T1 CHILD WAL-TAP COLD-ALLERGY T1 CHILD'S DIBROMM COLD-ALLERGY T1 CHILDREN'S CHEST CONGESTION T1 CHILDREN'S COLD-ALLERGY T1 CHILDREN'S COLD-COUGH T1 CHILDREN'S COUGH T1 CHILDREN'S COUGH DM ER T1 CHILDREN'S DIBROMM DM T1 CHILDREN'S MUCINEX COUGH T1

PAGE 471 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CHILDREN'S MUCUS RELIEF T1 CHILDREN'S STUFFY NOSE-COLD T1 CHILDRN COLD-COUGH-SORE THROAT T1 S CINQAIR T2 PS PA QL 2 / day CLARINEX-D 12 HOUR T2 PA QL 60 / day codeine phosphate/guaifenesin 10-100mg/5 liquid T1 AL At least 12 yrs old QL 60 / day codeine phosphate/guaifenesin 20-200/10 liquid T1 AL At least 6 yrs old COLD & SINUS PAIN RELIEF T1 COLD HEAD CONGESTION (CONGESTION CAPLET, GNP CONGESTION CAPLT, GNP CONGESTION CPLT, GS T1 CONGEST DAY-NIGHT, SM CONGESTION CAPLET) COLD MULTI-SYMPTOM (CAPLET, DAY-NIGHT, EQ T1 GELCAP, EQL GELCAP, GELCAP, GNP CAPLET, GS CAPLET) COLD MULTI-SYMPTOM SEVERE T1 COLD RELIEF HEAD CONGESTION (GNP RELIEF CONG, GNP T1 RLF CONGEST, RELIEF CONGEST, RLF CONGESTION) COLD RELIEF MULTI-SYMPTOM (GNP MULTI-SYM, MULTI- T1 SYMPTOM) COLD-ALLERGY (CVS ELIXIR, ELIXIR, GNP ELIXIR) T1 COLD-ALLERGY (GNP TABLET, TABLET) T0 COLD-ALLERGY PE T0

PAGE 472 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COLD-COUGH T1 COLD-COUGH DM T1 COLD-FLU RELIEF T1 COLD-SINUS RELIEF T1 COMBIVENT RESPIMAT T1 CONEX SOLUTION T0 PA CONEX TABLET T0 CORICIDIN HBP COLD AND FLU T1 COUGH & COLD MUCUS RELIEF CF T1 COUGH DM T1 COUGH DM ER T1 COUGH RELIEF T1 COUGH SYRUP T1 COUGH-CHEST CONGEST DM T1 COUGH-CHEST CONGESTION DM T1 COUGH-COLD (SYRUP, TABLET) T1 COUGH-COLD HBP T1 COUGH-COLD RELIEF HBP T1 cromolyn sodium 20 mg/2 ml ampul-neb T2 PA CUROSURF T2 PA DAY TIME T1 DAY TIME COLD-FLU (GNP SOFTGEL, GS LIQUID, SOFTGEL) T1 DAY TIME COLD-FLU RELIEF T1 DAY TIME PE T1

PAGE 473 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DAYTIME COLD AND FLU RELIEF T1 DAYTIME COLD MULTI-SYMPTOM T1 DAYTIME COLD-FLU (DAY TIME LIQUID, DAYTIME LIQUID, DAYTIME SOFTGEL, EQ DAYTIME LIQUID, EQ DAYTIME SOFTGEL, GNP DAY TIME LIQUID, GS DAYTIME SOFTGEL, T1 HM DAYTIME LIQUID, KRO DAYTIME SOFTGEL, SM DAY TIME LIQUID) DAYTIME COLD-FLU RELIEF (CVS DAYTIME RLF LIQ, CVS DAYTIME RLF SFTGL, DAY TIME RELIEF LIQ, DAYTIME RELIEF LIQUID, DAYTIME RELIEF SFTGL, EQL DAY RELIEF T1 SOFTGL, EQL DAYTIME RLF LIQ, PUB DAYTIME RELIEF, RA DAY RELIEF SOFTGEL, RA DAYTIME RELIEF LIQ, SM DAY TIME RELIEF LQ) DELSYM COUGH+CHEST CONGEST DM T1 DESGEN DM LIQUID T1 DESPEC DM T1 DESPEC DM-G T1 dextromethorphan polistirex T1 DIABETIC SILTUSSIN DAS-NA T1 DIABETIC SILTUSSIN-DM T1 DIABETIC SILTUSSIN-DM MAX STR T1 DIABETIC TUSSIN DM T1 DIABETIC TUSSIN EX T1 DIMAPHEN T1 DIMAPHEN DM T1 DOPRAM T2 PA hcl T2 PA

DULERA (100 MCG INHALER, 200 MCG INHALER) T1 AL At least 12 yrs old

PAGE 474 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.8 / day DYMISTA T2 PA ED-A-HIST 4 MG-10 MG TABLET T0 ED A-HIST PSE T1 ED-A-HIST DM T1 ENDACOF-DM T1 QL 9 / day ESBRIET 267 MG CAPSULE T2 S PA EXPECTORANT (100 MG/5 ML SYRUP, 200 MG TABLET, RA T1 COUGH SYRUP) EXPECTORANT COUGH SYRUP T1 EXPECTORANT DM COUGH LIQUID T0 EXPECTORANT DM COUGH SYRUP T1 EXTRA ACTION COUGH T1 FENESIN DM IR T1 QL 2 / day fexofenadine hcl/pseudoephedrine hcl T2 PA FLU RELIEF THERAPY DAYTIME T1 FLU-SEVERE COLD T1

AL At least 4 yrs fluticasone propion/ 100-50 mcg blst w/dev T2 old PA fluticasone propionate/salmeterol xinafoate AL At least 12 yrs (propion/salmeterol 250-50 mcg blst w/dev, T2 old propion/salmeterol 500-50 mcg blst w/dev) PA G TUSSIN AC T1 QL 60 / day

PAGE 475 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS G-FENESIN DM T1 GERI-TUSSIN T1 GERI-TUSSIN DM SYRUP T1 GILPHEX TR T2 PA GILTUSS TR T2 PA GLASSIA T2 PA GLENMAX PEB DM T1 QL 1 / day GRASTEK T2 PA GUAIASORB DM T1 QL 60 / day GUAIATUSSIN AC T1 AL At least 12 yrs old GUAICON DMS T0 guaifenesin (100 mg/5ml liquid, 200 mg tablet) T1 QL 60 / day GUAIFENESIN AC T1 AL At least 6 yrs old GUAIFENESIN DAC T1 guaifenesin/dextromethorphan hbr (guaifenesin/dextromethorphan 100-10mg/5 syrup, T1 guaifenesin/dextromethorphan 400mg-20mg tablet, guaifenesin/dextromethorphan 1200-60mg tab er 12h) guaifenesin/pseudoephedrne hcl 600mg-60mg tab er 12h T1 hydrocodone bitart/chlorpheniramine QL 20 / day T2 maleate/pseudoephedrine PA QL 30 / day hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup T1 AL At least 6 yrs old

PAGE 476 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 6 / day hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet T2 AL At least 6 yrs old PA QL 10 / day hydrocodone polistirex/chlorpheniramine polistirex T2 AL At least 6 yrs old PA QL 30 / day HYDROMET T1 AL At least 6 yrs old HYPER-SAL 7% VIAL T2 PA IBUPROFEN COLD & SINUS T1 IBUPROFEN COLD-SINUS T1 INFASURF T2 PA ipratropium bromide/albuterol sulfate T1 KIDKARE T1 LIQUITUSS GG T0 LOHIST-DM T1 LORATA-D T1 QL 1 / day QL 1 / day LORATA-DINE D T2 PA

LORATADINE-D (12 HOUR TABLET, GNP 12 HOUR TAB, SM QL 2 / day T2 12 HOUR TABLET) PA

LORATADINE-D (24HR TABLET, GNP 24HR TABLET, QC QL 1 / day T2 24HR TABLET) PA LORTUSS EX T1

PAGE 477 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LORTUSS LQ T0 M-CLEAR WC T2 PA M-END PE T2 PA M-HIST DM T1 MAPAP COLD FORMULA T1 MAPAP SINUS T1 MAR-COF BP T2 PA MAR-COF CG T2 PA

MAXI-TUSS AC T1 AL At least 12 yrs old MUCINEX FAST-MAX COLD-SINUS T1 MUCINEX FAST-MAX CONGEST-HEAD T1 MUCINEX SINUS-MAX SEVERE CPLT T1 MUCOSA DM T1 MUCUS D (CVS ER 600-60 MG TAB, ER 600-60 MG T1 TABLET, KRO ER 600-60 MG TAB) MUCUS DM ER T1 MUCUS DM MAX ER T1 MUCUS ER T1 MUCUS RELIEF (GNP 400 MG TABLET, RA 400 MG TABLET) T1 MUCUS RELIEF CHEST CONGESTION T1 MUCUS RELIEF COLD-SINUS T1 MUCUS RELIEF COUGH T1 MUCUS RELIEF D (HM RLF ER 600-60 MG TB, RA RELIEF ER 600-60 MG, RELIEF ER 600-60 MG TB, SM RELIEF ER 600- T1 60 MG)

PAGE 478 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MUCUS RELIEF DM T1 MUCUS RELIEF DM ER T1 MUCUS RELIEF DM MAX T1 MUCUS RELIEF DM MAX ER T1 MUCUS RELIEF ER T1 MUCUS RELIEF SEVERE COLD LIQ T1 MUCUS RELIEF SINUS PRES-PAIN T1 MUCUS RLF COLD-FLU-SORE THROAT (COLD-FLU-THROAT T1 LIQ, EQL COLD-FLU-THR LIQ) MUCUS RLF SEVERE SINUS CONGEST T1 MUCUS-ER MAX T1 MULTI-SYMPTOM COLD (, RA) T1 NEBUSAL 3% VIAL T2 PA NEO-TUSS T0 NEOTUSS PLUS T2 PA NIGHT TIME COLD-FLU (GNP SFTGL, SOFTGEL) T1 GS NIGHTTIME COLD-FLU SOFTGEL T1 NIGHTTIME COLD-FLU (GS LIQUID, LIQUID) T2 PA NIGHTTIME COLD-FLU RELIEF (CVS NIGHTTIME SOFTGEL, EQL NIGHT RELIEF SFGL, NIGHT RELIEF LIQ CAP, NIGHT RELIEF LIQ GEL, NIGHTTIME RLF SFTGL, NIGHTTIME RLF T1 SOFTGEL, QC NIGHTTIME SFTGL, RA NIGHT RELIEF SFTGL, SM NIGHTTIME SFTGL) NIGHTTIME COLD-FLU RELIEF (CVS LIQ, EQ LIQ, EQL LIQ, T2 PA RA LIQ) NINJACOF-XG T2 PA

PAGE 479 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NIVA-HIST DM T1 NOHIST-DM T1 NOHIST-LQ T0 QL 0.04 / day S NUCALA 100 MG VIAL T2 PS PA QL 60 / day OBREDON T2 PA QL 2 / day OFEV T2 PA ORALAIR (100 IR STARTER PACK, 300 IR ADULT SAMPLE T2 PA KT, 300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) PEDIA RELIEF COUGH-COLD T1 PEDIATRIC COUGH-COLD T1 PHENAGIL CH T0 phenylephrine hcl/promethazine hcl T1 AL At least 6 yrs old phenylephrine hcl/pyrilamine maleate T0 POLY-TUSSIN AC T2 PA PRES GEN T1

AL At least 2 yrs PRO-RED AC T2 old PA PROLASTIN C T2 PA promethazine hcl/codeine T1 AL At least 6 yrs old

PAGE 480 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS promethazine hcl/dextromethorphan hbr T1 AL At least 6 yrs old QL 30 / day promethazine/phenylephrine hcl/codeine T2 AL At least 6 yrs old PA PULMOSAL T2 PA QL 5 / day S PULMOZYME T1 PS PA QL 1 / day RAGWITEK T2 PA REFENESEN T1 REFENESEN DM T1 RESPA A.R. T2 PA RESPAIRE-30 T2 PA RI-TUSSIN T1 RI-TUSSIN DM T1 ribavirin 6 g vial-neb T2 PA

ROBAFEN 100 MG/5 ML SYRUP T1 AL At least 6 yrs old ROBAFEN 200 MG/10 ML SYRUP T1 ROBAFEN CF T1 ROBAFEN COUGH T1 ROBAFEN DM COUGH T1 ROBAFEN DM COUGH-CHEST CONGEST T1

PAGE 481 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ROBAFEN-DM T1 AL At least 6 yrs old ROBITUSSIN COUGH-CHEST DM LIQ T1 ROMPE PECHO MAX MULTI SYMPTOMS T1 RYDEX T2 PA RYNEX DM T1 RYNEX PE T1 RYNEX PSE T0 SAFETUSSIN DM T1 SCOT-TUSSIN 100 MG/5 ML LIQ T1 SCOT-TUSSIN EXPECTORANT T1 QL 4 / day SEMPREX-D T2 PA SEVERE COLD AND FLU DAYTIME T1 SEVERE SINUS T1 SILTUSSIN DM T1 SILTUSSIN DM DAS T1 SILTUSSIN SA T1 SINUS CONGESTION & PAIN T1 SINUS CONGESTION-PAIN (CONGESTION-PAIN CAPLET, CONGESTION-PAIN GELCAP, CVS PAIN-CONGEST CAPLET, EQ CONGEST-PAIN GELCAP, EQ CONGESTION-PAIN CPLT, T1 GNP CONGEST-PAIN CAPLET, GS CONGESTION-PAIN CPLT, RA CONGEST-PAIN GELCAP) SINUS CONGESTION-PAIN RELIEF T1 SINUS HEADACHE PE T1

PAGE 482 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SINUS MAXIMUM STRENGTH T1 SINUS PAIN RELIEF T1 SINUS PAIN-CONGESTION T1 SINUS PE PLUS ALLERGY T0 SINUS RELIEF (KRO, PUB) T1 SINUS RELIEF PRESSURE-PAIN (GNP RLF CPLT, KRO RLF T1 CPLT, RELIEF CAPLET) SINUS RELIEF SEVERE CONGESTION T1 SINUS RELIEF-CONGESTION & PAIN T1 SINUS-ALLERGY T0 SINUS-ALLERGY PE T0 SINUS-HEADACHE T1 sodium chloride for inhalation (3 % vial-neb, 7 % vial-neb, T2 PA 10 % vial-neb) SORBUGEN NR T1

STIOLTO RESPIMAT T1 AL At least 18 yrs old SUPHEDRINE PE COLD-ALLERGY T0 SUPHEDRINE PE SINUS HEADACHE T1 SUPHEDRINE PE SINUS-ALLERGY T0 SURVANTA T2 PA

SYMBICORT 160-4.5 MCG INHALER T1 AL At least 12 yrs old

SYMBICORT 80-4.5 MCG INHALER T1 AL At least 6 yrs old

AL At least 11 yrs TESSALON PERLE T2 old PA

PAGE 483 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THERAFLU EXPRESSMAX COLD DAY T1 THERAFLU EXPRESSMAX COLD-COUGH T1 TREXBROM T0 TUSNEL CAPLET T2 PA TUSNEL DIABETIC T1 TUSNEL DM PEDIATRIC DROPS T2 PA TUSNEL PEDIATRIC DROPS T1 TUSNEL PEDIATRIC LIQUID T1 TUSSI-PRES LIQUID T1 QL 6 / day TUSSICAPS T2 AL At least 6 yrs old PA

SM TUSSIN 100 MG/5 ML LIQUID T1 AL At least 6 yrs old TUSSIN (100 MG/5 ML SYRUP, CVS 100 MG/5 ML LIQUID, GNP 100 MG/5 ML SYRUP, GNP 400 MG TABLET, KRO 200 T1 MG/10 ML SYRUP, PUB 100 MG/5 ML SYRUP) TUSSIN CF T1 TUSSIN CF MAX T1 TUSSIN CHEST CONGESTION T1 TUSSIN COUGH (COUGH LIQUID, CVS CGH 15 MG LIQ GELS, CVS COUGH 15 MG LIQ GEL, GNP COUGH LIQUID, T1 RA COUGH LIQUID)

SM TUSSIN DM LIQUID T1 AL At least 6 yrs old

PAGE 484 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TUSSIN DM (400-20 MG TABLET, CVS LIQUID, EQ COUGH- CHEST SYR, EQL COUGH-CHEST SYR, GNP 400-20 MG TABLET, GNP SYRUP, GS COUGH SYRUP, GS LIQUID, KRO T1 LIQUID, LIQUID, PUB LIQUID, QC LIQUID, RA LIQUID, RA SYRUP, SM SYRUP, SYRUP)

TUSSIN DM CLEAR T1 AL At least 6 yrs old TUSSIN DM COUGH T1 TUSSIN DM COUGH-CHEST CONGEST T1 TUSSIN DM MAX T1 TUSSIN HONEY T1 TUSSIN LONG-ACTING T1 TUSSIN MUCUS-CHEST CONGESTION T1 QL 10 / day TUSSIONEX T2 PA TUSSLIN PEDIATRIC DROPS T1 QL 20 / day TUZISTRA XR T2 PA TYLENOL COLD MAX DAY CAPLET T1 TYLENOL COLD MULTI-SYMP CAPLET T1 ULTRA DM FREE & CLEAR T1 ULTRA TUSS T1

AL At least 18 yrs UTIBRON NEOHALER T2 old PA VALU-TAPP T0 VICKS DAYQUIL (LIQUICAPS, LIQUID) T1

PAGE 485 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VICKS DAYQUIL MUCUS CONTROL T0 VICKS NYQUIL LIQUICAPS T1 VIRAZOLE T2 PA QL 60 / day VIRTUSSIN AC 10-100 MG/5 ML LQ T1 AL At least 12 yrs old QL 60 / day VIRTUSSIN AC W-ALC 10-100 MG/5 T1 AL At least 6 yrs old VIRTUSSIN DAC T1 WAL-ACT D COLD & ALLERGY T1 WAL-ITIN D T1 QL 1 / day WAL-ITIN D 12 HOUR T1 QL 2 / day WAL-PHED PE SINUS HEADACHE T1 WAL-PHED PE SINUS-ALLERGY T0 WAL-PHED PE TRIPLE RELIEF T1 WAL-PROFEN COLD & SINUS CPLT T1 WAL-PROFEN D T1 WAL-TAP T1 WAL-TAP DM T1 WAL-TUSSIN SYRUP T1 WAL-TUSSIN COUGH (15 MG SOFTGEL, 15 MG/5 ML) T1 WAL-TUSSIN COUGH-COLD CF T1 WAL-TUSSIN DM T1 WAL-ZYR D T1 QL 2 / day

AL At least 4 yrs WIXELA 100-50 INHUB T2 old PA

PAGE 486 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 12 yrs WIXELA INHUB (250-50, 500-50) T2 old PA QL 0.22 / day S XOLAIR 150 MG VIAL T2 PS PA Z-TUSS AC T2 PA ZEMAIRA T2 PA ZODRYL AC 50 T2 PA ZODRYL AC 60 T2 PA ZODRYL AC 80 T2 PA ZODRYL DAC 50 T2 PA ZODRYL DAC 60 T2 PA ZODRYL DAC 80 T2 PA ZODRYL DEC 50 T2 PA ZODRYL DEC 60 T2 PA ZODRYL DEC 80 T2 PA ZYNCOF 400-20 MG TABLET T1 SKELETAL MUSCLE RELAXANTS

AMRIX T2 PA baclofen (10 mg tablet, 20 mg tablet) T1 S baclofen (20k mcg/20 vial, 10000/20ml vial, 40000/20ml T2 PS vial) PA

PAGE 487 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S BOTOX T2 PS PA carisoprodol 250 mg tablet T2 PA carisoprodol 350 mg tablet T1 carisoprodol/aspirin T2 PA (375 mg tablet, 500 mg tablet, 750 mg T1 tablet) cyclobenzaprine hcl (15 mg cap er 24h, 30 mg cap er 24h) T2 PA cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg T1 tablet) DANTRIUM (20 MG VIAL, 25 MG CAPSULE, 50 MG T2 PA CAPSULE) dantrolene sodium (25 mg capsule, 50 mg capsule, 100 T1 mg capsule) dantrolene sodium 20 mg vial T2 PA S DYSPORT T2 PS PA FEXMID T2 PA

GABLOFEN (50 MCG/ML SYRINGE, 10,000 MCG/20 ML S SYRG, 10,000 MCG/20 ML VIAL, 20,000 MCG/20 ML SYRG, T2 PS 20,000 MCG/20 ML VIAL, 40,000 MCG/20 ML SYRG, 40,000 MCG/20 ML VIAL) PA S LIORESAL INTRATHECAL T2 PS PA LORZONE T2 PA

PAGE 488 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METAXALL T2 PA metaxalone T2 PA methocarbamol (100 mg/ml vial, 500 mg tablet, 750 mg T1 tablet) orphenadrine citrate 100 mg tablet er T1 orphenadrine citrate 30 mg/ml vial T2 PA REVONTO T2 PA ROBAXIN (500 MG TABLET, 1,000 MG/10 ML VIAL) T2 PA ROBAXIN-750 T2 PA SKELAXIN T2 PA SOMA T2 PA tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg capsule) T2 PA tizanidine hcl (2 mg tablet, 4 mg tablet) T1 VANADOM T2 PA S XEOMIN T2 PS PA ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET, T2 PA 6 MG CAPSULE) SLEEP DISORDER AGENTS GABA RECEPTOR MODULATORS

QL 1 / day AMBIEN T2 PA QL 1 / day AMBIEN CR T2 PA

PAGE 489 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day DORAL T2 PA QL 1 / day EDLUAR T2 PA QL 1 / day T2 PA (1 mg tablet, 2 mg tablet) T1 QL 1 / day QL 1 / day eszopiclone 3 mg tablet T1 AL Up to 65 yrs old QL 2 / day HALCION T2 PA QL 1 / day INTERMEZZO T2 PA QL 1 / day LUNESTA (1 MG TABLET, 2 MG TABLET) T2 PA QL 1 / day LUNESTA 3 MG TABLET T2 AL Up to 65 yrs old PA QL 1 / day T2 PA QL 1 / day RESTORIL T2 PA (15 mg capsule, 30 mg capsule) T1 QL 1 / day QL 1 / day temazepam (7.5 mg capsule, 22.5 mg capsule) T2 PA 0.125 mg tablet T1 QL 1 / day

PAGE 490 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS triazolam 0.25 mg tablet T1 QL 2 / day T1 QL 1 / day tartrate (5 mg tablet, 10 mg tablet) T1 QL 1 / day zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 6.25 QL 1 / day T2 mg tab mphase, 12.5 mg tab mphase) PA QL 0.257 / day ZOLPIMIST T2 PA SLEEP DISORDERS, OTHER

QL 1 / day doxepin hcl (3 mg tablet, 6 mg tablet) T2 PA QL 1 / day hcl T2 PA QL 1 / day T2 PA QL 1 / day ROZEREM T2 PA QL 1 / day SILENOR T2 PA Sleep Disorders, Other

ACETADRYL T1 ACETAMINOPHEN PM T1 ACETAMINOPHEN PM XTRA STRENGTH T1 acetaminophen/diphenhydramine hcl T1 AMYTAL SODIUM T2 PA T2 PA

PAGE 491 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BELSOMRA T2 PA caffeine/sodium benzoate T2 PA DIABETIC SUPPORT FORMULA T0 EAZZZE THE PAIN T1 HEADACHE PM T1 HEADACHE PM FORMULA T1 HEADACHE RLF PM 25-500 MG TAB T1 QL 1 / day HETLIOZ T2 PA LYSIPLEX PLUS TABLET T1 MAPAP PM T1 MEGAVITE T0 MEGAVITE GOLDEN YEARS 55+ T0 QL 1 / DAY (100 mg tablet, 200 mg tablet) T2 PA QPD 1 per day NIGHT TIME PAIN MEDICINE T1 NON-ASPIRIN PM T1 NON-ASPIRIN PM EX-STRENGTH T1 NUVIGIL T2 PA PAIN & SLEEP T1 PAIN RELIEF PM T1 PAIN RELIEVER PM T1 QL 1 / DAY PROVIGIL (100 MG TABLET, 200 MG TABLET) T2 PA QPD 1 per day

PAGE 492 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SECONAL SODIUM T2 PA SIDEROL T2 PA TYLENOL PM EXTRA STRENGTH T1 VITAMIN D3 COMPLETE T0 WAL-NADOL PM T1 QL 18 / day XYREM T2 PA THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES ELECTROLYTE/MINERAL MODIFIERS

CHEMET T1 S CLOVIQUE T2 PS PA deferasirox (90 mg tablet, 125 mg tab disper, 180 mg S tablet, 250 mg tab disper, 360 mg tablet, 500 mg tab T2 PS disper) PA deferiprone T2 PA S EXJADE T2 PS PA FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) T2 PA GALZIN T2 PA S JADENU T2 PS PA

PAGE 493 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day JYNARQUE 15 MG TABLET T2 PA QL 2 / day JYNARQUE 30 MG TABLET T2 PA KIONEX T2 PA RADIOGARDASE T2 PA QL 1 / day SAMSCA 15 MG TABLET T2 S PA QL 2 / day SAMSCA 30 MG TABLET T2 S PA sodium polystyrene sulfonate (30 g/120ml enema, 50 T2 PA g/200ml enema) sodium polystyrene sulfonate 15 g/60 ml oral susp T2 PA sodium polystyrene sulfonate powder T1 SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA T2 PA SUSP) S SYPRINE T2 PS PA QL 2 / day S tolvaptan 30 mg tablet T1 PS PA S trientine hcl T2 PS PA

PAGE 494 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VAPRISOL-5% DEXTROSE T2 PA QL 1 / day VELTASSA T2 PA ELECTROLYTE/MINERAL REPLACEMENT

0.9 % sodium chloride T2 PA ACTIVE FE T2 PA ADDAMEL N T2 PA bacteriostatic sodium chloride T2 PA BEELITH T1 CAL-CITRATE T1 CAL-MINT T1 CALCI-MAX T1 CALCITRATE T1 CALCITRATE + VIT D T1 calcium acetate 668 mg tablet T1 calcium carbonate (260mg(650) tab chew, 500 mg/5ml T1 oral susp, 500(1250) tab chew) calcium carbonate (500(1250) tablet, 600 mg tablet) T1 calcium carbonate 390(1000) tablet T0 calcium carbonate and citrate/cholecalciferol (vit d3) T0 calcium carbonate/cholecalciferol (vitamin d3) (carbonate/vitamin 500 mg-200 tablet, T0 carbonate/vitamin 500 mg-400 tablet, carbonate/vitamin 600 mg-200 capsule)

PAGE 495 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS calcium carbonate/cholecalciferol (vitamin d3) (carbonate/vitamin 250 mg-125 tablet, carbonate/vitamin 500 mg-100 tab chew, T1 carbonate/vitamin 500 mg-400 tab chew, carbonate/vitamin 500 mg-600 tablet, carbonate/vitamin 600 mg-125 tablet, carbonate/vitamin 600 mg-200 tablet) calcium carbonate/cholecalciferol (vitamin d3) (carbonate/vitamin 500 mg-125 tablet, T0 carbonate/vitamin 600 mg-500 capsule) calcium carbonate/vitamin d3 600 mg-800 tablet T1 calcium carbonate/magnesium oxide/zinc gluconate T1 calcium carb/mag ox/zinc sulf 334-134-5 tablet T1 ca/d3/mag ox/zinc/cop/mang/bor 600 mg-800 tab chew T2 PA calcium chloride (100 mg/ml syringe, 100 mg/ml vial) T2 PA calcium citrate 200(950)mg tablet T0 calcium citrate/cholecalciferol (vitamin d3) (citrate/vitamin 200-3.125 tablet, citrate/vitamin 250mg- T0 5mcg tablet) calcium citrate/cholecalciferol (vitamin d3) (citrate/vitamin 315mg-5mcg tablet, citrate/vitamin T1 315mg-6.25 tablet) calcium citrate/vitamin d3 200mg-6.25 tablet T0 calcium gluconate 100 mg/ml vial T2 PA calcium gluconate in 0.9 % sodium chloride (in 1 g/100 ml plast. bag, in 1 g/110 ml plast. bag, in 1 g/50 ml plast. T2 PA bag, in 2 g/100 ml plast. bag, in 2 g/50 ml plast. bag, in 3 g/100 ml plast. bag) calcium gluconate in 0.9 % sodium chloride (in 1 g/50 ml T1 syringe, in 2 g/50 ml syringe)

PAGE 496 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS calcium gluconate/dextrose 5 % in water (gluconate/d5w 1 g/100 ml plast. bag, gluconate/d5w 1 g/50 ml plast. T2 PA bag, gluconate/d5w 2 g/100 ml plast. bag, gluconate/d5w 4 g/250 ml plast. bag) calcium phosphate trib/vit d3 250mg-5mcg tab chew T2 PA calcium/magnesium/zinc T1 CARBAGLU T2 PA CHILDREN'S IRON T1 cholecalciferol (vitamin d3) 25 mcg tablet T1 chromic chloride T2 PA chromium picolinate 200 mcg tablet T1 CITRACAL + D MAXIMUM T0 CITRACAL-D3 MAXIMUM PLUS T0 cupric chloride 0.4 mg/ml vial T2 PA cyanocobalamin (vitamin b-12) 1000 mcg tablet T1 DELFLEX WITH 1.5% DEXTROSE T2 PA DELFLEX WITH 2.5% DEXTROSE T2 PA DELFLEX WITH 4.25% DEXTROSE T2 PA dextrose 10 % and 0.2 % sodium chloride T2 PA dextrose 10 % and 0.45 % sodium chloride T2 PA dextrose 2.5 % and 0.45 % sodium chloride T2 PA dextrose 5 % and 0.2 % sodium chloride T2 PA dextrose 5 % and 0.3 % sodium chloride T2 PA dextrose 5 % and 0.45 % sodium chloride T2 PA dextrose 5 % and 0.9 % sodium chloride T2 PA

PAGE 497 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dextrose 5 % in lactated ringers T2 PA dextrose 5 % in ringer's T2 PA DIANEAL PD-2 W-1.5% DEXTROSE T2 PA DIANEAL PD-2 W-2.5% DEXTROSE T2 PA DIANEAL PD-2 W-4.25% DEXTROSE T2 PA DIANEAL WITH 1.5% DEXTROSE T2 PA DIANEAL WITH 2.5% DEXTROSE T2 PA DIANEAL WITH 4.25% DEXTROSE T2 PA S DILUENT FOR (XENLETA) T2 PS PA QL 1 / day DURLAZA T2 PA EFFER-K T2 PA ELECTROLYTE T1 electrolyte-48 solution/dextrose 5 % in water T2 PA ELLIOTTS B T2 PA ENFAMIL ENFALYTE T1 EXTRANEAL ICODEXTRIN DIALYSIS T2 PA FE C T1 FE C PLUS T1 FEOSOL 65 MG TABLET T0 FERATE T1 FEROCON T1

PAGE 498 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FEROSUL (220 MG/5 ML ELIXIR, 325 MG TABLET) T1 FERREX 150 FORTE T2 PA FERRO-TIME T1 FERROCITE T1 FERROCITE PLUS T1 ferrous fumarate 324(106)mg tablet T1 ferrous gluconate (236(27)mg tablet, 240(27)mg tablet, T1 324(37.5) tablet, 324(38)mg tablet) ferrous gluconate 256(28)mg tablet T0 ferrous sulfate 220 (44)/5 elixir T2 PA ferrous sulfate 220 (44)/5 solution T0 PA ferrous sulfate 325(65) mg tablet T0 ferrous sulfate (15 mg/ml drops, 300 mg/5ml liquid, T1 324(65)mg tablet dr, 325(65) mg tablet dr) ferrous sulfate (142(45)mg tablet er, 143(45) mg tablet T0 er) ferrous sulfate, dried 159(45)mg tablet er T1 FERROUSUL T1 fluoride (sodium) 0.25(0.55) tab chew T1 FLURA-DROPS T2 PA FOLITAB 500 T1 FOLIVANE-PLUS T2 PA FOLPLEX 2.2 T1 FOSFREE T1 FUSION PLUS T2 PA

PAGE 499 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FUSION SPRINKLES T2 PA GLYCOPHOS T2 PA HEMATINIC PLUS T1 HEMATINIC WITH FOLIC ACID T1 HEMAX T1 HEMOCYTE PLUS T2 PA HEMOCYTE-F T1 RA HI-CAL PLUS TAB T0 HIGH POTENCY IRON T0 HYPER-SAL 3.5% VIAL T2 PA HYPERLYTE CR T2 PA IODOPEN T2 PA IONOSOL B WITH DEXTROSE 5% T2 PA IONOSOL MB-DEXTROSE 5% T2 PA SM IRON 160 MG TABLET SA T1 IRON 100 PLUS T1 iron,carbonyl/ascorbic acid T1 ISOLYTE P WITH DEXTROSE T2 PA ISOLYTE S (IV OLN PH7.4, IV OLUTION-EXCEL) T2 PA K EFFERVESCENT T2 PA K-PHOS ORIGINAL T1 K-TAB ER T2 PA KLOR-CON T1 KLOR-CON 10 T1

PAGE 500 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KLOR-CON 8 T1 KLOR-CON M10 T1 KLOR-CON M15 T2 PA KLOR-CON M20 T1 KLOR-CON-EF T1 WITH IRON T1 LUDENT FLUORIDE 0.25 MG TB CHW T1 MAG-G T1 MAGBID ER T1 magnesium T1 magnesium amino acid chelate 100 mg tablet T1 magnesium chloride 200 mg/ml vial T2 PA magnesium citrate 100 mg tablet T1 magnesium gluconate (27 mg(500) tablet, 27.5 (500) T1 tablet, 30 mg(550) tablet) magnesium oxide (400 mg capsule, 500 mg capsule) T0 magnesium oxide (250 mg tablet, 500 mg tablet) T1 magnesium oxide 400 mg tablet T0 magnesium oxide/magnesium amino acid chelate T1 magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial) T2 PA

PAGE 501 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS magnesium sulfate in 0.9 % sodium chloride (in 1 g/50 ml piggyback, in 2 g/100 ml piggyback, in 2 g/50 ml piggyback, in 3 g/150 ml piggyback, in 3 g/50 ml piggyback, in 4 g/100 ml piggyback, in 4 g/50 ml T2 PA piggyback, in 6 g/100 ml piggyback, in 6 g/150 ml piggyback, in 20 g/290ml plast. bag, in 40 g/500ml plast. bag) magnesium sulfate in lactated ringers solution T2 PA magnesium sulfate in sterile water (in 2 g/50 ml piggyback, in 4 g/100 ml piggyback, in 4 g/50 ml T2 PA piggyback, in 20 g/500ml iv soln, in 40g/1000ml iv soln) magnesium sulfate/dextrose 5 % in water (sulfate/d5w 1 g/100 ml piggyback, sulfate/d5w 1 g/50 ml piggyback, sulfate/d5w 10 g/100ml plast. bag, sulfate/d5w 2 g/100 ml piggyback, sulfate/d5w 2 g/50 ml piggyback, sulfate/d5w 20 g/290ml plast. bag, sulfate/d5w 20 T2 PA g/500ml plast. bag, sulfate/d5w 20g/1000ml plast. bag, sulfate/d5w 3 g/50 ml piggyback, sulfate/d5w 4 g/100 ml piggyback, sulfate/d5w 4 g/50 ml piggyback, sulfate/d5w 50g/500ml plast. bag) MAGONATE T1 manganese chloride 0.1 mg/ml vial T2 PA manganese sulfate 0.1 mg/ml vial T2 PA MGO T0 MONOJECT 0.9% SODIUM CHLORIDE T2 PA MONOJECT PREFILL ADVANCED T2 PA MONOJECT SODIUM CHLORIDE FLUSH T2 PA MULTIGEN FOLIC T2 PA MULTIGEN PLUS T2 PA MULTITRACE-4 T2 PA

PAGE 502 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MULTITRACE-5 T2 PA NEBUSAL 6% VIAL T2 PA NEUT T2 PA NORMOSOL-M AND DEXTROSE T2 PA NORMOSOL-R T2 PA NORMOSOL-R AND DEXTROSE T2 PA NORMOSOL-R PH 7.4 T2 PA NU-MAG T1 NUTRILYTE T2 PA ORALYTE FREEZER POPS T1 ORALYTE SOLUTION T1 ORAZINC 220 MG CAPSULE T1 OS-CAL 500-VIT D3 T1 OYSCO 500-VIT D3 T1 OYSCO-500 T1 OYSTERCAL-D T0 PEDIATRIC ELECTROLYTE (CVS PEDIATRIC POPS, CVS PEDIATRIC SOLN, GNP PEDIATRIC SOLN, HEB PEDIATRIC T0 SOLN, HM PEDIATRIC SOLN, PEDI FREEZER POP, RA PEDIATRIC SOLN) PEDIATRIC ELECTROLYTE (SM SOLN, SOLUTION) T1 PEDIATRIC FREEZER POPS T0 PEDITRACE T2 PA PHILLIPS T0 PHOS-NAK T1

PAGE 503 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PHYSIOLYTE T2 PA PHYSIOSOL T2 PA PLASMA-LYTE 148 T2 PA PLASMA-LYTE A PH 7.4 T2 PA potassium acetate 2 meq/ml vial T2 PA potassium bicarbonate/citric acid T2 PA potassium chloride (2 meq/ml ampul, 2 meq/ml vial) T2 PA potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10 meq tab er prt, 10 meq tablet er, 20 T1 meq packet, 20 meq tab er prt, 20 meq tablet er, 20meq/15ml liquid, 40meq/15ml liquid) potassium chloride in 0.45 % sodium chloride T2 PA potassium chloride in 0.9 % sodium chloride (in 20 T2 PA meq/250 iv soln, in 20 meq/l iv soln, in 40 meq/l iv soln) potassium chloride in 5 % dextrose in water T2 PA potassium chloride in dextrose 5 % and 0.9 % sodium T2 PA chloride potassium chloride in dextrose 5 %-0.2 % sodium chloride (chloride/d5-0.2%nacl 10 meq/l iv soln, chloride/d5- T2 PA 0.2%nacl 20 meq/l iv soln, chloride/d5-0.2%nacl 30 meq/l iv soln, chloride/d5-0.2%nacl 40 meq/l iv soln) potassium chloride in dextrose 5 %-0.45 % sodium chloride (chloride/d5-0.45nacl 10 meq/l iv soln, chloride/d5-0.45nacl 20 meq/l iv soln, chloride/d5- T2 PA 0.45nacl 30 meq/l iv soln, chloride/d5-0.45nacl 40 meq/l iv soln) potassium chloride/d5-0.3%nacl 20 meq/l iv soln T2 PA potassium chloride in lactated ringers and 5 % dextrose T2 PA

PAGE 504 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium chloride in water for injection, sterile (in 10meq/0.1l piggyback, in 10meq/50ml piggyback, in T2 PA 20meq/0.1l piggyback, in 20meq/50ml piggyback, in 30meq/0.1l piggyback, in 40meq/0.1l piggyback) potassium chloride/lidocaine hcl in 0.9 % sodium chloride T2 PA potassium chloride/potassium bicarbonate/citric acid T2 PA potassium phosphate in 0.9 % sodium chloride (in 0.9 % 10mmol/250 plast. bag, in 0.9 % 15mmol/100 piggyback, T2 PA in 0.9 % 15mmol/250 plast. bag, in 0.9 % 30mmol/250 plast. bag, in 0.9 % 30mmol/500 plast. bag) potassium phos,m-basic-d-basic 3mmol/ml vial T2 PA PRENA1 TRUE T2 PA PROFERRIN-FORTE T2 PA ringer's solution iv soln T2 PA ringer's solution,lactated iv soln T2 PA selenium (40 mcg/ml vial, 200 mcg tablet) T2 PA SLOW FE T0 SLOW RELEASE IRON (EQL 50 MG TB, SM 45 MG TAB) T0 SLOW RELEASE IRON TABLET T1 SLOW-MAG T1 sodium acetate (2 meq/ml vial, 4 meq/ml vial) T2 PA sodium bicarbonate (0.5meq/ml syringe, 0.5meq/ml vial, 0.9meq/ml syringe, 1 meq/ml syringe, 1 meq/ml vial, T2 PA 10meq/10ml syringe) sodium bicarbonate in dextrose 5%-water T2 PA sodium chloride 1000 mg tablet sol T1 sodium chloride (2.5 meq/ml vial, 4 meq/ml vial) T2 PA

PAGE 505 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium chloride 0.45 % T2 PA sodium chloride 0.9 % (flush) 0.9 % syringe T2 PA sodium chloride 0.9 % (flush) 0.9 % syringe cp T2 PA sodium chloride 3 % T2 PA sodium chloride 5 % T2 PA sodium chloride for inhalation 0.9 % vial-neb T1 sodium lactate 5 meq/ml vial T2 PA sodium phosphate in 0.9 % nacl 15mmol/250 plast. bag T2 PA sod phosphate,monobasic-dibas 3mmol/ml vial T2 PA SSKI T2 PA SUPER CALCIUM T1 SWABFLUSH T2 PA THAM T2 PA TPN ELECTROLYTES T2 PA TPN ELECTROLYTES II T2 PA TRACE ELEMENTS-4 T2 PA UROQID-ACID NO.2 T2 PA VITATRUE T2 PA zinc amino acid chelate 50 mg tablet T1 zinc chloride 1 mg/ml vial T2 PA zinc gluconate 50 mg tablet T1 zinc sulfate 220(50) mg capsule T1 zinc sulfate (1 mg/ml vial, 5 mg/ml vial) T2 PA

PAGE 506 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZINC-220 T1 A THRU Z (DVNCED FORMULTB, MEN'S ULTIMTE TBLET) T0 A THRU Z ADVANCED FORMULA T0 A THRU Z SELECT (MEN 50+ TBLET, MULTIVIT TB, TBLET, T0 WOMEN'S TBLET) A THRU Z SELECT 50 PLUS T0 ABC PLUS T0 ACERFLEX T2 PA acetylcysteine 600 mg capsule T1 ADULT MULTI GUMMIES T0 ADULT MULTIVITAMIN GUMMIES T0 ADULT ONE DAILY GUMMIES T0 ADULTS 50 PLUS DAILY FORMULA T1 ADULTS 50 PLUS MULTIVITAMIN T1 CVS ALGAL-900 DHA 300 MG SFTGL T2 PA amino acid 3.5 % comb no.2 (pediatric) in 10 % dextrose T2 PA AMINOSYN (8.5% IV SOLUTION, 10% IV SOLUTION) T2 PA AMINOSYN II (7% IV SOLUTION, 8.5% IV SOLUTION, 10% T2 PA IV SOLUTION, 15% IV SOLUTION) AMINOSYN II WITH ELECTROLYTES T2 PA AMINOSYN M T2 PA AMINOSYN WITH ELECTROLYTES (7%-ELECTROLYTE SOL, T2 PA 8.5%-ELECTROLYTES SOL) AMINOSYN-HBC T2 PA AMINOSYN-PF (7% IV SOLUTION, 10% IV SOLUTION) T2 PA

PAGE 507 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AMINOSYN-RF T2 PA CHEWS T1 ANIMAL SHAPES T1 ANIMAL SHAPES COMPLETE (HM CHEW, SM CHEW) T0 ANIMAL SHAPES PLUS IRON T0 ANIMAL SHAPES VITAMINS T0 antiarthritic combination no.2 T1 FORMULA T1 AQUADEKS (CHEWABLE TABLET, PEDIATRIC LIQUID) T1 AQUASOL A T2 PA ARKALIOX T1 ascorbate calcium 500 mg tablet T1 ascorbic acid (250 mg tab chew, 250 mg tablet, 500 mg capsule er, 500 mg tab chew, 500 mg tablet, 1000 mg T1 tablet) ascorbic acid (100 % granules, 500 mg/ml vial, granules) T2 PA ascorbic acid/ascorbate sodium 500 mg tab chew T1 B-12 COMPLIANCE T2 PA B-12 DOTS T1 b-complex with tablet T1 PA BAL-CARE DHA T2 PA BAL-CARE DHA ESSENTIAL T2 PA BALANCE B-100 T1 BALANCE B-50 T1 BCAD 1 T2 PA

PAGE 508 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BCAD 2 T2 PA BETAQUIK T2 PA BIO-35 T0 BIOCEL T1 bioflavonoids, citrus powder T2 PA biotin 300 mcg tablet T1 BODY, HAIR, SKIN AND NAILS T1 BOOST LIQUID T2 PA BREWER'S YEAST T1 C-NATE DHA T2 PA CADEAU DHA T2 PA CALCIDOL T1 CARBZERO T2 PA CARDIOVID PLUS T2 PA CARNITOR (1 GM/5 ML VIAL, 100 MG/ML ORAL SOLN, T2 PA 330 MG TABLET) CARNITOR SF T2 PA CENTAMIN T1 CENTRAL-VITE WOMEN'S MATURE T0 CENTRAM-CARE T1 CENTRAVITES T0 CENTRAVITES 50 PLUS T1 CENTRUM T1 CENTRUM ADULTS T1

PAGE 509 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CENTRUM CHEWABLES ADULTS TAB T1 CENTRUM COMPLETE T1 CENTRUM KIDS T1 CENTRUM MEN T1 CENTRUM SILVER CHEWABLE TABLET T1 CENTRUM SILVER ULTRA MEN'S T1 CENTRUM SILVER WOMEN T1 CENTRUM SPECIALIST HEART T1 CENTRUM ULTRA MEN'S T1 CENTRUM WOMEN T1 CENTURY (ADULTS 50 PLUS TAB, TABLET) T0 CENTURY (ADULTS 50 PLUS TABLET, TABLET) T1 CENTURY CARDIO TABLET T1 GNP CENTURY CARDIO TABLET T0 CENTURY MATURE (EQL TABLET, GNP TABLET) T0 CENTURY ULTIMATE MEN'S TABLET T1 GNP CENTURY ULTIMATE MEN'S TAB T0 CENTURY ULTIMATE WOMEN'S TAB T1 GNP CENTURY ULTIMATE WOMEN TAB T0 CEREFOLIN T1 CEREFOLIN NAC T1 CEROVITE ADVANCED FORMULA T1 CEROVITE JR T1 CEROVITE SENIOR T1 CERTA PLUS T1

PAGE 510 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CERTAVITE SENIOR-ANTIOXIDANT T1 CERTAVITE-ANTIOXIDANT T1 CHEWABLE-VITE T1 CHEWABLE-VITE WITH IRON T1 CHILD CHEW + IRON T1 CHILD CHEWABLE VITAMN COMPLETE T1 CHILD COMPLETE CHEWABLE VITAMN T1 CHILD COMPLETE MULTIVITAMIN T0 CHILD LITTLE VITAMINS T1 CHILD MULTIVITAMINS T0 CHILDREN'S CHEW MULTIVIT-IRON T1 CHILDREN'S CHEW MULTIVITAMIN T1 CHILDREN'S CHEWABLE T1 CHILDREN'S CHEWABLE MULTIVITMN T1 CHILDREN'S CHEWABLE VITAMIN (CHILD'S CHEWABLE T1 TAB, CHILDREN'S CHEWABLE, CHILDRENS CHEW TAB) CHILDREN'S CHEWABLES T1 CHILDREN MULTIVITAMIN CHEW TAB T0 EQ CHILD MULTIVITAMIN GUMMIES T0 CHILDREN'S VITAMINS WITH IRON T1 cholecalciferol (vitamin d3) (10 mcg capsule, 10 mcg tablet, 10(400)/ml drops, 25 mcg capsule, 50 mcg capsule, T1 50 mcg tablet, 125 mcg capsule, 125 mcg tablet, 1250 mcg capsule) cinnamon T1 CITRANATAL B-CALM T2 PA

PAGE 511 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLASSIC PRENATAL T1 CLINIMIX (2.75%-5% SOLUTION, 4.25%-10% SOLUTION, 4.25%-20% SOLUTION, 4.25%-25% SOLUTION, 4.25%-5% T2 PA SOLUTION, 5%-15% SOLUTION, 5%-20% SOLUTION, 5%- 25% SOLUTION) CLINIMIX E (2.75%-10% SOLUTION, 2.75%-5% SOLUTION, 4.25%-10% SOLUTION, 4.25%-25% SOLUTION, 4.25%-5% T2 PA SOLUTION, 5%-15% SOLUTION, 5%-20% SOLUTION, 5%- 25% SOLUTION) CLINIMIX N9G20E T2 PA CLINISOL T2 PA cod liver oil capsule T1 COD LIVER OIL SOFTGEL T1 cod liver oil 100 % oil T2 PA COMPANION T0 SM COMPLETE ADVANCED TABLET T1 COMPLETE 50 PLUS T0 COMPLETE MEN T0 COMPLETE MULTI T0 COMPLETE MULTI 50+ T0 HM COMPLETE MULTI-VIT-MINERAL T0 SM COMPLETE MULTI-VIT-MINERAL T1 COMPLETE MULTIVITAMIN TAB T1 EQ COMPLETE MULTIVITAMIN TAB T0 COMPLETE MV ADULT 50 PLUS T0 COMPLETE NATAL DHA T2 PA

PAGE 512 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMPLETE PREMIUM VITAMIN T1 COMPLETE SENIOR T1 COMPLETE WOMEN T0 COMPLEX B-100 T1 cyanocobalamin (vitamin b-12) (100 mcg tablet, 250 mcg tablet, 500 mcg tablet, 1000mcg/ml vial, 2500 mcg tab T1 subl) cyanocobalamin (vitamin b-12) 1000 mcg tablet er T2 PA CYCLINEX-1 T2 PA cysteine hcl 50 mg/ml vial T2 PA D3-2000 T1 D3-50 T1 DAFLONEX-XL T2 PA DAILY GUMMIES T0 CVS DAILY MULTIPLE TABLET T1 DAILY MULTIPLE TABLET T0 DAILY MULTIPLE VITAMIN T0 DAILY MULTIVITAMIN T0 DAILY MULTIVITAMIN-IRON T0 DAILY PRENATAL COMBO PACK T1 GNP DAILY PRENATAL COMBO PACK T0 DAILY VALUE T1 DAILY VITAMIN FORMULA T1 DAILY VITAMIN FORMULA-IRON T0 DAILY VITAMIN FORMULA-MINERALS T1

PAGE 513 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DAILY-VITE TABLET T1 DAILY VITE WITH IRON T1 DAILY-VITE T1 DECARA 50,000 UNIT SOFTGEL T1 DECUBI VITE T0 DELTA D3 T1 DEPLIN-ALGAL OIL T1 DERMACINRX FOLIXAPURE T2 PA dextrose 10 % in water (10 % in 10 % dehp fr bg, 10 % in T2 PA 10 % iv soln) dextrose 20 % in water T2 PA dextrose 25 % in water T2 PA dextrose 30 % in water T2 PA dextrose 40 % in water T2 PA dextrose 5 % in water (5 % in pggybk prt, 5 % in pgy vl T1 prt) dextrose 5 % in water (5 % in 5 % iv soln, 5 % in 5 % vial) T2 PA dextrose 50 % in water (50 % in 50 % iv soln, 50 % in 50 % T2 PA syringe, 50 % in 50 % vial) dextrose 70 % in water T2 PA DIABETES HEALTH FORMULA T0 DIALYVITE T1 DIALYVITE 800 TABLET T1 DIALYVITE 800 WITH IRON T2 PA DIALYVITE 800 WITH ZINC T1

PAGE 514 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIALYVITE 800-ULTRA D T1 DIALYVITE SUPREME D T1 DIALYVITE VITAMIN D T1 DIALYVITE VITAMIN D3 MAX T1 DINO- T1 DINO-LIFE EXTRA C MULTIVITAMIN T1 DINO-LIFE MULTIVITAMIN T1 DOTHELLE DHA T2 PA DRISDOL T2 PA DUET DHA 400 T2 PA DUET DHA BALANCED T2 PA DUOCAL T2 PA EAA T2 PA EGG-PRO T2 PA ELECARE T2 PA ELECARE JR T2 PA ELITE-OB T2 PA QL 6 / day ENDARI T2 S PA ENSURE T0 ENSURE ACTIVE HEART HEALTH T0 PA ENSURE ACTIVE HIGH PROTEIN T0 ENSURE ACTIVE LIGHT T0

PAGE 515 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ENSURE ACTIVE MUSCLE HEALTH T0 ENSURE ACTIVE PROTEIN-MUSCLE T0 ENSURE CLEAR T0 ENSURE CLEAR THERAPEUTIC T0 ENSURE COMPACT T0 ENSURE ENLIVE T0 ENSURE HIGH PROTEIN LIQUID T0 ENSURE HIGH PROTEIN POWDER T0 PA ENSURE LIQUID T0 PA ENSURE MUSCLE HEALTH T0 ENSURE ORIGINAL LIQUID T0 ENSURE ORIGINAL POWDER T2 PA ENSURE PLUS T0 ENSURE POWDER T0 PA ergocalciferol (vitamin d2) (200 mcg/ml drops, 1250 mcg T1 capsule) ESCAVITE LQ T2 PA ESSENTIA T0 ESSENTIAL BALANCE T0 ESSENTIAL DAILY T0 ESSENTIAL MAN T0 ESSENTIAL MAN 50+ T0 ESSENTIAL WOMAN 50+ T0 ethyl alcohol (98 % ampul, 98 % vial) T2 PA

PAGE 516 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EYE HEALTH AND LUTEIN T2 PA EYE HEALTH PLUS LUTEIN TABLET T2 PA FA-8 T0 S FERAHEME T2 PS PA FERREX 150 T1 FERRIC X-150 T1 S FERRLECIT T2 PS PA FISH OIL (OIL 500 MG, OIL 1,000 MG) T1 flaxseed oil 1000 mg capsule T2 PA FLINTSTONES (GUMMIES CHEW TAB, MULTIVIT CHEW T0 TAB, TABLET CHEWABLE) FLINTSTONES COMPLETE (CHEW TAB, TABLET) T0 FLINTSTONES GUMMIES T0 FLINTSTONES PLUS CALCIUM T0 FLINTSTONES EXTRA C TAB CHEW T0 FLUORABON T2 PA fluoride (sodium) (0.5 mg/ml drops, 0.5(1.1)mg tab chew, T1 1mg(2.2mg) tab chew) FLUORITAB T1 FOLBEE T1 FOLBEE PLUS T1 FOLBEE PLUS CZ T1

PAGE 517 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FOLBIC T1 FOLBIC RF T1 folic acid (0.8 mg capsule, 20 mg capsule) T0 folic acid (0.4 mg tablet, 0.8 mg tablet) T1 folic acid 1 mg tablet T1 folic acid 5 mg/ml vial T2 PA folic acid/multivit with minerals/lutein T0 folic acid/vitamin b complex and c/rice bran T0 folic acid/vit b complex and c 400 mcg tablet T1 FOLINIC-PLUS T1 FOLTANX T1 FOLTANX RF T1 FORTAVIT T2 PA FREAMINE HBC T2 PA FREAMINE III T2 PA FREEDAVITE T1 FRUIT C-500 T1 FRUITIVITS T2 PA FULL SPECTRUM B T1 GA T2 PA GA EXPRESS 15 T2 PA GA GEL T2 PA 500 mg capsule T1 GLUTAREX-1 T2 PA

PAGE 518 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLUTAREX-2 T2 PA GLYCOSADE POWDER PACKET T2 PA GLYTACTIN 15 PE BETTERMILK T2 PA GLYTACTIN RTD 10 PE T2 PA GLYTACTIN RTD 15 PE T2 PA GUMMI BEAR MULTIVITAMIN T0 GUMMIES CHILDREN MULTIVITAMIN T0 GUMMY T0 CVS CHILD GUMMY DINOS GUMMIES T0 H2Q T1 HAIR VITAMIN T1 GNP HAIR, SKIN AND NAILS TAB T0 HAIR, SKIN AND NAILS (SM CAPLET, SOFTGEL, SV CAPLET) T0 HAIR, SKIN AND NAILS CAPLET T1 HCU EXPRESS POWDER T2 PA HCU EXPRESS20 T2 PA HCU GEL T2 PA HCY 1 T2 PA HCY 2 T2 PA HEALTHY EYES TABLET T1 HEALTHY EYES SUPERVISION SFTGL T1 HEARTBURN & ACID REFLUX T1 HEMENATAL OB + DHA T2 PA HEPATAMINE T2 PA

PAGE 519 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HOMINEX-1 T2 PA HOMINEX-2 T2 PA HONEY BEARS T1 HONEY BEARS MULTIVITAMIN T1 hydroxocobalamin 1000mcg/ml vial T2 PA I-VALEX-1 T2 PA I-VALEX-2 T2 PA I-VITE (PROTECT TABLET, TABLET) T1 ICAPS (AREDS FORMULA DR TABLET, TABLET) T1 ICAPS AREDS T1 ICAPS MV T1 IFEREX 150 T1 IMMULIFE T2 PA S INFED T2 PS PA INFUVITE ADULT T2 PA INFUVITE PEDIATRIC T2 PA S INJECTAFER T2 PS PA INTRALIPID T2 PA K-PAX T2 PA K-PAX IMMUNE BOOSTER T2 PA

PAGE 520 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS K-PAX IMMUNE SUPPORT T0 KETOCAL 3:1 T2 PA KETOCAL 4:1 POWDER T2 PA KETONEX-1 T2 PA KETONEX-2 T2 PA KETOVOLVE T2 PA KOBEE T1 KOSHER PRENATAL PLUS IRON T2 PA KPN PRENATAL TABLET T1 KPN TABLET T1 L-METHYL-B6-B12 T1 L-METHYLFOLATE FORTE T1 LANAFLEX T2 PA oil T1 lecithin 1200 mg capsule T1 lecithin, soy 1200 mg capsule T1 levocarnitine 330 mg tablet T2 PA levocarnitine (with sugar) T2 PA levomefolate calcium 7.5 mg tablet T1 levomefolate calcium/schizochytrium algal oil (levomefolate/algal oil 7.5-90.314 capsule, T1 levomefolate/algal oil 15-90.314 capsule) LIPISTART T2 PA LIQUIGEN T2 PA

PAGE 521 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LITTLE ANIMALS PLUS IRON T1 LITTLE ANIMALS WITH IRON T1 LMD T2 PA QL 4 / day LOVAZA T2 PA LUDENT FLUORIDE (0.5 MG TB CHEW, 1 MG TAB CHEW) T1 lysine 500 mg tablet T1 M-NATAL PLUS T1 M.V.I. ADULT T2 PA M.V.I. PEDIATRIC T2 PA M.V.I.-12 T2 PA MARNATAL-F T2 PA MAXIMUM DAILY MULTIVITAMIN T1 MCT OIL T2 PA MCT PRO-CAL T2 PA MEDTYCHOLL-B COMPLEX W-LIVER T1 MEGA MULTI (MEN TABLET, WOMEN TAB) T0 MEGA MULTI (MEN TABLET, WOMEN TAB) T1 MEGA MULTI W-CHELATED MINERALS T1 HM MENS 50 PLUS ADV ONE DAILY T0 MEN'S DAILY FORMULA CAPSULE T1 MEN'S DAILY GUMMIES T0 MEN'S DAILY MULTIVIT-MINERAL T0 MEN'S MULTIVITAMIN GUMMIES T0

PAGE 522 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MEN'S ONE DAILY (EQL DAILY TABLET, HM DAILY TABLET, T0 RA DAILY TABLET, SM DAILY TABLET) MEPHYTON T2 PA METAFOLBIC T1 METAFOLBIC PLUS RF T1 METANX T1 METHIONAID T2 PA MICROLIPID T2 PA MILLTRIUM SENIOR T0 MINI PRENATAL T1 MONOCAPS T1 MTERYTI T2 PA MTERYTI FOLIC 5 T2 PA MULTI COMPLETE-IRON T0 MULTI FOR HER TABLET T0 MULTI-BETIC T1 MULTI-DAY PLUS IRON T1 MULTI-DELYN T1 MULTI-VITAMIN DAILY T1 MULTILEX T1 MULTILEX T-M T1 multivit with calcium, iron, and other minerals T0 multivitamin capsule T0 multivitamin tablet T0 multivitamin combination no.51/ferrous fumarate/folic T1 acid

PAGE 523 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS multivitamin with iron T1 MULTIVITAMIN WITH IRON TABLET T0 multivitamin with minerals tablet T1 multivitamin with minerals/ferrous gluconate T1 multivitamin,ther and minerals capsule T0 multivitamin,ther and minerals tablet T1 multivitamin-mins/calcium/biotin/cholecalciferol/folic T1 acid MVC-FLUORIDE 0.25 MG TAB CHEW T1 MVW COMPLETE FORMLTN PEDIATRIC T0 PA MVW COMPLETE FORMUL D3000 SFGL T0 PA MVW COMPLETE FORM MULTIVI SFGL T0 MY FAVORITE MULTIPLE T0 MYNATAL T2 PA MYNATAL PLUS T1 MYNATAL-Z T1 MYVITALIFE T1 NASCOBAL T2 PA NATACHEW T2 PA NATURAL BALANCED B-100 T1 NEOKE MCT70 T2 PA NEPHRAMINE T2 PA NEPHRO-VITE RX T2 PA NEPHROCAPS T2 PA

PAGE 524 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEPHRONEX T1 NEPHRONEX-SL T1 NESTABS T2 PA NESTABS ABC T2 PA NESTABS DHA T2 PA NEWGEN T2 PA niacin 250 mg capsule er T1 niacin 100 mg tablet T1 niacin 50 mg tablet T1 NIACIN 500 MG TABLET T1 niacin (inositol niacinate) 500 mg tablet T0 NIVA-FOL T1 NIVA-PLUS T1 NU-IRON 150 T1 NUTRILIPID T2 PA NUTRIVIT T2 PA O-CAL PRENATAL T1 OB COMPLETE T2 PA OB COMPLETE ONE T2 PA OB COMPLETE PETITE T2 PA OB COMPLETE PREMIER T2 PA OB COMPLETE WITH DHA T2 PA OCUVITE ADULT 50 PLUS T1 OCUVITE EYE HEALTH T1

PAGE 525 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OCUVITE LUTEIN-ZEAXANTHIN T1 OCUVITE WITH LUTEIN T1 omega-3 acid ethyl esters T1 QL 4 / day omega-3 fatty acids (100 mg tab chew, 1000 mg capsule) T1 omega-3 fatty acids/dha/epa/other omega-3s/fish oil (omega-3s/dha/epa/fish oil 300-1000mg capsule, omega- 3s/dha/epa/fish oil 300-1000mg capsule dr, omega- T1 3s/dha/epa/fish oil 360-1200mg capsule, omega- 3s/dha/epa/fish oil 720-1200mg capsule dr) omega-3 fatty acids//epa/fish oil (omega-3/dha/epa/fish oil 1000 mg capsule, omega- T1 3/dha/epa/fish oil 300-1000mg capsule dr) omega-3 fatty acids/docosahexanoic acid/epa/fish oil (omega-3/dha/epa/fish oil 120-180 mg capsule, omega- 3/dha/epa/fish oil 250-500 mg capsule, omega- 3/dha/epa/fish oil 300-1000mg capsule, omega- T1 3/dha/epa/fish oil 360-1200mg capsule dr, omega- 3/dha/epa/fish oil 500-1000mg capsule, omega- 3/dha/epa/fish oil 60 mg-90mg capsule) omega-3 fatty acids/fish oil (acids/fish oil 300-1000mg T1 capsule, acids/fish oil 340-1000mg capsule) OMEGA-3 FISH OIL T1 OMNICAP T0 OMNICT T2 PA ONCE DAILY T1 ONCOVITE T1 ONE A DAY WOMEN'S PRENATAL DHA T1 EQ ONE DAILY TABLET T0 ONE DAILY (DAILY WOMEN 50 PLUS TAB, GNP DAILY T0 TABLET)

PAGE 526 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ONE DAILY TABLET T1 ONE DAILY COMPLETE T0 ONE DAILY ENERGY (DAILY TABLET, RA DAILY TABLET) T0 GNP ONE DAILY ESSENTIAL TABLET T0 ONE DAILY ESSENTIAL (CVS DAILY TABLET, DAILY TABLET) T1 RA ONE DAILY ESSENTIAL TABLET T0 ONE DAILY FOR MEN T0 ONE DAILY FOR MEN 50+ ADVANCED T0 ONE DAILY FOR WOMEN T0 ONE DAILY FOR WOMEN 50+ ADV T0 ONE DAILY HEALTHY WEIGHT T0 ONE DAILY MAXIMUM (GNP DAILY TABLET, RA DAILY T0 TABLET) ONE DAILY MAXIMUM TABLET T1 ONE DAILY MEN'S T0 GNP ONE DAILY MEN'S 50+ TABLET T0 ONE DAILY MEN'S 50+ TABLET T1 CVS ONE DAILY MEN'S HEALTH TAB T2 PA ONE DAILY MEN'S HEALTH TABLET T0 ONE DAILY MULTIVITAMIN (DAILY TABLET, SM DAILY TAB) T0 ONE DAILY MULTIVITAMIN TAB T1 ONE DAILY MULTIVITAMIN-IRON T0 ONE DAILY MULTIVITAMIN-MINERAL T0 GNP ONE DAILY PLUS IRON TABLET T0 ONE DAILY PLUS IRON TABLET T1

PAGE 527 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ONE DAILY PLUS MINERALS T0 HM ONE DAILY PRENATAL COMBO PK T2 PA ONE DAILY WITH CALCIUM-IRON T0 ONE DAILY WITH IRON T1 ONE DAILY WOMEN'S (EQ DAILY TABLET, RA DAILY T0 TABLET) ONE DAILY WOMEN'S TABLET T1 ONE DAILY WOMEN'S 50 PLUS ADV T2 PA GNP ONE DAILY WOMEN'S 50+ TAB T0 ONE DAILY WOMEN'S 50+ TABLET T1 GNP ONE DAILY WOMEN'S HLTH TAB T0 ONE DAILY WOMEN'S HEALTH TAB T1 ONE DAILY WOMENS 50 PLUS T0 ONE-A-DAY T0 ONE-A-DAY ENERGY T0 ONE-A-DAY ESSENTIAL T0 ONE-A-DAY MAXIMUM FORMULA T0 ONE-A-DAY MEN VITACRAVES T0 ONE-A-DAY MEN'S T0 ONE-A-DAY MEN'S 50 PLUS T0 ONE-A-DAY MENOPAUSE FORMULA T0 ONE-A-DAY TEEN ADVANTAGE T0 ONE-A-DAY TEEN HIM VITACRAVES T0 ONE-A-DAY VITACRAVES T0 ONE-A-DAY VITACRAVES IMMUNITY T0

PAGE 528 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ONE-A-DAY VITACRAVES OMEGA-3 T0 ONE-A-DAY VITACRAVES SOUR T0 ONE-A-DAY WEIGHTSMART T0 ONE-A-DAY WOMEN VITACRAVES T0 ONE-A-DAY WOMEN'S T0 ONE-A-DAY WOMEN'S HEALTHY SKIN T0 ONE-A-DAY WOMEN'S PETITES T0 ONE-A-DAY WOMEN'S PRENATAL 1 T2 PA ONE-DAILY MULTI-VITAMIN TAB T1 ONE-DAILY MULTI-VITAMIN-IRON T0 OPTI-VITAMIN T1 OPTIMAL D3 T1 OPTISOURCE TABLET CHEWABLE T0 OPURITY MULTIVITAMIN T0 PARVLEX T1 PEDIA POLY-VITE T1 PEDIASURE (LIQUID, SHAKE MIX POWDER) T0 PEDIASURE 1.5 T0 PEDIASURE 1.5 WITH FIBER T0 PEDIASURE ENTERAL T0 PEDIASURE ENTERAL WITH FIBER T0 PEDIASURE GROW-GAIN LIQUID T0 PEDIASURE 1.0 CAL T0 PEDIASURE PEPTIDE 1.5 CAL T0

PAGE 529 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PEDIASURE SIDEKICKS (CLEAR LIQ, LIQUID) T0 PEDIASURE WITH FIBER T0 ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops T1 pedi multivit no.16 w-fluoride 0.25 mg tab chew T1 pedi multivit no.2 w-fluoride 0.25 mg/ml drops T1 pediatric multivitamins no.17 with sodium fluoride T1 oil oil T1 PERRY PRENATAL T1 PHENYLADE GMP (POWDER, POWDER PKT) T2 PA phytonadione (vit k1) (1mg/0.5ml ampul, 1mg/0.5ml T2 PA syringe, 10 mg/ml ampul) phytonadione (vit k1) 5 mg tablet T1 PA PLENAMINE T2 PA PNV 29-1 T1 PNV OB+DHA T2 PA PNV-OMEGA T2 PA PNV-SELECT T2 PA PNV-VP-U T2 PA POLY-IRON T1 POLY-VI-FLOR (0.25 MG DROPS, 0.25 MG TAB CHEW, 0.5 T2 PA MG TAB CHEW, 1 MG TAB CHEW) POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) T2 PA POLY-VI-SOL WITH IRON T1 POLY-VITAMIN T1 POLYVITAMIN WITH IRON T1

PAGE 530 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POTABA T2 PA PR NATAL 400 T2 PA PR NATAL 400 EC T2 PA PR NATAL 430 T2 PA PR NATAL 430 EC T2 PA PREMASOL (6% IV SOLUTION, 10% IV SOLUTION) T2 PA PRENA1 CHEW T2 PA PRENA1 PEARL T2 PA PRENATABS FA T1 PRENATABS RX T1 PRENATAL FORMULA-DHA T1 prenatal vit with calcium 95/ferrous fumarate/folic T1 acid/dha prenatal vit with calcium no.122/ferrous fumarate/folic T1 acid prenatal vit with calcium no.129/ferrous fumarate/folic T1 acid prenatal vit with calcium no.130/ferrous fumarate/folic T1 acid prenatal vitamins no.121/ferrous fumarate/folic acid T1 prenatal vitamins no.40/ferrous fumarate/folic acid/dha T1 prenatal vitamins no.62/folic acid/omega- T0 3s/dha/epa/fish oil prenatal vit/iron fum/folic ac 27mg-0.8mg tablet T1 prenatal vit/iron fum/folic ac 28mg-0.8mg tablet T1 prenatal vits no.151/iron fum/folic T1 acid/omega3/dha/epa/fish

PAGE 531 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prenatal vits with calcium 118/ferrous fumarate/folic acid T1 prenatal vits with calcium 133/ferrous fumarate/folic acid T1 prenatal vits with calcium 137/ferrous fumarate/folic acid T2 PA prenatal vits with calcium 95/ferrous fumarate/folic acid T0 prenatal vits with calcium no.124/ferrous fumarat/folic T1 acid prenatal vits with calcium no.21/ferrous fumarate/folic T0 acid prenatal vits with calcium no.72/ferrous fumarate/folic T1 acid prenatal vits with calcium no.72/iron,carbonyl/folic acid T1 prenatal vits with calcium no.74/ferrous fumarate/folic T1 acid prenatal vits with calcium no.93/ferrous fumarate/folic T1 acid prenatal vits with calcium no.96/ferrous fumarate/folic T1 acid prenatal vits, calcium no.91/ferrous fumarate/folic T1 acid/dha PRENATE DHA T2 PA PRENATE ELITE T2 PA PRENATE ENHANCE T2 PA PRENATE MINI T2 PA PRENATE PIXIE T2 PA PRENATE RESTORE T2 PA PRENATE STAR T2 PA

PAGE 532 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREPLUS T1 PRESERVISION AREDS (SOFTGEL, TABLET) T1 PRESERVISION LUTEIN T1 PRETAB T1 PROCALAMINE T2 PA PROCERV HP T0 PROMOD T2 PA PRORENAL T1 PRORENAL QD T1 PROSIGHT T1 PROSIGHT WITH LUTEIN T1 PROSOL T2 PA PROSOURCE TF T2 PA PROTECT CARDIO AF T0 PROTECT IRON T2 PA PROTECT PLUS SO T0 PROTEOLIN CAPLET T2 PA PROVIDA DHA T2 PA PROVIDA OB T2 PA pyridoxine hcl (vitamin b6) (25 mg tablet, 50 mg tablet, T1 100 mg tablet) pyridoxine hcl (vitamin b6) 100 mg/ml vial T2 PA Q-SORB CO Q-10 (100 MG SOFTGEL, SV 100 MG SFTGL, T1 200 MG SOFTGEL, SV 200 MG SFTGL) QUFLORA (0.25 MG CHEW TAB, 0.5 MG CHEW TAB, 1 MG T2 PA CHEW TAB)

PAGE 533 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QUIN B STRONG T1 QUINTABS T1 QUINTABS-M T1 QUINTABS-M IRON FREE T1 R-NATAL OB T2 PA RENA-VITE T1 RENA-VITE RX T1 RENAL CAPS T1 RENAL VITAMIN T1 RENAL-VITE T1 RENO CAPS T1 REQ49+ T2 PA riboflavin (vitamin b2) 25 mg tablet T1 ringer's solution irrig soln T2 PA ringer's solution,lactated irrig soln T2 PA SAVISION T1 SCOOBY-DOO ONE A DAY TABLET T0 SE-NATAL 19 T2 PA SE-NATAL-19 T1 SEA-OMEGA 30 T1 SELECT-OB T2 PA SELECT-OB + DHA T2 PA SENIOR TABS T0 SENTRY T1

PAGE 534 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SENTRY SENIOR T0 SMOFLIPID T2 PA S sodium ferric gluconate complex in sucrose T2 PS PA SOL CARB T2 PA SOLO T0 SOOTHING PUREWAY-C T1 SPECTRAVITE ADULT 50+ T0 SPECTRAVITE ADVANCED FORMULA T0 SPECTRAVITE MEN'S T0 SPECTRAVITE SENIOR (TAB, TABLET) T0 SPECTRAVITE ULTRA MEN 50+ T0 SPECTRAVITE ULTRA MEN'S T0 SPECTRAVITE ULTRA WOMEN T0 SPECTRAVITE ULTRA WOMEN'S T0 STRESS B WITH ZINC T0 STRESS FORMULA (FORMULA TABLET, SM T1 FORMULA+ZINC TABLET) STRESS FORMULA WITH IRON T1 STRESS FORMULA WITH ZINC T1 STRESS-C T1 STROVITE ONE T1 STUART ONE T2 PA SUPER B COMPLEX-VITAMIN C T1

PAGE 535 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SUPER B-50 COMPLEX T1 SUPER MULTIPLE (CAPSULE, VIT-MINERAL TAB) T1 SUPER MULTIPLE-LOW IRON T0 SUPER MULTIVITAMIN T1 SUPER OMEGA-3 T1 SUPER QUINTS (TABLET, TABLETS) T1 SUPER THERAVITE-M T1 SUPERPLEX-T T1 SUPERVITE T2 PA SUPPORT T2 PA SUPPORT-500 T2 PA SYNTHAMIN 17 WITHOUT ELTYE T2 PA TAB-A-VITE T1 TAB-A-VITE WITH IRON T1 THERA (CAPLET, TABLET) T1 THERA M PLUS T1 THERA-D SPORT 2,000 UNIT TAB T1 THERA-M (CAPLET, TABLET) T1 THERA-TABS T1 THERA-TABS M T0 THERADEX M T1 THERAGRAN-M PREMIER 50 PLUS T0 THERANATAL T0 THERANATAL OVAVITE T2 PA

PAGE 536 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THERANATAL PLUS T2 PA THERAPEUTIC M T1 THERAPEUTIC-M (GNP CAPLET, TABLET) T0 THERAPEUTIC-M CAPLET T1 THERATRUM COMPLETE T1 THERATRUM COMPLETE 50 PLUS T1 THEREMS T1 THEREMS-H T1 THEREMS-M T1 THEROMEGA SPORT T1 thiamine hcl (50 mg tablet, 100 mg tablet) T1 thiamine hcl 100 mg/ml vial T2 PA thiamine T2 PA hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine thiamine mononitrate (vit b1) 100 mg tablet T1 THRIVITE RX T2 PA TOTAL B WITH C T1 TRAVASOL T2 PA TRI-VI-FLOR T1 TRI-VI-SOL T1 TRICARE T2 PA TRICARE PRENATAL DHA ONE T2 PA S TRIFERIC 27.2 MG/5 ML AMPULE T2 PS PA

PAGE 537 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRIKLO T1 QL 4 / day TRINATAL RX 1 T1 TRINATE T2 PA TRIPHROCAPS T1 TRISTART DHA T2 PA TRIVEEN-DUO DHA T2 PA TROPHAMINE (6% IV SOLUTION, 10% IV SOLUTION) T2 PA TRUEPLUS MULTIVITAMIN T0 TRUST NATAL DHA T2 PA tryptophan (500 mg capsule, 500 mg tablet) T1 ubidecarenone (30 mg capsule, 50 mg capsule, 100 mg T1 capsule, 200 mg capsule) ubidecarenone/vitamin e T1 ubidecarenone/vitamin e acetate T1 UDAMIN SP T2 PA ULTIMATE MEN'S COMPLETE 50+ T0 ULTIMATE WOMEN'S COMPLETE 50+ T0 ULTRA B-100 COMPLEX (TAB SA, TABLET) T1 ULTRA FREEDA (TABLET, WITH IRON TABLET) T1 UNICOMPLEX-M T1 V-C FORTE T1 S VENOFER T2 PS PA VIC-FORTE T1

PAGE 538 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VINACAL B T2 PA VINATE DHA RF T2 PA VINATE ONE T1 VINATE-M T1 VIRT-C DHA T2 PA VIRT-CAPS T1 VIRT-NATE DHA T2 PA VIRT-PN T2 PA VIRT-PN DHA T2 PA VIRT-PN PLUS T2 PA VISION PLUS LUTEIN T1 VIT 3 T2 PA vit b complex/vit c/folic acid/ferrous fumarate/vit e acet T1 VITA-BEE WITH C T1 VITA-RESPA T2 PA VITACEL T1 VITAFOL GUMMIES T2 PA VITAFOL NANO T2 PA VITAFOL ULTRA T2 PA VITAFOL-OB T2 PA VITAFOL-OB+DHA T2 PA VITAFOL-ONE T2 PA VITAL-D RX T1

PAGE 539 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITALEE T0 VITALETS T1 VITAMEDMD ONE RX T2 PA VITAMEDMD REDICHEW RX T2 PA vitamin a 10000 unit capsule T1 vitamin a 8000 unit capsule T2 PA vit a and d3 in cod liver oil 1250-135 capsule T1 vitamin a palmitate/beta-carotene/vit d2/vit e/selenium T1 vitamin b complex (capsule, talet) T1 vitamin b complex with vitamin c combination no.3 T1 vitamin b complex/folic acid 0.4 mg tablet T1 vitamin e (100 unit capsul, 200 unit capsul, 400 unit T1 capsul, 1000 unit capsul) vitamin e (dl-alpha tocopheryl acetate) ((dl,tocophryl act) 22.5mg(50) drops, (dl,tocophryl act) 100 unit capsul, (dl,tocophryl act) 100/0.25ml drops, (dl,tocophryl act) 200 T1 unit capsul, (dl,tocophryl act) 400 unit capsul, (dl,tocophryl act) 450 mg capsul) vitamin e acetate (actat200 unit capsul, actat400 unit T1 capsul, actat600 unit capsul, actat1000 unit capsul) vitamin e acid succinate (succinat100 unit tablt, T1 succinat200 unit tablt, succinat400 unit tablt) vitamin e mixed (mixd 100 unit tablt, mixd 200 unit tablt, mixd 400 unit capsul, mixd 400 unit tablt, mixd 1000 unit T1 capsul) VITAMINS FOR HAIR T1 VITAPEARL T2 PA

PAGE 540 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITATRUM T1 VITRUM 50 PLUS SENIOR T1 VITRUM SENIOR T1 VOL-PLUS T1 VP-PNV-DHA T2 PA wheat germ oil T1 WOMEN'S DAILY T0 WOMEN'S DAILY FORMULA CAPLET T1 WOMEN'S MULTIVITAMIN GUMMIES T0 WOMEN'S ONE DAILY T0 WOMENS DAILY GUMMIES T0 YELETS T1 ZOO FRIENDS T0 ZOO FRIENDS ORIGINAL T1 Uncategorized Unclassified

QL 1 / day ABILIFY MYCITE T2 AL At least 18 yrs old PA ABSORICA LD T2 PA ACD-A 30 ML VIAL T2 PA acetaminophen (325mg/32.5 syringe, 500mg/50ml T2 PA syringe, 650mg/65ml piggyback)

DC SHORT ACTING acetaminophen/caff/dihydrocod 325-30-16 tablet T2 OPIOIDS PA

PAGE 541 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ACTEMRA ACTPEN T2 PS PA S ADAKVEO T2 PS PA QL 1 / day adapalene 0.1 % med. swab T2 PA QL 2 / day adapalene 0.1 % solution T2 PA QL 1 / DAY ADHANSIA XR T2 AL 6.0 to 17.0 yrs old PA ADYPHREN AMP II T2 PA ADYPHREN II T2 PA

AL 4.0 to 17.0 yrs ADZENYS ER T2 old PA AFLURIA QUAD 2019-20 (3YR UP) T1 AFLURIA QUAD 2019-20 (6-35MO) T1 AFLURIA QUAD 2019-2020 T1 AFLURIA QUAD 2020-2021 T1 AFLURIA QUAD 2020-21 (3YR UP) T1 AFLURIA QUAD 2020-21 (6-35MO) T1 AFREZZA (4 UNIT/8 UNIT/12 UNIT, 8 UNIT CARTRIDGE, 12 T2 PA UNIT CARTRIDGE, 90-8 UNIT / 90-12 UNIT)

PAGE 542 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.04 / day AIMOVIG 140 MG/ML AUTOINJECTOR T1 AL At least 18 yrs old PA QL 0.067 / day AIMOVIG 70 MG/ML AUTOINJECTOR T1 AL At least 18 yrs old PA QL 0.067 / day AIMOVIG AUTOINJECTOR (2 PACK) T1 AL At least 18 yrs old PA

AL At least 12 yrs AIRDUO RESPICLICK T2 old PA QL 0.057 / day AJOVY AUTOINJECTOR T1 AL At least 18 yrs old PA QL 0.057 / day AJOVY SYRINGE T1 AL At least 18 yrs old PA QL 1.5 / day AKLIEF T2 PA S AKYNZEO 235-0.25 MG VIAL T2 PS PA S AKYNZEO 235-0.25 MG/20 ML VIAL T2 PA

PAGE 543 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S ALIQOPA T2 PS PA allergenic extract-aspergillus fumigatus T2 PA allergenic extract-aureobasidium pullulans T2 PA allergenic extract-botrytis cinerea T2 PA allergenic extract-cladosporium cladosporioides T2 PA allergenic extract-epicoccum nigrum T2 PA allergenic extract-mucor plumbeus T2 PA allergenic extract-penicillium notatum T2 PA allergenic extract-trichophyton mentagrophytes T2 PA QL 1.5 / day ALTRENO T2 PA QL 2 / day ALUNBRIG (90 MG TABLET, 90 MG-180 MG TAB PACK) T2 PA QL 1 / day ALUNBRIG 180 MG TABLET T2 PA QL 6 / day ALUNBRIG 30 MG TABLET T2 PA amino acid 3 % comb no.2 (pediatric) in 10 % dextrose T2 PA ammonia n-13 (3.75-260 syringe, 3.75-260 vial, 3.75-37.5 T2 PA vial)

AL 4.0 to 17.0 yrs amphetamine T2 old PA QL 1 / day AMZEEQ T2 PA

PAGE 544 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANDEXXA 200 MG VIAL T2 PA ANJESO T2 PA GNP ANTI-DIARRHEAL 2 MG SFTGEL T0 QL 12 / day AL At least 18 yrs old APADAZ T2 DC SHORT ACTING OPIOIDS PA QL 42 / 365 days ARAKODA T2 PA ARAZLO T2 PA QL 9 / day ARIKAYCE T2 AL At least 18 yrs old PA

ARISTADA ER 1064 MG/3.9 ML SYR T1 AL At least 18 yrs old

ARISTADA INITIO T1 AL At least 18 yrs old

AL At least 12 yrs ARMONAIR DIGIHALER T2 old PA ARMONAIR RESPICLICK T2 PA ARNUITY ELLIPTA 50 MCG INH T2 PA S (10 mg/10ml vial, 12 mg/6 ml vial) T2 PS PA

DC LONG ACTING ARYMO ER T2 OPIOIDS PA

PAGE 545 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ASCENIV T2 PA ascorbic acid 500 mg powd pack T2 PA ASMANEX HFA 50 MCG INHALER T2 PA asparagine monohydrate powder T2 PA S ASPARLAS T2 PS PA ATABEX OB T2 PA atropine sulfate/0.9 %sod chlr 1.2 mg/3ml syringe T2 PA QL 4 / day S AUSTEDO T2 PS PA QL 2 / fill AUVI-Q 0.1 MG AUTO-INJECTOR T2 PA S AVSOLA T2 PA QL 1 / day AYVAKIT T2 PA AZADROX T2 PA BABY PROBIOTIC T0 BACICAP T2 PA baclofen 5 mg tablet T1 QL 4 / day BAFIERTAM T2 PA

PAGE 546 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BALCOLTRA T2 PA QL 3 / day BALVERSA 3 MG TABLET T2 PA QL 2 / day BALVERSA 4 MG TABLET T2 PA QL 1 / day BALVERSA 5 MG TABLET T2 PA BAQSIMI T1 QL 2 / 30 days BARHEMSYS T2 PA BASADROX T2 PA BAVENCIO T2 PA BAXDELA (300 MG VIAL, 450 MG TABLET) T2 PA QL 12 / day AL At least 18 yrs old benzhydrocodone hcl/acetaminophen T2 DC SHORT ACTING OPIOIDS PA T2 PA QL 1 / rx BEOVU T2 PA betamethasone acetate and sodium phos in sterile T2 PA water/pf betamethasone acetate/betamethasone sodium T2 PA phosphate/water betamethasone sodium phosph in sterile water for T2 PA injection

PAGE 547 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1.25 / day BEVYXXA T2 PA QL 1 / day BIJUVA T2 PA S BIKTARVY T1 PS BIOGAIA GASTRUS T0 BIORPHEN T2 PA bivalirudin 250mg/50ml vial T2 PA bivalirudin in 0.9 % sodium chloride T2 PA S BLENREP T2 PA blood-glucose and blood pressure meter with adult cuff T2 PA QL 2 / day BONJESTA T2 PA S T2 PS PA QL 1 / day BOSULIF 400 MG TABLET T2 PA BRAINSTRONG PRENATAL T1 tosylate T2 PA BREZTRI AEROSPHERE T2 PA QL 4 / day BRUKINSA T2 PA

PAGE 548 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BRYHALI T2 PA butalbital/aspirin/caffeine 50-325-40 tablet T1 QL 6 / day BYDUREON BCISE T2 PA QL 0.6 / day S BYNFEZIA T2 PS PA c.i. acid blue 90 T2 PA calcium carbonate/vitamin d3 600mg-2500 capsule T0 calcium carbonate/vitamin d3 500 mg-200 powd pack T2 PA calcium citrate/vitamin d3 1000-10/30 liquid T2 PA calcium gluconate in 0.9 % sodium chloride (in 1 g/60 ml plast. bag, in 2 g/120 ml plast. bag, in 2 g/70 ml plast. T2 PA bag) calcium gluc in nacl, iso-osm 1 g/50 ml plast. bag T2 PA calcium gluconate/dextrose 5 % in water (gluconate/d5w 1 g/110 ml plast. bag, gluconate/d5w 1 g/60 ml plast. T2 PA bag) QL 2 / day CALQUENCE T2 PA QL 1 / day CAPLYTA T2 PA carbinoxamine maleate 6 mg tablet T1 AL At least 2 yrs old CAROSPIR T2 PA catheter 14fr-6" each T2 PA cefazolin sodium/d5w 3 g/100 ml piggyback T2 PA

PAGE 549 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CERETEC 0.5 MG VIAL T2 PA chlorzoxazone 250 mg tablet T1 CHOLECAL DF T2 PA S CIMDUO T1 PS S CINVANTI T2 PS PA CLENPIQ T2 PA CLINIMIX N14G30E T2 PA CLINIMIX N9G15E T2 PA CLINOLIPID T2 PA clobetasol propionate/calcipotriene T2 PA CONRAY-43 VIAL T2 PA QL 1 / day CONSENSI T2 PA corn extract T2 PA

AL 4.0 to 17.0 yrs COTEMPLA XR-ODT T2 old PA covid-19 antigen immunoassay test T2 PA covid-19 molecular nucleic acid test assay T2 PA cream base no.220 T2 PA cream base no.221 T2 PA cream base no.222 T2 PA

PAGE 550 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cream base no.226 T2 PA cream base no.228 T2 PA S cyclophosphamide 200 mg/ml vial T2 PA S D-PENAMINE T2 PA EQL DAILY PROBIOTIC CAPSULE T0 DAYVIGO T2 PA deferasirox (90 mg gran pack, 180 mg gran pack, 360 mg S T2 gran pack) PA DELFLEX-2.5% DEXTROSE T2 PA S DELSTRIGO T2 PS PA desoximetasone/niacinamide T2 PA DEXABLISS T2 PA dexamethasone acetate and sodium phosphate in sterile T2 PA water dexamethasone acetate in sodium chloride, iso-osmotic T2 PA dexamethasone sodium phosp/pf 10 mg/ml syringe T2 PA maleate T2 PA DEXTENZA T2 PA

DIACOMIT (250 MG CAPSULE, 250 MG POWDER PACKET, QL 2 / day T2 500 MG CAPSULE, 500 MG POWDER PACKET) PA DICLOVIX M T2 PA

PAGE 551 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS digoxin, micronized T2 PA

DC SHORT ACTING DILAUDID 0.2 MG/ML SYRINGE T2 OPIOIDS PA diltiazem hcl in 0.9% nacl 100mg/0.1l plast. bag T2 PA S diluent for dexrazoxane (sodium lactate) T2 PA S DILUENT FOR ELITEK 1 ML AMPULE T2 PS PA S DILUENT FOR IXEMPRA T2 PS PA DIMENTHO T2 PA dl-3-hydroxybutyric acid, sodium salt T2 PA S docetaxel 200mg/10ml vial T2 PS PA DOJOLVI T2 PA DOPTELET T2 PA DOTAREM 2.5 MMOL/5 ML VIAL T2 PA QL 1 / day S DOVATO T2 PS PA doxycycline hyclate 80 mg tablet dr T2 PA

PAGE 552 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day DRIZALMA SPRINKLE T2 PA

DC SHORT ACTING DSUVIA T2 OPIOIDS PA QL 0.0333 / day DUAKLIR PRESSAIR T2 PA

DULERA 50 MCG-5 MCG INHALER T1 AL At least 12 yrs old QL 7 / day DUOBRII T2 PA

AL At least 12 yrs old DUPIXENT PEN T2 S PA QL 0.15 / day AL At least 12 yrs DUPIXENT SYRINGE T2 old S PA S DUROLANE T2 PS PA DURYSTA T2 PA dutasteride 100 % powder T2 PA QL 1 / day DUZALLO T2 PA

DC SHORT ACTING DVORAH T2 OPIOIDS PA

PAGE 553 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DXEVO T2 PA EGATEN T2 PA ELIQUIS DVT-PE TREAT START 5MG T1 ELLZIA PAK T2 PA

EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML AL At least 5 yrs T2 old ORAL SUSP, 30 MG TABLET, 36 MG TABLET) PA QL 0.04 / day EMGALITY PEN T1 AL At least 18 yrs old PA QL 0.04 / day EMGALITY 120 MG/ML SYRINGE T1 AL At least 18 yrs old PA QL 0.1 / day EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG T1 AL At least 18 yrs (100 MG X3SYR)) old PA QL 0.144 / day ENBREL 25 MG/0.5 ML VIAL T1 AL At least 2 yrs old S ENHERTU T2 PA

AL At least 6 yrs old EPCLUSA 200 MG-50 MG TABLET T2 S PA

EPIDIOLEX T1 AL At least 2 yrs old

PAGE 554 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS epinephrine hcl in 0.9 % nacl 200 mcg/10 syringe T2 PA epinephrine hcl in dextrose 5 % in water (in 5 mg/250ml T2 PA plast. bag, in 100 mcg/10 syringe) EQUACARE JR T2 PA QL 4 / day ERLEADA T2 PA QL 9 / day ESBRIET 267 MG TABLET T2 S PA QL 3 / day ESBRIET 801 MG TABLET T2 S PA S ESPEROCT T2 PS PA ESSENTIAL CARE JR T2 PA QL 2.143 / day EUCRISA T1 AL At least 3 yrs old PA

AL 4.0 to 17.0 yrs EVEKEO ODT T2 old PA EVRYSDI T2 PA QL 1 / day EZALLOR SPRINKLE T2 PA famotidine 20 mg/2 ml syringe T2 PA

PAGE 555 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS famotidine in 0.9 % nacl 20 mg/10ml syringe T2 PA QL 0.04 / day FASENRA T2 PA QL 0.04 / day FASENRA PEN T2 PA feeder container with gravity set, enfit T2 PA fentanyl citrate in 0.9 % sodium chloride/pf (% nacl/pf 5 mcg/ml syringe, % nacl/pf 25 mcg/2.5 syringe, % nacl/pf 25 mcg/ml plast. bag, % nacl/pf 50mcg/5ml syringe, % T2 PA nacl/pf 1100mcg/55 pca syring, % nacl/pf 1250mcg/25 pca syring, % nacl/pf 1250mcg/50 pca syring)

DC SHORT ACTING fentanyl/bupivacaine/ns/pf 2mcg-0.25% plast. bag T2 OPIOIDS PA fentanyl citrate/bupivacaine hcl in 0.9 % sodium chloride/pf (fentanyl/bupivacaine/ns/pf 1.5/1-.125 T2 PA syringe, fentanyl/bupivacaine/ns/pf 5-400 mcg pump resvr, fentanyl/bupivacaine/ns/pf 5-750mcg pump resvr) fentanyl citrate/pf (citrate/pf 1000mcg/20 pca syring, citrate/pf 1250mcg/25 pca syring, citrate/pf 12500/.25l T2 PA pump resvr) FERRIPROX 1,000 MG TABLET T2 PA FERRIPROX (2 TIMES A DAY) T2 PA FETROJA T2 PA FIASP T2 PA FIASP FLEXTOUCH T2 PA FIASP PENFILL T2 PA S FIBRYGA T2 PS PA

PAGE 556 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FINTEPLA T2 PA FIRVANQ T1

AL At least 18 yrs flash glucose scanning reader T1 old PA QL 0.1 / day flash glucose sensor T1 AL At least 18 yrs old PA QL 10 / day FLOLIPID 20 MG/5 ML ORAL SUSP T2 PA QL 5 / day FLOLIPID 40 MG/5 ML ORAL SUSP T2 PA FLONASE SENSIMIST T1 FLUAD 2019-2020 T1 FLUAD 2020-2021 T1 FLUAD QUAD 2020-2021 T1 FLUARIX QUAD 2019-2020 T1 FLUARIX QUAD 2020-2021 T1 FLUBLOK QUAD 2019-2020 T1 FLUBLOK QUAD 2020-2021 T1 FLUCELVAX QUAD 2019-2020 (2019-2020 SYR, 2019-2020 T1 VIAL) FLUCELVAX QUAD 2020-2021 (2020-2021 SYR, 2020-2021 T1 VIAL) FLULAVAL QUAD 2019-2020 (2019-2020 SYR, 2019-2020 T1 VIAL)

PAGE 557 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLULAVAL QUAD 2020-2021 T1 FLUMIST QUAD 2019-2020 T1 FLUMIST QUAD 2020-2021 T1 FLUOPAR T2 PA fluticasone propionate/salmeterol xinafoate (propion/salmeterol 55-14 mcg aer pow ba, AL At least 12 yrs T2 old propion/salmeterol 113-14 mcg aer pow ba, PA propion/salmeterol 232-14 mcg aer pow ba) FLUZONE HIGH-DOSE 2019-2020 T1 FLUZONE HIGH-DOSE QUAD 2020-21 T1 FLUZONE QUAD 2019-2020 (2019-2020 SYRINGE, 2019- T1 2020 VIAL) FLUZONE QUAD 2020-2021 (2020-2021 SYRINGE, 2020- T1 2021 VIAL) FOLIKA-NC T2 PA FORAXA T2 PA S FULPHILA T2 PS PA GABACAINE T2 PA GABAPAL T2 PA GAMIFANT T2 PA S GAMMAPLEX (5 GRAM/50 ML VIAL, 10 GRAM/100 ML T2 PS VIAL, 20 GRAM/200 ML VIAL) PA S ganciclovir sodium 500mg/10ml vial T2 PS PA

PAGE 558 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS gel-matrix pad dressing, silicone (pad 2"x5.5" pad, pad T2 PA 4.7" x5.7" pad) GELFOAM JMI SPONGE KIT T2 PA S gemcitabine hcl 100 mg/ml vial T2 PS PA gentamicin sulfate/sodium citrate (sulf/sodium 0.9 T2 PA mg/3ml syringe, sulf/sodium 320 mcg/ml vial) QL 2 / day S GILENYA 0.25 MG CAPSULE T1 PS PA GIVLAARI T2 PA GLOPERBA T2 PA glycopyrrolate 1.5 mg tablet T1 glycopyrrolate in water/pf 0.2 mg/ml syringe T2 PA GLYTACTIN BURST 10-10 T2 PA GLYTACTIN BURST 20-20 T2 PA QL 2 / day GOCOVRI ER 137 MG CAPSULE T2 PA QL 1 / day GOCOVRI ER 68.5 MG CAPSULE T2 PA S GRANIX (300 MCG/ML VIAL, 480 MCG/1.6 ML VIAL) T2 PS PA GVOKE PFS 1-PACK SYRINGE T1 QL 0.007 / day

PAGE 559 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GVOKE PFS 2-PACK SYRINGE T1 QL 0.007 / day QL 1.25 / day HAEGARDA T2 PA halobetasol propionate 0.05 % foam T2 PA HALOG 0.1% SOLUTION T2 PA haloperidol lactate 5 mg/ml syringe T1 AL At least 18 yrs old HALUCORT T2 PA S HARVONI (33.75-150 MG PELLET PK, 45-200 MG PELLET T2 PS PACKT) PA

AL At least 3 yrs old HARVONI 45-200 MG TABLET T2 S PS PA HEALON GV PRO T2 PA HELIDAC T2 PA QL 12 / day S HEMLIBRA T2 PS PA heparin sodium,porcine in 0.45 % sodium chloride/pf T2 PA heparin sodium,porcine in 0.9 % sodium chloride (sod,porcine/0.9 % 2500/250ml iv soln, sod,porcine/0.9 % T2 PA 4000/500ml iv soln, sod,porcine/0.9 % 5000/5 ml syringe) heparin sodium,porcine/pf 5000/ml syringe T2 PA

PAGE 560 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEPLISAV-B 20 MCG/0.5 ML SYRNG T1 HEPLISAV-B 20 MCG/0.5 ML VIAL T1 S HERCEPTIN HYLECTA T2 PS PA S HIZENTRA (1 GRAM/5 ML SYRINGE, 2 GRAM/10 ML T2 PS SYRINGE, 4 GRAM/20 ML SYRINGE) PA HUMALOG JUNIOR KWIKPEN T1 QL 0.08 / day HUMIRA(CF) (10 MG/0.1 ML SYRING, 40 MG/0.4 ML AL At least 2 yrs T1 old SYRING) S PS QL 0.08 / day AL At least 2 yrs HUMIRA(CF) PEDIATRIC CROHN'S T1 old S PS QL 0.08 / day AL At least 2 yrs HUMIRA(CF) PEN T1 old S PS QL 0.08 / day AL At least 2 yrs HUMIRA(CF) PEN CROHN'S-UC-HS T1 old S PS

PAGE 561 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.08 / day AL At least 2 yrs HUMIRA(CF) PEN PSOR-UV-ADOL HS T1 old S PS HYCLODEX T2 PA

DC SHORT ACTING hydromorphone hcl in 0.9% nacl 250 mg/250 pump resvr T2 OPIOIDS PA hydromorphone hcl in 0.9 % sodium chloride/pf (hcl/0.9% nacl/pf 1 mg/5 ml syringe, hcl/0.9% nacl/pf 12mg/30ml T2 PA pca syring, hcl/0.9% nacl/pf 25 mg/25ml pca syring) S HYPERRAB T2 PS PA QL 1.25 / day IBRANCE 100 MG TABLET T2 PA QL 1 / day IBRANCE 125 MG TABLET T2 PA QL 1.667 / day IBRANCE 75 MG TABLET T2 PA QL 1 / day IDHIFA T2 PA ILIDERM T2 PA

AL At least 18 yrs old ILUMYA T2 S PS PA

PAGE 562 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 8 / day IMBRUVICA 70 MG CAPSULE T2 PA QL 4 / day IMBRUVICA 140 MG TABLET T2 PA QL 2 / day IMBRUVICA 280 MG TABLET T2 PA QL 1.47 / day IMBRUVICA 420 MG TABLET T2 PA QL 1 / day IMBRUVICA 560 MG TABLET T2 PA IMODIUM A-D 2 MG SOFTGEL T0 QL 4 / day IMPOYZ T2 PA IMVEXXY (4 MCG MAINTENANCE PACK, 4 MCG STARTER QL 1 / day PACK, 10 MCG MAINTENANCE PAK, 10 MCG STARTER T2 PACK) PA INFLATHERM(DICLOFENAC-MENTHOL) T2 PA infusion set for insulin pump infus.set T2 PA QL 2 / day INGREZZA 40 MG CAPSULE T2 PA QL 1 / day INGREZZA 80 MG CAPSULE T2 PA QL 1 / day AL At least 18 yrs old INGREZZA INITIATION PACK T2 S PS PA

PAGE 563 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INQOVI T2 PA insulin lispro 100/ml ins pen hf T1 insulin pump cartridge T1 PA insulin pump controller T1 PA INTRAROSA T1 QL 1 / day QL 0.4 / day INVELTYS T2 PA S ISENTRESS HD T1 PS ISTURISA T2 PA S JADENU SPRINKLE T2 PS PA JATENZO T2 PA S JEUVEAU T2 PS PA S JIVI T2 PS PA

AL 4.0 to 17.0 yrs JORNAY PM T2 old PA QL 1 / day S JULUCA T2 PS PA

PAGE 564 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS JYNARQUE (15 MG-15 MG TABLET, 30 MG-15 MG TABLET, QL 2 / day 45 MG-15 MG TABLET, 60 MG-30 MG TABLET, 90 MG-30 T2 MG TABLET) PA QL 2 / day KALYDECO 25 MG GRANULES PACKET T2 PA S KANJINTI T1 PS PA KAPSPARGO SPRINKLE T2 PA QL 10 / day KATERZIA T2 PA KETOCAL 2.5:1 T2 PA ketoconazole/niacinamide T2 PA ketoprofen 25 mg capsule T2 PA

AL At least 18 yrs KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 ML old SYRINGE, 200 MG/1.14 ML PEN INJ, 200 MG/1.14 ML T2 S SYRINGE) PS PA S KHAPZORY T2 PS PA QL 1 / day S KISQALI 200 MG DAILY DOSE T2 PS PA QL 2 / day S KISQALI 400 MG DAILY DOSE T2 PS PA

PAGE 565 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 3 / day S KISQALI 600 MG DAILY DOSE T2 PS PA kit for prep tc-99m/mertiatide (betiatide) T2 PA KOSELUGO T2 PA KRINTAFEL T2 PA KYNMOBI T2 PA S KYPROLIS 10 MG VIAL T2 PS PA labetalol hcl 50 mg/10ml syringe T2 PA labetalol in dextrose 5 % in water T2 PA lactobacillus acidophilus 500mm cell capsule T0 lancing device, vacuum/lancets T1 QL 3 / day LENVIMA (4 MG CAPSULE, 12 MG DAILY DOSE) T2 PA S leucovorin calcium 10 mg/ml vial T2 PS PA S levoleucovorin calcium 175 mg vial T2 PS PA

DC LONG ACTING levorphanol tartrate 3 mg tablet T2 OPIOIDS PA

PAGE 566 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levothyroxine sodium (100mcg/5ml vial, 200mcg/5ml vial, T2 PA 500mcg/5ml vial) LEXETTE T2 PA LICART T2 PA lidocaine hcl 50 mg/5 ml syringe T2 PA lidocaine hcl buffered with 8.4 % sodium bicarbonate (1.8 T2 PA %(3ml) syringe, 1.8 %(5ml) syringe) lidocaine hcl in 0.9 % nacl/pf 10mg/ml(1) syringe T2 PA lidocaine hcl/pf (hcl/pf 40 mg/2 ml syringe, hcl/pf T2 PA 400mg/20ml syringe) LIDOTIN T2 PA LIDOTREX 2%-1.2%-1% WOUND GEL T2 PA LIDTOPIC MAX T2 PA QL 1 / day LINZESS 72 MCG CAPSULE T1 AL At least 6 yrs old PA LIPIODOL 4.8 GM/10 ML VIAL T2 PA LIPRITIN T2 PA LIPRITIN II T2 PA LIQUACEL LIQ PROTEIN PUMP-GO T2 PA liquid base no.223 T2 PA QL 1 / day LOKELMA T2 PA lollipop base no.232 T2 PA lollipop base no.233 T2 PA

PAGE 567 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LONHALA MAGNAIR REFILL T2 PA LONHALA MAGNAIR STARTER T2 PA LORMATE T2 PA QL 10 / fill LOTEMAX SM T2 PA QL 0.267 / DAY LUCEMYRA T2 PA QL 0.04 / day S LUCENTIS 0.5 MG/0.05 ML SYRING T2 PS PA LYNPARZA T2 PA QL 3 / day LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) T2 PA QL 2 / day LYRICA CR 330 MG TABLET T2 PA LYUMJEV T2 PA LYUMJEV KWIKPEN U-100 T2 PA LYUMJEV KWIKPEN U-200 T2 PA magnesium glycinate 10 % powder T2 PA magnesium sulfate in 0.9 % sodium chloride (in 1 g/100 ml piggyback, in 6 g/50 ml piggyback, in 10 g/250ml T2 PA plast. bag, in 40g/1000ml plast. bag)

PAGE 568 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS magnesium sulfate/dextrose 5 % in water (sulfate/d5w 40 g/500ml plast. bag, sulfate/d5w 40g/1000ml plast. bag, T2 PA sulfate/d5w 5 g/100 ml piggyback, sulfate/d5w 6 g/100 ml piggyback, sulfate/d5w 6 g/50 ml piggyback) S MAKENA 275 MG/1.1 ML AUTOINJCT T1 PS QL 0.667 / DAY MAVENCLAD T2 PA

AL At least 12 yrs old MAVYRET T1 S PS PA MAXI-TUSS CD T2 PA QL 2.5 / day S MAYZENT 0.25 MG STARTER PACK T2 PS PA QL 4 / DAY S MAYZENT 0.25 MG TABLET T2 PS PA QL 1 / day S MAYZENT 2 MG TABLET T2 PS PA methacholine chloride (0-48mg/3ml vial-neb, 0.1875/3ml vial-neb, 0.75/3ml vial-neb, 3 mg/3 ml vial-neb, 12 mg/3 T2 PA ml vial-neb, 48 mg/3 ml vial-neb)

PAGE 569 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methadone hcl 5 mg/0.5ml syringe T2 PA

DC LONG ACTING methadone in 0.9 % sod.chlorid 2.5 mg/0.5 syringe T2 OPIOIDS PA sodium in sterile water for injection/pf T2 PA

AL 4.0 to 17.0 yrs methylphenidate hcl 72 mg tab er 24 T2 old PA methylprednisolone acetate in sodium chloride,iso- T2 PA osmotic/pf methylprednisolone acetate in sterile water for injection T2 PA microplegic solution no.1/citrate phosphate double T2 PA dextrose midazolam in 0.9 % sod.chlorid 55 mg/55ml syringe T2 PA midazolam in 5 % dextrose 1 mg/ml plast. bag T2 PA midazolam in sodium chloride, iso-osmotic/pf T2 PA minocycline hcl (45 mg cap er 24h, 90 mg cap er 24h, 135 T2 PA mg cap er 24h) S MIRCERA (30 MCG/0.3 ML SYRINGE, 150 MCG/0.3 ML T2 PS SYRINGE) PA S mitomycin 20 mg/40ml syringe T2 PS PA MONJUVI T2 PA

DC LONG ACTING MORPHABOND ER T2 OPIOIDS PA

PAGE 570 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS morphine sulfate in 0.9 % sodium chloride (in 0.9 % 10 DC SHORT ACTING T2 OPIOIDS mg/ml plast. bag, in 0.9 % 1000mg/100 pump resvr) PA morphine sulfate in 0.9 % sodium chloride (in 0.9 % 150mg/30ml pca syring, in 0.9 % 3 mg/3 ml syringe, in 0.9 T2 PA % 50 mg/25ml pca syring) QL 100 / day morphine sulfate/0.9% nacl/pf 0.5mg/.5ml syringe T2 PA morphine sulfate/dextrose 5 % in water T2 PA QL 1 / day MOTEGRITY T2 PA GNP MOTION SICKNESS RLF 25 MG T1 moxifloxacin hcl in sodium chloride,iso-osmotic/pf (in nacl,iso-os/pf 0.8mg/0.8 vial, in nacl,iso-os/pf 4 mg/0.8ml T2 PA vial) S MULPLETA T2 PS PA S MVASI T2 PS PA QL 2 / day MYCAPSSA T2 PA

AL 4.0 to 17.0 yrs MYDAYIS T2 old PA MYXREDLIN T2 PA

DC SHORT ACTING NALOCET T2 OPIOIDS PA

PAGE 571 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS naltrexone T2 PA QL 0.334 / DAY NAYZILAM T2 PA NEOVITE T2 PA QL 6 / day NERLYNX T2 PA NEXLETOL T2 PA NEXLIZET T2 PA nicardipine hcl-0.9% sod chlor 0.5 mg/5ml syringe T2 PA nifedipine, micronized T2 PA NITYR T2 PA S NIVESTYM (300 MCG/0.5 ML SYRING, 480 MCG/0.8 ML T2 PS SYRING) PA QL 0.1 / DAY NOCTIVA T2 PA NOPIOID-TC KIT T2 PA norepinephrine bitartrate in 0.9 % sodium chloride (bit/0.9 % 0.16 mg/10 syringe, bit/0.9 % 15mg/250ml T2 PA plast. bag) norepinephrine bitartrate in 0.9 % sodium chloride/pf T2 PA norepinephrine bitartrate in 5 % dextrose in water (bitartrate/d5w 0.16 mg/10 syringe, bitartrate/d5w 100 T2 PA mcg/10 syringe) NORGESIC FORTE T2 PA S NORVIR 100 MG POWDER PACKET T2 PS PA

PAGE 572 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day NOURIANZ T2 PA S NOVAREL 5,000 UNIT VIAL T2 PS PA NOVOLIN R FLEXPEN T2 PA S NPLATE 125 MCG VIAL T2 PS PA QL 0.04 / day NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/ML S T2 SYRINGE) PS PA NUCARACLINPAK T2 PA NUCARARXPAK T2 PA NUMBRINO T2 PA QL 1 / day NUPLAZID (10 MG TABLET, 34 MG CAPSULE) T2 PA QL 0.54 / day NURTEC ODT T2 PA

NYMALIZE (30 MG/5 ML ORAL SYRNG, 60 MG/10 ML QL 60 / day T2 ORAL SYRN) PA oats extract T2 PA OBTREX DHA T2 PA QL 1 / day ODACTRA T2 PA

PAGE 573 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S OGIVRI T1 PS PA QL 1 / day S OLUMIANT 1 MG TABLET T2 PS PA S OLUMIANT 2 MG TABLET T2 PS PA OMEGAVEN T2 PA omeprazole 20 mg tab rap dr T1 OMNIPAQUE 12 MG/ML ORAL SOLN T2 PA S ondansetron hcl in 0.9 % nacl 16mg/100ml piggyback T2 PS PA S ondansetron hcl in dextrose 5% in water T2 PS PA S ONTRUZANT T1 PS PA S OPDIVO 240 MG/24 ML VIAL T2 PS PA OPTIRAY 240 (240 MG/ML) SYRN T2 PA orange extract T2 PA

PAGE 574 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ORAPEUTIC T2 PA S ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML T2 PS SYRINGE) PA QL 3 / day ORENITRAM ER 5 MG TABLET T2 PA ORIAHNN T2 PA QL 1 / day ORILISSA 150 MG TABLET T2 PA QL 2 / day ORILISSA 200 MG TABLET T2 PA

ORKAMBI (100-125 MG GRANULE PKT, 150-188 MG QL 2 / day T2 GRANULE PKT) PA orphenadrine citrate/aspirin/caffeine T2 PA ORPHENGESIC FORTE T2 PA QL 2 / day OSMOLEX ER 322 MG DAILY DOSE T2 PA OVEEZA T2 PA QL 3 / day OXBRYTA T2 PA QL 12 / day oxycodone hcl/acetaminophen 2.5-300 mg tablet T1 DC SHORT ACTING OPIOIDS OZEMPIC T2 PA OZOBAX T2 PA PADCEV T2 PA

PAGE 575 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1.5 / day PALFORZIA (3 MG 1), 12 MG 3)) T1 PA

PALFORZIA (40 MG (LEVEL 5), 200 MG (LEVEL 9), 300 MG QL 31 / 30 days T1 (MAINTENANCE)) PA QL 2 / day PALFORZIA (80 MG 6), 160 MG 8), 240 MG 10)) T1 PA QL 1.034 / DAY PALFORZIA 120 MG (LEVEL 7) T1 PA QL 3 / day PALFORZIA 6 MG (LEVEL 2) T1 PA QL 0.434 / day PALFORZIA INITIAL DOSE PACK T1 PA QL 0.5 / DAY PALFORZIA (20 MG 4), 300 MG 11)) T1 PA S palonosetron hcl (0.25mg/2ml vial, 0.25mg/5ml syringe) T2 PS PA QL 2 / day PALYNZIQ (10 MG/0.5 ML SYRINGE, 20 MG/ML SYRINGE) T2 PA QL 8 / day PALYNZIQ 2.5 MG/0.5 ML SYRINGE T2 PA S PANHEMATIN T2 PA S PANZYGA T2 PS PA

PAGE 576 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS S PARSABIV T2 PS PA PATADAY 0.1% EYE DROPS T2 PA peanut extract T2 PA pecan extract T2 PA PEDIZOL PAK T2 PA PEMAZYRE T2 PA pen needle, diabetic, safety (pen 29gx 5/16" dis needle, pen 29gx3/16" dis needle, pen 31 g x1/4" dis needle, pen T1 31 gx3/16" dis needle, pen 31 gx5/16" dis needle) PENTICAN T2 PA

AL At least 18 yrs PERSERIS T2 old PA PERTZYE DR 24,000 UNIT CAPSULE T2 PA maleate T2 PA PHENYLADE GMP MIX-IN POWDER T2 PA phenylephrine hcl in 0.9 % sodium chloride (in 10mg/100ml plast. bag, in 10mg/250ml plast. bag, in 100 T2 PA mcg/10 syringe, in 200mg/.25l plast. bag, in 1200mcg/10 syringe) phenylephrine hcl in dextrose 5 % in water (hcl/dextrose 5 % 100mg/250 plast. bag, hcl/dextrose 5 % 20mg/500ml plast. bag, hcl/dextrose 5 % 25mg/250ml plast. bag, T2 PA hcl/dextrose 5 % 30mg/250ml plast. bag, hcl/dextrose 5 % 8 mg/100ml plast. bag) phenylephrine hcl in sterile water for injection (in T2 PA 0.4mg/10ml syringe, in 1 mg/10 ml syringe)

PAGE 577 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS citrate (dihydrogen) T2 PA S PHESGO T2 PA PHEXXI T2 PA S PIFELTRO T2 PS PA QL 2 / day S PIQRAY (250 MG DAILY, 300 MG DAILY) T2 PS PA QL 1 / day S PIQRAY 200 MG DAILY DOSE T2 PS PA pistachio nut extract T2 PA poloxalene 100 % beads T2 PA polyethylene glycol 4500 T2 PA pork extract T2 PA potassium chloride in 0.9 % sodium chloride (in 10 meq/l T2 PA iv soln, in 10meq/0.1l piggyback) QL 1 / day pretomanid T2 PA S PREVYMIS (240 MG TABLET, 240 MG/12 ML VIAL, 480 MG T2 PS TABLET, 480 MG/24 ML VIAL) PA

PAGE 578 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRILO PATCH T2 PA PRIMACARE T2 PA PRIMATENE MIST T2 PA PRIZOTRAL-II T2 PA CVS PROBIOTIC 100 BIL CELL CAP T0 PROBIOTIC ACIDOPHILUS 250 MILL T0 PROBIOTIC PLUS COLOSTRUM T0 PROCYSBI (DR 75 MG GRANULE PKT, DR 300 MG T2 PA GRANULE PKT) S PROGRAF (0.2 MG GRANULE PACKET, 1 MG GRANULE T2 PS PACKET) PA S PROMACTA (12.5 MG SUSPEN PACKET, 25 MG T2 PS SUSPENSION PCKT) PA PROMELLA T2 PA PROPOVEN (EUA) T2 PA PROSILK GEL T2 PA QL 1 / day QBREXZA T2 PA QINLOCK T2 PA QL 1 / day QMIIZ ODT T2 PA

AL At least 18 yrs QTERN 10 MG-5 MG TABLET T2 old PA

PAGE 579 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day QTERN 5 MG-5 MG TABLET T2 AL At least 18 yrs old PA QUZYTTIR T2 PA S REBINYN T2 PS PA S REBLOZYL T2 PS PA RECARBRIO T2 PA RELAFEN DS T2 PA

AL 4.0 to 17.0 yrs RELEXXII T2 old PA remdesivir (100 mg vial, 100mg/20ml vial) T2 PA REMEDIENT T2 PA REMEDY PHYTOPLEX MOISTURIZER T2 PA RETACRIT (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL, S 4,000 UNIT/ML VIAL, 10,000 UNIT/ML VIAL, 40,000 T1 UNIT/ML VIAL) PS RETEVMO T2 PA QL 1.667 / DAY RETIN-A MICRO PUMP 0.06% GEL T2 PA QL 0.3 / day REYVOW 100 MG TABLET T2 AL At least 18 yrs old PA

PAGE 580 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.134 / DAY REYVOW 50 MG TABLET T2 AL At least 18 yrs old PA QL 1.25 / day RHOFADE T2 PA RHOPRESSA T1 QL 0.1 / DAY rice extract T2 PA rice starch T2 PA S RINVOQ T2 PS PA QL 20 / day RIOMET ER T2 PA S RITUXAN HYCELA T2 PS PA ROBITUSSIN COUGH-CHEST CONG DM T2 PA ROCKLATAN T1 QL 0.1 / day ropivacaine hcl/pf 5 mg/ml plast. bag T2 PA

DC SHORT ACTING ROXYBOND (15 MG TABLET, 30 MG TABLET) T2 OPIOIDS PA QL 2 / day RUBRACA T2 PA RUKOBIA T1 S S RUXIENCE T1 PS PA

PAGE 581 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day RUZURGI T2 PA QL 1 / day RYBELSUS T2 AL At least 18 yrs old PA RYCLORA T2 PA QL 2 / day S RYDAPT T2 PS PA RYVENT T2 PA SARCLISA T2 PA SCENESSE T2 PA QL 1 / day SECUADO T2 PA

AL At least 18 yrs SEGLUROMET T2 old PA

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 S T1 MG TABLET) PS sesame seed extract T2 PA

SHINGRIX T1 AL At least 50 yrs old SHINGRIX ADJUVANT COMPONENT T2 PA

SHINGRIX GE ANTIGEN COMPONENT T1 AL At least 50 yrs old shrimp extract T2 PA

PAGE 582 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.1 / DAY SIGNIFOR LAR (10 MG KIT, 10 MG VIAL, 30 MG KIT, 30 MG T2 PS VIAL) PA S SIKLOS T2 PS PA

AL At least 18 yrs old SILIQ T2 S PS PA silver/silicone/foam bandage T2 PA QL 5 / day simvastatin 20 mg/5 ml oral susp T2 PA SIRTURO 20 MG TABLET T2 PA QL 0.07 / day S SKYRIZI T2 PS PA QL 0.04 / day S SKYRIZI (2 SYRINGES) KIT T2 PS PA SLYND T2 PA sodium aspartate monohydrate T2 PA sodium fluoride f-18 T2 PA sodium phosphate in 0.9 % nacl 30mmol/250 plast. bag T2 PA

PAGE 583 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium phosphate in 5 % dextrose in water T2 PA QL 1 / fill SOLOSEC T2 PA S SOVALDI (150 MG PELLET PACKET, 200 MG PELLET T2 PS PACKET) PA S SOVALDI 200 MG TABLET T2 PS PA soybean extract T2 PA QL 8 / 28 days SPRAVATO T2 PA S stabilizer for blinatumomab T2 PA STAMARIL T1

AL At least 18 yrs STEGLATRO T2 old PA

AL At least 18 yrs STEGLUJAN T2 old PA S STERILE HYDROGEL FOR JELMYTO T2 PA strawberry extract T2 PA subcutaneous bolus insulin patch pump, 200 unit, T2 PA disposable

AL Up to 999 yrs old SUBLOCADE T1 S PS PA

PAGE 584 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day SUNOSI T2 PA suppository base no.234 T2 PA QL 2 / day SYMDEKO T2 PA S SYMFI T1 PS S SYMFI LO T1 PS QL 2 / fill SYMJEPI T2 PA QL 2 / day S SYMPAZAN T2 PS PA QL 1 / day SYMPROIC T2 PA S SYMTUZA T1 PS QL 13 / day SYNDROS T2 PA

AL At least 18 yrs SYNJARDY XR T2 old PA syringe cap, enfit,non-sterile T1 syringe,needle,insuln,sf,0.3ml 31gx15/64" disp syrin T1 syringe,needle,insuln,sf 0.5ml 31gx15/64" disp syrin T1

PAGE 585 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS syringe,needle,insuln,safe,1ml 31gx15/64" disp syrin T1 syringe and needle,insulin,1ml 30gx15/64" disp syrin T1 syrge-ndl,ins 0.3 ml half mark 30gx1/2" disp syrin T1 syringe with needle,insulin 0.5 ml (half unit mark) T1 syring-needl,disp,insul,0.3 ml 30gx15/64" disp syrin T1 syringe, enfit 1 ml, non-sterile T1 syringe, enfit 1 ml, sterile T1 syringe, enfit 12 ml, non-sterile T1 syringe, enfit 12 ml, sterile T1 syringe, enfit 3 ml, sterile T2 PA syringe, enfit 35 ml, non-sterile T1 syringe, enfit 35 ml, sterile T1 syringe, enfit 6 ml, non-sterile T1 syringe, enfit 6 ml, sterile T1 syringe, enfit 60 ml, non-sterile T1 syringe, enfit 60 ml, sterile T1 syringe,enfit 3 ml,non-sterile T1 syringe,safety with needle,1 ml (23gx1" disp syrin, T2 PA 27gx5/8" disp syrin) S TABRECTA T2 PS PA tadalafil 100 % powder T2 PA QL 0.144 / day TAKHZYRO T2 PA

PAGE 586 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 12 / day TALICIA T2 PA TAPERDEX (7 1.5 MG TAB PACK, 12 1.5 MG TABLET) T2 PA QL 6 / day S TASIGNA 50 MG CAPSULE T2 PS PA TASOPROL T2 PA TAVALISSE T2 PA TAZVERIK T2 PA TECARTUS T2 PA S TECENTRIQ 840 MG/14 ML VIAL T2 PA TECHNELITE TC-99M GENERATOR T2 PA QL 1 / day TEMIXYS T1 S PS TENDERA-OB T2 PA S TEPADINA 100 MG VIAL T2 PS PA TEPEZZA T2 PA S T1 PS PA tetrahydrocurcumin T2 PA

PAGE 587 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THIOLA EC 300 MG TABLET T2 PA S thiotepa 100 mg vial T2 PS PA TICALAST T2 PA QL 1 / day TIROSINT-SOL T2 PA TISSUEBLUE T2 PA S TIVICAY PD T1 PS S TOLSURA T2 PS PA QL 0.4 / day TOSYMRA T2 PA TOUJEO MAX SOLOSTAR T2 PA TPOXX (NATIONAL STOCKPILE) T2 PA QL 2 / day TRACLEER 32 MG TABLET FOR SUSP T2 PA QL 4 / day AL At least 12 yrs tramadol hcl 100 mg tablet T1 old DC SHORT ACTING OPIOIDS S TRAZIMERA T1 PS PA

PAGE 588 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 18 yrs TRELEGY ELLIPTA 100-62.5-25 T2 old PA S TREMFYA (100 MG/ML INJECTOR, 100 MG/ML SYRINGE) T2 PS PA TRESIBA T2 PA triamcinolone aceton/0.9% nacl 50 mg/ml vial T2 PA triamcinolone diacetate in 0.9 % sodium chloride T2 PA triamcinolone diacetate in 0.9 % sodium chloride/pf T2 PA S TRIFERIC 272 MG POWDER PACKET T2 PS PA

AL At least 18 yrs TRIJARDY XR T2 old PA QL 3 / day TRIKAFTA T2 PA S TRISENOX T2 PS PA troche base no.235 T2 PA tromethamine in sterile water for injection T2 PA QL 1 / day TRULANCE T1 PA S TRUXIMA T2 PS PA

PAGE 589 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TUKYSA T2 PA QL 2 / day TUXARIN ER T2 PA TWIRLA T2 PA QL 1.6 / day S TYMLOS T2 PS PA QL 0.54 / day UBRELVY T1 AL At least 18 yrs old ULTIMATE PROBIOTIC-10 T0 S UPLIZNA T2 PA UPNEEQ T2 PA urinary bag/catheter 14 fr-16 " combo. pkg T2 PA QL 0.334 / DAY VALTOCO T1 AL At least 6 yrs old vancomycin hcl (1.25 g vial, 1.5 g vial, 50 mg/ml soln T2 PA recon) vancomycin hcl in water for injection (peg-400, nada) (vancomycin/water inj 1.25 g/250 piggyback, T2 PA vancomycin/water inj 1.5g/300ml piggyback, vancomycin/water inj 1.75 g/350 piggyback) vancomycin hcl/balanced salt solution no.2/pf T2 PA vancomycin in 0.9 % sodium chloride (vancomycin/0.9 % 1.5g/300ml plast. bag, vancomycin/0.9 % 1g/150ml plast. T2 PA bag)

PAGE 590 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS vancomycin in 5 % dextrose in water (in 5 % 1.5g/500ml plast. bag, in 5 % 1.75 g/500 plast. bag, in 5 % 2 g/500 ml T2 PA plast. bag) VARUBI 166.5 MG/92.5 ML VIAL T2 PA vasopressin in 0.9 % nacl 20/50 ml plast. bag T2 PA QL 2 / day VERZENIO T2 PA VILTEPSO T2 PA QL 2 / day VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 100 S T2 MG CAPSULE) PS PA QL 3.73 / day S VUMERITY T2 PS PA VYEPTI T2 PA QL 1 / day VYNDAMAX T2 PA VYONDYS-53 T2 PA VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET, T1 AL 4.0 to 17.0 yrs 40 MG TABLET, 50 MG TABLET, 60 MG TABLET) old QL 0.25 / day VYZULTA T2 PA QL 2 / day WAKIX T2 PA QL 1 / day XADAGO T2 PA

PAGE 591 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XARELTO 2.5 MG TABLET T1 XATMEP T2 PA XCOPRI (12.5-25 MG TITRATION PK, 50 MG TABLET, 50- 100 MG TITRATION PAK, 100 MG TABLET, 150 MG T2 PA TABLET, 150-200 MG TITRATION PK, 200 MG TABLET, 250 MG DAILY DOSE PACK, 350 MG DAILY DOSE PACK) S XELJANZ 10 MG TABLET T2 PS PA S XELJANZ XR 22 MG TABLET T2 PS PA QL 0.1 / DAY XELPROS T2 PA XEMBIFY T2 PA 133 in dioxide T2 PA XEPI T2 PA XERMELO T2 PA QL 1.25 / day XHANCE T2 PA

XIGDUO XR 2.5 MG-1,000 MG TAB T1 AL At least 18 yrs old XIMINO T2 PA QL 2 / fill XOFLUZA T2 PA QL 0.15 / day S XOLAIR 150 MG/ML SYRINGE T2 PS PA

PAGE 592 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 0.04 / day S XOLAIR 75 MG/0.5 ML SYRINGE T2 PS PA QL 3 / day XOSPATA T2 PA XPOVIO (40 MG ONCE, 40 MG TWICE, 60 MG TWICE) T2 PA XYZMUNE T2 PA QL 4 / day S YONSA T2 PS PA

AL At least 18 yrs YUPELRI T2 old PA ZALVIT T2 PA ZCORT T2 PA QL 3 / day ZEJULA T2 PA QL 1 / day ZEPOSIA (0.23-0.46 MG START PCK, 0.23-0.46-0.92 MG S T2 KIT, 0.92 MG CAPSULE) PS PA ZEPZELCA T2 PA QL 2 / day ZERVIATE T2 PA S ZIEXTENZO T2 PS PA

PAGE 593 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZILXI T2 PA zinc sulfate 3 mg/ml vial T2 PA S ZIRABEV T1 PS PA ZOLPAK T2 PA S ZORTRESS 1 MG TABLET T2 PS PA QL 3 / day ZTLIDO T2 PA QL 2 / day ZUBSOLV 0.7-0.18 MG TABLET SL T2 AL At least 16 yrs old PA QL 8 / day AL At least 18 yrs old ZYKADIA 150 MG TABLET T2 S PS PA QL 1 / day ZYPITAMAG T2 PA

PAGE 594 LAST UPDATED 01/2021 Index of Covered Drugs 8 HOUR PAIN RELIEF 198 ( 8HR ARTHRITIS PAIN 198 (d)-limonene flavor 324 8HR ARTHRITIS PAIN RELIEF 198

0 A 0.9 % sodium chloride 495 A AND D 211 A AND D DIAPER RASH 211 1 A THRU Z 507 1,2-pentanediol 324 A THRU Z ADVANCED FORMULA 507 1,3-butanediol 325 A THRU Z SELECT 507 1,4-benzoquinone 325 A THRU Z SELECT 50 PLUS 507 12 HOUR DECONGESTANT 325 A-HYDROCORT 280 12 HOUR NASAL DECONGESTANT 325 abacavir sulfate 136 12 HOUR NASAL RELIEF 325 abacavir sulfate/lamivudine 136 12 HOUR NASAL SPRAY 325 abacavir sulfate/lamivudine/zidovudine 136 12-HOUR COUGH RELIEF 467 ABATINEX 249 ABATUSS DMX 467 2 ABC PLUS 507 2-deoxy-d-glucose 325 ABELCET 77 2-methoxyestradiol 325 ABILIFY 121 2-methoxyethanol 325 ABILIFY MAINTENA 121 24HOUR ALLERGY 450 ABILIFY MYCITE 541 24HR ALLERGY RELIEF 450 abiraterone acetate 92 ABRAXANE 97 3 ABREVA 211 3 DAY VAGINAL 77 ABSORICA 211 3,5-diiodothyronine 325 ABSORICA LD 541 3-DAY VAGINAL CREAM 77 ABSTRAL 11 acacia 325 4 acamprosate calcium 38 4 WAY 325 ACANYA 211 acarbose 146 5 ACCOLATE 458 5-hydroxy-l-tryptophan (oxitriptan) 325 ACCUPRIL 166 ACCURETIC 176 7 ACD SOLUTION A 154 7-oxodehydroepiandrosterone 325 ACD-A 154,541 7-oxodehydroepiandrosterone, micronized 325 acebutolol hcl 170,325 acepromazine maleate 325 8 ACERFLEX 507 8 HOUR ACETAMINOPHEN 198 acesulfame potassium 325 ACETADOTE 325 ACTEMRA 317 ACETADRYL 491 ACTEMRA ACTPEN 542 acetaminophen 199,325,541 ACTHAR 283 ACETAMINOPHEN CONGESTION-PAIN 467 ACTHIB 318 ACETAMINOPHEN PM 491 ACTHREL 326 ACETAMINOPHEN PM XTRA STRENGTH 491 ACTICLATE 55 acetaminophen with codeine phosphate 11,12 ACTICON 467 acetaminophen/caffeine/dihydrocodeine ACTIGALL 249 bitartrate 12,541 ACTIMMUNE 317 acetaminophen/diphenhydramine hcl 491 ACTIQ 12 acetarsol 325 ACTIVASE 154 acetazolamide 184,325 activated charcoal 326 acetazolamide sodium 184 ACTIVE FE 495 acetic acid 42,326,447 ACTIVELLA 287 acetone 326 ACTONEL 321 acetyl hexapeptide-8 326 ACTOPLUS MET 146 acetylcarnitine hcl 326 ACTOPLUS MET XR 146 acetylcholine chloride 326 ACTOS 146 acetylcysteine 326,467,507 ACULAR 442 acetylcysteine in sterile water/pf 432 ACULAR LS 442 acetylglucosamine 326 ACUVAIL 443 ACID CONTROL 261 acyclovir 141,326 ACID CONTROLLER 40,261 acyclovir sodium 141 ACID CONTROLLER COMPLETE 261 acyclovir sodium/dextrose 5 % in water 141 ACID GONE 249 ACZONE 211 ACID GONE ANTACID 249 ADACEL TDAP 318 acid green 50 326 ADAGEN 245 ACID REDUCER 262,272 ADAKVEO 542 ACID REDUCER 150 262 ADALAT CC 172 ACID REDUCER COMPLETE 262 adapalene 212,542 ACIPHEX 272 adapalene/benzoyl peroxide 212 ACIPHEX SPRINKLE 272 adapter cap for bottle 326 acitretin 211 ADASUVE 120 ACNE CLEANSING BAR 211 ADCETRIS 113 ACNE MEDICATION 211 ADCIRCA 464 ACNE TREATMENT CLEANSING BAR 211 ADDAMEL N 495 ACNECLEAR 211 ADDED STRENGTH HEADACHE 3 ACNEFREE 211 ADDERALL 194 ACNEFREE SEVERE 211 ADDERALL XR 194 acrylamide/sod acryloyldimethyl taurat copoly adefovir dipivoxil 131 isohex poly 80 326 ADEMPAS 464 ADENOSCAN 168 ADVATE 159 adenosine 168,326 ADVIL JUNIOR STRENGTH 3 adenosine triphosphate disodium trihydrate 326 ADYNOVATE 159 ADHANSIA XR 542 ADYPHREN 459 adhesive bandage 326 ADYPHREN AMP 459 adhesive tape 326 ADYPHREN AMP II 542 ADLT WAL-TUSSIN COUGH-COLD CF 467 ADYPHREN II 542 ADLYXIN 146 ADZENYS ER 542 ADMELOG 152 ADZENYS XR-ODT 194 ADMELOG SOLOSTAR 152 AF 77 ADRENALIN 459 AFEDITAB CR 172 ADRENALIN CHLORIDE 459 AFINITOR 106 ADREVIEW 326 AFINITOR DISPERZ 106 ADRIAMYCIN 97 AFIRMELLE 287 ADRUCIL 94 AFLURIA QUAD 2019-20 (3YR UP) 542 ADULT 50 + PROBIOTIC 249 AFLURIA QUAD 2019-20 (6-35MO) 542 ADULT COUGH FORMULA DM MAX 467 AFLURIA QUAD 2019-2020 542 ADULT DM MAXIMUM 467 AFLURIA QUAD 2020-2021 542 ADULT GLYCERIN 264 AFLURIA QUAD 2020-21 (3YR UP) 542 ADULT LOW DOSE ASPIRIN EC 3 AFLURIA QUAD 2020-21 (6-35MO) 542 ADULT MULTI GUMMIES 507 AFREZZA 152,542 ADULT MULTIVITAMIN GUMMIES 507 AFSTYLA 159 ADULT NASAL DECONGESTANT 326 AFTERA 287 ADULT ONE DAILY GUMMIES 507 AGGRASTAT 154,163 ADULT PROBIOTIC 249 AGGRENOX 163 ADULT TUSSIN CHEST CONGESTION 467 AGRYLIN 157 ADULT TUSSIN COUGH CONGEST DM 467 AIMOVIG AUTOINJECTOR 543 ADULT TUSSIN DM 467 AIMOVIG AUTOINJECTOR (2 PACK) 543 ADULT TUSSIN MULTI-SYMP COLD 467 AIRDUO RESPICLICK 543 ADULT WAL-TUSSIN 467 AJOVY AUTOINJECTOR 543 ADULT WAL-TUSSIN DM 467 AJOVY SYRINGE 543 ADULT WAL-TUSSIN DM MAX 467 AK-FLUOR 432 ADULTS 50 PLUS DAILY FORMULA 507 AK-POLY-BAC 433 ADULTS 50 PLUS MULTIVITAMIN 507 AKLIEF 543 ADVAIR DISKUS 468 AKOVAZ 176 ADVAIR HFA 468 AKTEN 433 ADVANCED ACNE WASH 212 AKTIPAK 212 ADVANCED ANTACID 249 AKYNZEO 73,543 ADVANCED ANTACID-ANTIGAS 249 ALA-CORT 212 ADVANCED EXFOLIATING CLEANSER 212 ALA-HIST PE 468 ADVANCED PROBIOTIC 249 ALA-QUIN 212 ALA-SCALP 212 ALKERAN 90 alanine 326 alkyl (c12-15) benzoate 327 ALAVERT 450,468 alkyl acrylate crosspolymer 327 ALAWAY 441 ALL DAY ALLERGY 450 albendazole 115,327 ALL DAY ALLERGY RELIEF 450 ALBENZA 115 ALL DAY ALLERGY-D 468 ALBUKED-25 327 ALL DAY PAIN RELIEF 3 ALBUKED-5 327 ALL DAY RELIEF 3 albumin human 327 allantoin 327 ALBUMINAR-5 327 ALLER-CHLOR 450 ALBURX 327 ALLER-EASE 450 ALBUTEIN 327 ALLER-FEX 451 albuterol sulfate 327,459,460 ALLER-FLO 448 ALCAINE 433 ALLER-G-TIME 451 ALCALAK 249 ALLER-TEC 451 alclometasone dipropionate 212 ALLER-TEC D 468 alcohol 327 ALLERCLEAR 451 alcohol antiseptic pads 327 ALLERCLEAR D-12HR 468 ALCORTIN A 212 ALLERCLEAR D-24HR 468 ALDACTAZIDE 176,185 allergenic extract tree pollen-american elm 327 ALDACTONE 185 allergenic extract, grass pollen-bermuda, ALDARA 212 standard 327 aldosterone 327 allergenic extract, grass pollen-orchard grass, ALDURAZYME 245 standard 327 ALECENSA 106 allergenic extract, mite-d.farinae- alendronate sodium 321,322 d.pteronyssinus,standard 327 ALER-CAPS 450 allergenic extract,grass pollen-june(kentucky ALEVAZOL 77 blue),standard 327 alfentanil hcl 12 allergenic extract,grass pollen-redtop, ALFERON N 141 standard 327 alfuzosin hcl 276 allergenic extract,grass pollen- ALGAL-900 DHA 507 timothy,standard 327,328 alginic acid 327 allergenic extract,mite-dermatophagoides ALIGN 249 pteronyssinus, std 328 ALIGN JR 249 allergenic extract-american cockroach 328 ALIMTA 94 allergenic extract-aspergillus fumigatus 544 ALINIA 116 allergenic extract-aureobasidium pullulans 544 ALIQOPA 544 allergenic extract-botrytis cinerea 544 aliskiren hemifumarate 176 allergenic extract-cattle epithelium 328 ALKA-SELTZER PLUS DAY 468 allergenic extract-cladosporium ALKA-SELTZER PLUS SINUS-COUGH 468 cladosporioides 544 allergenic extract-cockroach (american and allergenic extract-tree pollen-elm, cedar 329 german) 328 allergenic extract-tree pollen-hackberry 329 allergenic extract-corn smut 328 allergenic extract-tree pollen-juniper, western 329 allergenic extract-cultivated crop pollen-corn 328 allergenic extract-tree pollen-kapok 329 allergenic extract-dog epithelium 328 allergenic extract-tree pollen-melaleuca 329 allergenic extract-epicoccum nigrum 544 allergenic extract-tree pollen-mesquite 329 allergenic extract-fire ant 328 allergenic extract-tree pollen-mountain cedar 329 allergenic extract-german cockroach 328 allergenic extract-tree pollen-mulberry, red 329 allergenic extract-grass pollen-bahia 328 allergenic extract-tree pollen-mulberry, white 329 allergenic extract-grass pollen-johnson 328 allergenic extract-tree pollen-olive 330 allergenic extract-grass pollen-meadow fescue, allergenic extract-tree pollen-palm, queen 330 standardized 328 allergenic extract-tree pollen-pecan 330 allergenic extract-grass pollen-perennial rye, allergenic extract-tree pollen-pepper tree, standard 328 california 330 allergenic extract-grass pollen-quack 328 allergenic extract-tree pollen-pine, white 330 allergenic extract-grass pollen-smooth brome 328 allergenic extract-tree pollen-privet 330 allergenic extract-horse epithelium 328 allergenic extract-tree pollen-red birch 330 allergenic extract-mixed feathers, chicken, duck, allergenic extract-tree pollen-red cedar 330 goose 328 allergenic extract-tree pollen-red maple 330 allergenic extract-mixed weed pollen-short and allergenic extract-tree pollen-red oak 330 tall ragweed 328 allergenic extract-tree pollen-shagbark hickory330 allergenic extract-mosquito 328 allergenic extract-tree pollen-sweet gum 330 allergenic extract-mouse epithelium 328 allergenic extract-tree pollen-virginia live oak 330 allergenic extract-mucor plumbeus 544 allergenic extract-tree pollen-white ash 330 allergenic extract-penicillium notatum 544 allergenic extract-tree pollen-white birch 330 allergenic extract-rabbit epithelium 329 allergenic extract-tree pollen-white oak 330 allergenic extract-sweet vernal, standardized 329 allergenic extract-trichophyton allergenic extract-tree pollen-acacia 329 mentagrophytes 544 allergenic extract-tree pollen-alder white 329 allergenic extract-venom-honey bee 330 allergenic extract-tree pollen-american beech 329 allergenic extract-venom-mixed vespid allergenic extract-tree pollen-american protein 330 sycamore 329 allergenic extract-venom-wasp protein 330 allergenic extract-tree pollen-arizona cypress 329 allergenic extract-venom-white-faced hornet allergenic extract-tree pollen-australian pine 329 protein 330 allergenic extract-tree pollen-bald cypress 329 allergenic extract-venom-yellow hornet allergenic extract-tree pollen-bayberry 329 protein 330 allergenic extract-tree pollen-black walnut 329 allergenic extract-venom-yellow jacket allergenic extract-tree pollen-black willow 329 protein 330 allergenic extract-tree pollen-box elder 329 allergenic extract-weed pollen-carelessweed 330 allergenic extract-tree pollen-eastern allergenic extract-weed pollen-cocklebur 331 cottonwood 329 allergenic extract-weed pollen-dog fennel 331 allergenic extract-weed pollen-english ALLERGY-CONGESTION RELIEF-D 469 plantain 331 ALLERGY-TIME 452 allergenic extract-weed pollen-giant (tall) allopurinol 85,331 ragweed 331 allopurinol sodium 85 allergenic extract-weed pollen-goldenrod 331 ALLZITAL 199 allergenic extract-weed pollen-kochia ALMACONE 249 (firebush) 331 ALMACONE-2 249 allergenic extract-weed pollen-lambsquarters 331 almond extract 331 allergenic extract-weed pollen-mugwort 331 almond oil 331 allergenic extract-weed pollen-rough pigweed 331 almond oil/silicic acid/butylated allergenic extract-weed pollen-russian thistle 331 hydroxytoluene 331 allergenic extract-weed pollen-sagebrush 331 almotriptan malate 86 allergenic extract-weed pollen-sheep sorrel 331 ALOCRIL 441 allergenic extract-weed pollen-sheep aloe vera 331 sorrel,yellow dock 331 aloe vera leaf gel extract 332 allergenic extract-weed pollen-short ragweed 331 alogliptin benzoate 146 allergenic extract-weed pollen-spiny pigweed 331 alogliptin benzoate/metformin hcl 146 allergenic extract-weed pollen-true marsh alogliptin benzoate/pioglitazone hcl 146 elder 331 ALOMIDE 441 allergenic extract-weed pollen-western ALOPHEN PILLS 264 ragweed 331 ALOPRIM 85 allergenic extract-weed pollen-yellow dock 331 ALORA 287 ALLERGY 451 alosetron hcl 263 ALLERGY 4-HOUR 451 ALOXI 75 ALLERGY COMPLETE-D 468 alpha lipoic acid 332 ALLERGY D-12 468 alpha pinene 332 ALLERGY EYE DROPS 441 alpha-ketoglutaric acid 332 ALLERGY MEDICATION 451 ALPHAGAN P 445 ALLERGY MEDICINE 451 ALPHANATE 159 ALLERGY RELIEF 448,451,452 ALPHANINE SD 159 ALLERGY RELIEF D 468 alprazolam 143,332 ALLERGY RELIEF D-12 468 ALPRAZOLAM INTENSOL 143 ALLERGY RELIEF D-24HR 468 ALPROLIX 159 ALLERGY RELIEF-D 468 alprostadil 177,332 ALLERGY RELIEF-D12 469 ALREX 443 ALLERGY RELIEF-NASAL DECONGEST 469 ALTABAX 212 ALLERGY+CONGESTION RELIEF-D 469 ALTACAINE 433 ALLERGY-CONGESTION 12HR 469 ALTACE 167 ALLERGY-CONGESTION ER 469 ALTACHLORE 433 ALLERGY-CONGESTION RELIEF 469 ALTAMIST 332 ALLERGY-CONGESTION RELIEF 12HR 469 ALTAVERA 288 ALTAZINE 433 aminosalicylate sodium 332 ALTIPRES 469 aminosalicylic acid 332 ALTOPREV 188 AMINOSYN 507 ALTRENO 544 AMINOSYN II 507 aluminum chloride 332 AMINOSYN II WITH ELECTROLYTES 507 aluminum chlorohydrate 332 AMINOSYN M 507 aluminum hydroxide 249,332 AMINOSYN WITH ELECTROLYTES 507 aluminum sulfate 332 AMINOSYN-HBC 507 aluminum, (acetato-o)dihydroxy 332 AMINOSYN-PF 507 ALUNBRIG 544 AMINOSYN-RF 508 ALVESCO 449 amiodarone hcl 168 ALYACEN 288 amiodarone hcl/dextrose 5 % in water 168 ALYQ 464 AMITIZA 263 AMABELZ 288 amitriptyline hcl 72,332 amantadine hcl 117,332 amitriptyline hcl/chlordiazepoxide 65 AMARYL 146 amlodipine besylate 172,332 AMBIEN 489 amlodipine besylate/atorvastatin calcium 177 AMBIEN CR 489 amlodipine besylate/benazepril hcl 177 AMBISOME 77 amlodipine besylate/olmesartan medoxomil 177 ambrisentan 464 amlodipine besylate/valsartan 177 amcinonide 212 amlodipine AMERGE 86 besylate/valsartan/hydrochlorothiazide 177 american ginseng root 332 ammonia n-13 544 AMETHIA 288 , strong 333 AMETHIA LO 288 ammonium alum 333 AMETHYST 288 ammonium bromide 333 AMICAR 159 ammonium chloride 333 AMIDATE 33 ammonium lactate 212,333 amifampridine 332 ammonium lauryl sulfate 333 amifostine crystalline 97 ammonium sulfate 333 amikacin sulfate 41 ammonium tetrathiomolybdate 333 amiloride hcl 185 AMMONUL 245 amiloride hcl/hydrochlorothiazide 177 AMNESTEEM 212 amino acid 3 % comb no.2 (pediatric) in 10 % amoxapine 72 dextrose 544 amoxicillin 50,333 amino acid 3.5 % comb no.2 (pediatric) in 10 % amoxicillin/potassium clavulanate 50 dextrose 507 amphetamine 544 AMINOACETIC ACID 277 amphetamine sulfate 194 aminobenzoic acid 332 amphotericin b 78,333 aminocaproic acid 160,332 ampicillin sodium 50 aminophylline 332,463 ampicillin sodium/sulbactam sodium 50 ampicillin trihydrate 50 ANTACID CALCIUM 250 AMPYRA 206 ANTACID EXTRA STRENGTH 250,333 AMRIX 487 ANTACID M 250 AMVISC 433 ANTACID MAXIMUM STRENGTH 250 AMVISC PLUS 433 ANTACID PLUS ANTI-GAS 250 amyl nitrite 192 ANTACID PLUS GAS RELIEF 250 AMYTAL SODIUM 491 ANTACID ULTRA STRENGTH 250,251 AMYVID 333 ANTACID WITH SIMETHICONE 251 AMZEEQ 544 ANTACID-ANTIGAS 251 ANACAINE 213 ANTACID-GAS RELIEF 251 ANADROL-50 285 ANTARA 186 ANAFRANIL 72 anthralin 333 anagrelide hcl 157 ANTI-DANDRUFF 213 ANALPRAM HC 213 ANTI-DIARRHEAL 251,545 ANAPROX DS 3 ANTI-FUNGAL 78 ANASCORP 313 ANTI-FUNGAL CREAM 78 ANASPAZ 247 ANTI-FUNGAL POWDER 78 ANASTIA 34 ANTI-GAS 251 anastrozole 105,333 ANTI-ITCH 213 ANCOBON 78 ANTI-ITCH CREAM 213 ANDEXXA 545 ANTI-ITCH VAGINAL 213 ANDRODERM 285 ANTI-ITCH WITH ALOE 213 ANDROGEL 285 antiarthritic combination no.2 508 ANDROID 285 ANTIBIOTIC 213 androstenedione 333 ANTIBIOTIC + PAIN RELIEF 213 ANECREAM5 213 ANTIBIOTIC PLUS PAIN RELIEF 213 ANEFRIN 333 ANTIBIOTIC-PAIN RELIEF 213 ANGELIQ 288 ANTIFUNGAL 78 ANGIOMAX 154 ANTIFUNGAL CREAM 78 ANIMAL CHEWS 508 ANTIFUNGAL POWDER 78 ANIMAL SHAPES 508 antimony trichloride 333 ANIMAL SHAPES COMPLETE 508 antimony trisulfide colloid 333 ANIMAL SHAPES PLUS IRON 508 ANTIOXIDANT FORMULA 508 ANIMAL SHAPES VITAMINS 508 antipyrine 333 anise flavor extract 333 ANTISEPTIC 333 anise oil 333 ANTISEPTIC SKIN CLEANSER 213 anisindione 333 ANTITUSSIVE DM 469 ANJESO 545 antivenin,latrodectus mactans 313 ANORO ELLIPTA 469 antivenin,micrurus fulvius 313 ANTABUSE 38 ANUCORT-HC 280 ANTACID 250 ANUSOL-HC 280,320 AP-HIST DM 469 ARIKAYCE 545 APADAZ 545 ARIMIDEX 105 APEXICON E 213 aripiprazole 121,122 APIDRA 152 ARISTADA 122,545 APIDRA SOLOSTAR 152 ARISTADA INITIO 545 APLENZIN 65 ARISTOSPAN 280 APLIGRAF 334 ARIXTRA 154 APLISOL 334 ARKALIOX 508 APOKYN 118 armodafinil 491 apomorphine hcl 334 ARMONAIR DIGIHALER 545 apple extract 334 ARMONAIR RESPICLICK 545 apple flavor 334 ARMOUR THYROID 302 apraclonidine hcl 445 arnica flower 334 aprepitant 75 arnica flower extract 334 APRI 288 ARNUITY ELLIPTA 449,545 apricot flavor 334 AROMASIN 105 APRISO 320 aromatic cascara fluid extract 334 APRIZIO PAK II 213 ARRANON 97 APRODINE 469 arrowroot starch 334 APTENSIO XR 196 arsenic trioxide 334,545 APTIOM 62 ARTHRITIS PAIN 199 APTIVUS 139 ARTHRITIS PAIN RELIEF 199,214 AQUA GLYCOLIC HC 213 ARTHRITIS PAIN RELIEVER 199 AQUADEKS 508 ARTHRITIS PAIN RELIEVING 214 AQUANIL HC 214 ARTHROTEC 50 3 AQUASOL A 508 ARTHROTEC 75 3 AQUORAL 209 articaine hcl/epinephrine bitartrate 34 ARAKODA 545 ARTIFICIAL TEARS 433 ARALAST NP 469 ARTISS 214 ARANELLE 288 ARYMO ER 545 ARANESP 157 ARZERRA 113 ARAVA 317 ASACOL HD 320 ARAZLO 545 ASCENIV 546 ARCALYST 317 ASCLERA 334 ARCAPTA NEOHALER 460 ASCOMP WITH CODEINE 12 argatroban 154 ascorbate calcium 334,508 argatroban in 0.9 % sodium chloride 154 ascorbate sodium 334 argatroban in sodium chloride, iso-osmotic 154 ascorbic acid 334,508,546 arginine 334 ascorbic acid/ascorbate sodium 508 arginine hcl 334 ascorbyl palmitate 334 ARICEPT 64 ASHLYNA 288 ASMANEX 449 ATRAPRO DERMAL SPRAY 214 ASMANEX HFA 449,546 ATRAPRO HYDROGEL 214 asparagine monohydrate 334,546 ATRIPLA 135 ASPARLAS 546 ATROPEN 247 aspartame 334 atropine sulfate 247,335,433 aspartic acid 334 atropine sulfate in 0.9 % sodium ASPERCREME LIDOCAINE 214 chloride 247,433,546 ASPIR 81 3 ATROVENT HFA 459 ASPIR-LOW 3 ATRYN 155 ASPIR-TRIN 3 attapulgite 335 aspirin 3,334 AUBAGIO 206 aspirin/calcium carbonate/magnesium 3 AUBRA 288 aspirin/dipyridamole 163 AUBRA EQ 288 ASTAGRAF XL 308 AUGMENTIN 50 ASTHMANEFRIN REFILL 460 AUGMENTIN ES-600 50 astragalus root 334 AUGMENTIN XR 50 ASTRINGENT EYE DROPS 433 AUROVELA 288 ASTRINGENT SOLUTION 214 AUROVELA 24 FE 288 ASTRINGYN 160 AUROVELA FE 288 ATABEX OB 546 AURYXIA 279 ATACAND 165 AUSTEDO 546 ATACAND HCT 177 AUVI-Q 460,546 atazanavir sulfate 139 AVALIDE 177 ATELVIA 322 AVANDIA 146,147 atenolol 170,335 AVAPRO 165 atenolol/chlorthalidone 177 AVAR 214 ATGAM 313 AVAR LS 214 ATHENOL 199 AVAR-E 214 ATHLETE'S FOOT 78 AVAR-E GREEN 214 ATHLETE'S FOOT AF 78 AVAR-E LS 214 ATHLETE'S FOOT SPRAY 78 AVASTIN 113 ATHLETIC FOOT CREAM 78 AVC 55 ATIVAN 143 AVEED 285 atomoxetine hcl 196 AVEENO INTENSE RELIEF 214 ATOPADERM 335 AVELOX 53 ATOPAVO 214 AVELOX IV 53 ATOPICLAIR 214 AVENOVA 214 atorvastatin calcium 188 AVIANE 288 atovaquone 116 AVIDOXY 55 atovaquone/proguanil hcl 116 AVITA 214 ATRALIN 214 AVITENE 335 AVO CREAM 214 BACID 251 avocado extract 335 BACIIM 42 avocado oil 335 bacitracin 42,215,335 AVODART 276 bacitracin zinc 215 AVONEX 206 bacitracin zinc micronized 335 AVONEX PEN 206 bacitracin, micronized 335 AVSOLA 546 bacitracin/polymyxin b sulfate 433 AVYCAZ 42 BACITRAYCIN PLUS 215 AXIRON 285 baclofen 335,487,546 AYGESTIN 300 bacteriostatic sodium chloride 495 AYR 335 BACTRIM 55 AYR SALINE 335 BACTRIM DS 55 AYUNA 288 BACTROBAN 215 AYVAKIT 546 BACTROBAN NASAL 42 azacitidine 97 BAFIERTAM 546 AZACTAM 49 BAL IN OIL 335 AZACTAM-ISO-OSMOTIC DEXTROSE 49 BAL-CARE DHA 508 AZADROX 546 BAL-CARE DHA ESSENTIAL 508 AZASAN 308 BALANCE B-100 508 AZASITE 433 BALANCE B-50 508 azathioprine 308,335 balanced salt irrig soln no.2 433 azathioprine sodium 308 BALCOLTRA 547 azelaic acid 214,335 balsalazide disodium 320 azelastine hcl 335,441,452 balsam canada 335 azelastine hcl/fluticasone propionate 469 balsam peru 335 AZELEX 215 balsam peru/castor oil 215 AZILECT 119 BALVERSA 547 azithromycin 52,335 BALZIVA 289 AZOPT 445 BAN-ACID 251 AZOR 177 banana creme flavor 336 aztreonam 49 banana extract 336 AZULFIDINE 321 banana flavor 336 AZURETTE 288 BANOPHEN 453 BANOPHEN ANTI-ITCH 215 B BANZEL 62 B-12 COMPLIANCE 508 BAQSIMI 547 B-12 DOTS 508 BARACLUDE 131 b-complex with vitamin c 508 BARHEMSYS 547 BABY AYR SALINE 335 336 BABY PROBIOTIC 546 BASADROX 547 BACICAP 546 BASAGLAR KWIKPEN U-100 152 BAVENCIO 547 BENZEFOAM ULTRA 215 BAXDELA 547 BENZEPRO 215 BAYER ADVANCED 3 benzethonium chloride 336 BAYER CHEWABLE ASPIRIN 3 benzhydrocodone hcl/acetaminophen 547 BAYER MIGRAINE 3 benznidazole 547 BAZA ANTIFUNGAL 78 benzocaine 336 BCAD 1 508 benzocaine micronized 336 BCAD 2 509 benzoic acid 336 bcg live 97 benzoin 336 bcg vaccine, live/pf 318 benzoin compound 216 bean pod extract 336 benzoin gum 336 BEAU RX 215 benzoin/aloe vera/storax/tolu balsam 216 beclomethasone dipropionate 336 benzonatate 469,470 BECONASE AQ 449 benzoyl peroxide 216,336 beef extract 336 benzoyl peroxide microspheres 216 BEELITH 495 benztropine mesylate 117 beeswax 336 benzyl alcohol 336 BEKYREE 289 benzyl benzoate 337 BELBUCA 30 BEOVU 547 BELEODAQ 105 BEPREVE 441 belladonna alkaloids 336 BERINERT 307 belladonna alkaloids leaf extract 336 BESER 216 BELSOMRA 492 BESIVANCE 53 benactyzine hcl 336 beta 1,3 glucan 337 BENADRYL 453 BETA HC 216 BENADRYL ALLERGY 453 BETA MED 216 benazepril hcl 167,336 beta-carotene 337 benazepril hcl/hydrochlorothiazide 177 beta-glucan, (1-3) (1-4) 337 bendamustine hcl 90 betadex 337 BENEFIBER 264 BETADINE 433 BENEFIX 160 betahistine hcl 337 BENICAR 165 betaine 337 BENICAR HCT 177 betaine hcl 337 BENLYSTA 317 betamethasone acetate and sodium phos in BENSAL HP 78 sterile water/pf 547 bentonite 336 betamethasone acetate, micronized 337 BENTYL 247 betamethasone acetate/betamethasone sodium BENZACLIN 215 phosphate 280 benzalkonium chloride 336 betamethasone acetate/betamethasone sodium BENZAMYCIN 215 phosphate/water 547 BENZEFOAM 12 betamethasone dipropionate 216,337 betamethasone dipropionate/propylene bioflavonoids, citrus 337,509 glycol 216 BIOGAIA 251 betamethasone sodium phosph in sterile water BIOGAIA GASTRUS 548 for injection 547 BIOGAIA PROTECTIS BABY 251 betamethasone sodium phosphate 337 BIOGAIA PROTECTIS BABY-VIT D3 251 betamethasone valerate 216,337 BIOGLO 433 betanaphthol 337 BIONECT 216 BETAPACE 168 BIORPHEN 548 BETAPACE AF 168 BIOTHRAX 318 BETAQUIK 509 biotin 337,509 BETASAL 216 BISA-LAX 264 BETASERON 206 bisabolol 337 BETATEMP 199 bisacodyl 264,337 betaxolol hcl 170,445 BISACODYL 264 bethanechol chloride 277,337 BISCOLAX 264 BETHKIS 462 BISMATROL 252 BETIMOL 445 BISMUTH 252 BETOPTIC S 445 bismuth citrate 337 bevacizumab 433 BISMUTH MAXIMUM STRENGTH 252 BEVESPI AEROSPHERE 470 bismuth subcarbonate 337 BEVYXXA 548 bismuth subgallate 337 bexarotene 115 bismuth subnitrate 337 BEXSERO 318 bismuth subsalicylate 252,338 BEYAZ 289 bismuth tribromophenate/petrolatum,white 338 BIAFINE 216 bisoprolol fumarate 170 bicalutamide 92 bisoprolol fumarate/hydrochlorothiazide 178 BICILLIN C-R 51 bitter almond oil 338 BICILLIN L-A 51 bitter mask flavor combination no.2 338 BICNU 90 bitter mask flavoring 338 BIDIL 178 bivalirudin 155,548 BIJUVA 548 bivalirudin in 0.9 % sodium chloride 548 BIKTARVY 548 BIVIGAM 314 BILTRICIDE 115 black (food color) 338 bimatoprost 447 blackberry flavor 338 BINOSTO 322 blade lancet, safety 338 BIO T PRES 470 BLENREP 548 BIO-35 509 bleomycin sulfate 97 BIO-B KIDS 470 BLEPH-10 433 BIOCEL 509 BLEPHAMIDE 434 BIOCOTRON 470 BLEPHAMIDE S.O.P. 434 bioflavonoid, lemon 337 BLINCYTO 113 BLIS-TO-SOL 78 blueberry flavor 339 BLISOVI 24 FE 289 blunt needle, disposable 339 BLISOVI FE 289 BODY, HAIR, SKIN AND NAILS 509 blood collection set 338 BONIVA 322 blood glucose and ketone control, normal 338 BONJESTA 548 blood glucose calibration control high and low 338 BOOST 509 blood glucose calibration control solution, BOOSTRIX TDAP 318 high 338 boric acid 339 blood glucose calibration control solution, high boron 340 and normal 338 boron citrate 340 blood glucose calibration control solution, low 338 bortezomib 548 blood glucose calibration control solution, bosentan 464 normal 338 BOSULIF 106,548 blood glucose calibration control solutions boswellia serrata extract 340 high,normal,low 338 BOTOX 488 blood ketone test, strips 338 BP 10-1 217 blood pressure kit-extra large 338 BP FOAM 217 blood pressure test kit 339 BPO 217 blood pressure test kit medium and large cuffs339 BRAINSTRONG PRENATAL 548 blood pressure test kit-large 339 BREO ELLIPTA 470 blood pressure test kit-medium 339 bretylium tosylate 548 blood pressure test kit-small 339 BREVIBLOC 170 blood pressure test kit-wrist 339 BREVITAL SODIUM 142 blood sugar diagnostic 339 BREWER'S YEAST 509 blood-glucose and blood pressure meter with BREZTRI AEROSPHERE 548 adult cuff 548 BRIELLYN 289 blood-glucose calib. control 339 BRILINTA 163 blood-glucose meter 339 brilliant green 340 blood-glucose meter and wrist blood pressure brimonidine tartrate 340,445 monitor 339 BRISDELLE 67 blood-glucose meter,continuous 339 BRIVIACT 57 blood-glucose sensor 339 bromelains 340 blood-glucose transmitter 339 BROMFED DM 470 blood-glucose transmitter/blood-glucose bromfenac sodium 340,443 sensor 339 bromhexine hcl 340 BLOXIVERZ 88 bromocriptine mesylate 118,340 blue (food color) 339 brompheniramine maleate 340 blue agave extract 339 brompheniramine maleate/pseudoephedrine BLUE GEL 216 hcl/dextromethorphan 470 blue royal (food color) 339 BROMSITE 443 blue-green algae 339 BRONCHIAL MIST 460 BROTAPP DM 470 butter flavor 340 BROVANA 460 butter rum flavor 340 brown (food color) 340 butterscotch flavor 341 BRUKINSA 548 butyl alcohol 341 BRYHALI 549 butylated hydroxyanisole 341 BSS 434 butylated hydroxytoluene 341 BSS PLUS 434 butylparaben 341 bubblegum flavor 340 BYDUREON 147 budesonide 320,321,449 BYDUREON BCISE 549 budesonide, micronized 340 BYDUREON PEN 147 budesonide/formoterol fumarate 470 BYETTA 147 buflomedil hcl 340 BYNFEZIA 549 bumetanide 184 BYSTOLIC 170 BUMINATE 340 BYVALSON 178 BUNAVAIL 38 BUPAP 199 C BUPHENYL 245 C-NATE DHA 509 bupivacaine hcl 340 c.i. acid blue 90 549 bupivacaine hcl in 0.9 % sodium chloride/pf 34 c10-18 triglycerides 341 bupivacaine hcl in dextrose/pf 34 cabergoline 304 bupivacaine hcl/epinephrine 34 CABOMETYX 107 bupivacaine hcl/epinephrine bitartrate 34 CADEAU DHA 509 bupivacaine hcl/epinephrine/pf 34 CADUET 178 bupivacaine hcl/pf 34 CAFCIT 463 BUPRENEX 39 CAFERGOT 86 buprenorphine 30 caffeine citrate 464 buprenorphine hcl 39,340 caffeine/sodium benzoate 492 buprenorphine hcl/naloxone hcl 39 CAL-CITRATE 495 bupropion hcl 65,66,340 CAL-GEST 252 buspirone hcl 142,340 CAL-MINT 495 busulfan 90 calamine 341 BUSULFEX 90 calamine/phenol liquid 217 butalbital 340 calamine/zinc oxide 217 butalbital/acetaminophen 199,200 calamine/zinc oxide/phenol liquid 217 butalbital/acetaminophen/caffeine 200 CALAN 172 butalbital/acetaminophen/caffeine/codeine CALAN SR 172 phosphate 12 CALCI-MAX 495 butalbital/aspirin/caffeine 200,549 CALCIDOL 509 butenafine hcl 79 calcipotriene 217,341 butorphanol tartrate 13,340 calcipotriene/betamethasone dipropionate 217 BUTRANS 30 calcitonin,salmon,synthetic 322 CALCITRATE 495 calcium phosphate, tribasic/cholecalciferol CALCITRATE + VIT D 495 (vitamin d3) 497 CALCITRENE 217 calcium polycarbophil 264 calcitriol 217,322,341 calcium pyruvate 342 calcitriol/almond oil 341 calcium sulfate 342 calcium acetate 279,341,495 calcium thioglycolate trihydrate 342 calcium alginate 341 calcium/magnesium/zinc 497 calcium alginate/honey 341 CALDOLOR 4 calcium amino acid chelate 341 CALPHRON 279 CALCIUM ANTACID 252 CALQUENCE 549 calcium carbonate 252,341,495 CAMBIA 4 calcium carbonate and citrate/cholecalciferol (vit CAMILA 300 d3) 495 CAMPATH 97 calcium carbonate/cholecalciferol (vitamin camphor 342 d3) 264,495,496,549 CAMPTOSAR 98 calcium carbonate/magnesium oxide/zinc CAMRESE 289 gluconate 496 CAMRESE LO 289 calcium carbonate/magnesium oxide/zinc cananga oil 342 sulfate 496 CANASA 320 calcium carbonate/vit d3/mag CANCIDAS 79 ox/zinc/copper/manganese/boron 496 candesartan cilexetil 165 calcium chloride 341,496 candesartan cilexetil/hydrochlorothiazide 178 calcium citrate 341,496 CANDIN 342 calcium citrate/cholecalciferol (vitamin cantaloupe extract 342 d3) 496,549 cantharidin 342 calcium glubionate 341 CAPASTAT SULFATE 89 calcium glucarate 341 CAPCOF 470 calcium gluconate 341,496 capecitabine 94 calcium gluconate in 0.9 % sodium CAPEX SHAMPOO 217 chloride 496,549 CAPHOSOL 209 calcium gluconate in sodium chloride, iso- CAPLYTA 549 osmotic 549 CAPRELSA 107 calcium gluconate monohydrate 341 caprylic/capric triglyceride 342 calcium gluconate/dextrose 5 % in water 497,549 capsaicin 217,342 calcium hydroxide 342 capsaicin palmitate 342 calcium lactate 342 CAPSFENAC PAK 217 calcium levulinate dihydrate 342 capsicum oleoresin 342 calcium pantothenate 342 capsule compounding base no.138 342 calcium phosphate 342 captopril 167,342 calcium phosphate, tribasic 342 captopril/hydrochlorothiazide 178 CAPZASIN 217 CAPZASIN-HP 218 carnauba wax 343 CARAC 218 CARNITOR 509 CARAFATE 272 CARNITOR SF 509 caramel flavor 342 carnosine 343 carbachol 342 carob 343 CARBAGLU 497 CAROSPIR 549 carbamazepine 63,342 carrageenan 343 carbamide peroxide 343 CARRINGTON MOISTURE BARRIER 218 CARBAMOXIDE 447 carteolol hcl 445 CARBATROL 63 CARTIA XT 173 carbazochrome 343 carvedilol 170 carbidopa 119,343 carvedilol phosphate 170 carbidopa/levodopa 119 casein extract 343 carbidopa/levodopa/entacapone 117 CASODEX 92 carbimazole 343 caspofungin acetate 79 carbinoxamine maleate 453,549 cat hair standardized allergenic extract 343 carbitol 343 CATAPRES 164 CARBOCAINE 34 CATAPRES-TTS 1 164 carbomer 934 343 CATAPRES-TTS 2 164 carbomer 940 343 CATAPRES-TTS 3 164 carbomer homopolymer type c 343 catheter 344,549 carboplatin 98 catheterization tray 344 carboxymethylcellulose 343 CATHFLO ACTIVASE 155 carboxymethylcellulose sodium 343 CAYSTON 462 carboxymethylcellulose sodium, low CAZIANT 289 substituted 343 cedar leaf oil 344 CARBZERO 509 cefaclor 47 CARDENE I.V. 172 cefadroxil 47 CARDIOLITE 343 cefazolin sodium 47 cardioplegic solution no.1 178 cefazolin sodium in 0.9 % sodium chloride 47 cardioplegic solution no.10 178 cefazolin sodium/dextrose 5 % in water 47,549 CARDIOVID PLUS 509 cefazolin sodium/dextrose, iso-osmotic 47 CARDIZEM 172 cefazolin sodium/water for injection,sterile 47 CARDIZEM CD 172 cefdinir 47 CARDIZEM LA 173 cefditoren pivoxil 47 CARDURA 165 cefepime hcl 47 CARDURA XL 276 cefepime hcl in dextrose 5 % in water 47 carisoprodol 343,488 cefepime hcl in iso-osmotic dextrose 48 carisoprodol/aspirin 488 cefixime 48 carisoprodol/aspirin/codeine phosphate 13 CEFOTAN 48 carmustine 90 cefotaxime sodium 48 cefotetan disodium 48 CENTRUM SILVER 510 cefotetan disodium in iso-osmotic dextrose 48 CENTRUM SILVER ULTRA MEN'S 510 cefoxitin sodium 48 CENTRUM SILVER WOMEN 510 cefoxitin sodium/dextrose, iso-osmotic 48 CENTRUM SPECIALIST HEART 510 cefpodoxime proxetil 48 CENTRUM ULTRA MEN'S 510 cefprozil 48 CENTRUM WOMEN 510 ceftazidime 48,344 CENTURY 510 ceftazidime in dextrose 5% and water 48 CENTURY CARDIO 510 ceftriaxone sodium 48,344 CENTURY MATURE 510 ceftriaxone sodium in iso-osmotic dextrose 48 CENTURY ULTIMATE MEN'S 510 cefuroxime axetil 48 CENTURY ULTIMATE WOMEN'S 510 cefuroxime sodium 48 cephalexin 48 CELEBREX 4 CERAMAX 218 celecoxib 4,344 CERAVE 218,344 CELESTONE 280 CERAVE MOISTURIZING 344 CELEXA 67 CERDELGA 245 CELLCEPT 308 CEREBYX 63 CELLUGEL 434 CEREFOLIN 510 cellulase 344 CEREFOLIN NAC 510 cellulose 344 ceresin 344 cellulose/carboxymethylcellulose sodium 344 CERETEC 344,550 cellulose/silica gel/magnesium stearate 344 CEREZYME 245 cellulose/silica gel/mannitol/magnesium CEROVITE ADVANCED FORMULA 510 stearate 344 CEROVITE JR 510 cellulose/silica/mannit/sodium lauryl sulf/sod CEROVITE SENIOR 510 starch glyc 344 CERTA PLUS 510 CELONTIN 58 CERTAVITE SENIOR-ANTIOXIDANT 511 CEM-UREA 218 CERTAVITE-ANTIOXIDANT 511 CENTAMIN 509 cervical cap 344 CENTANY 218 CERVIDIL 277 CENTANY AT 218 CESAMET 75 CENTRAL-VITE WOMEN'S MATURE 509 cesium chloride 344 CENTRAM-CARE 509 CETACAINE 218 CENTRAVITES 509 CETAPHIL 218,344 CENTRAVITES 50 PLUS 509 CETAPHIL RESTORADERM 218 CENTRUM 509 CETIRI-D 470 CENTRUM ADULTS 509 cetirizine hcl 453 CENTRUM CHEWABLES 510 cetirizine hcl/pseudoephedrine hcl 470 CENTRUM COMPLETE 510 cetostearyl alcohol/ceteareth-20 345 CENTRUM KIDS 510 CETRAXAL 53 CENTRUM MEN 510 cetyl alcohol 345 cetyl esters 345 CHILDREN 24 HR ALLERGY RELIEF 449 cetyl myristoleate 345 CHILDREN'S ACETAMINOPHEN 200 cetylpyridinium chloride 345 CHILDREN'S ALAWAY 441 cevimeline hcl 209 CHILDREN'S ALL DAY ALLERGY 453 chamomile flower 345 CHILDREN'S ALLERGY 453 CHANTIX 40 CHILDREN'S ALLERGY RELIEF 453,454 CHARCOCAPS 345 CHILDREN'S BENADRYL ALLERGY 454 CHATEAL 289 CHILDREN'S CHEST CONGESTION 471 CHATEAL EQ 289 CHILDREN'S CHEW MULTIVIT-IRON 511 cheesecake flavor 345 CHILDREN'S CHEW MULTIVITAMIN 511 CHEMET 493 CHILDREN'S CHEWABLE 511 CHENODAL 252 CHILDREN'S CHEWABLE MULTIVITMN 511 CHERATUSSIN AC 471 CHILDREN'S CHEWABLE PROBIOTIC 252 cherry flavor 345 CHILDREN'S CHEWABLE VITAMIN 511 cherry-ade flavor 345 CHILDREN'S CHEWABLES 511 CHEST CONGESTION RELIEF 264,471 CHILDREN'S CLARITIN 454 CHEST CONGESTION RELIEF DM 471 CHILDREN'S COLD-ALLERGY 471 CHEST CONGESTION-COUGH RELIEF 471 CHILDREN'S COLD-COUGH 471 CHEWABLE-VITE 511 CHILDREN'S COUGH 471 CHEWABLE-VITE WITH IRON 511 CHILDREN'S COUGH DM ER 471 chicken meat extract 345 CHILDREN'S DIBROMM DM 471 CHILD CHEST CONGESTION-COUGH 471 CHILDREN'S EASY-MELTS 200 CHILD CHEW + IRON 511 CHILDREN'S FEVER REDUCER 200 CHILD CHEWABLE VITAMN COMPLETE 511 CHILDREN'S FEVER REDUCING 200 CHILD COMPLETE CHEWABLE VITAMN 511 CHILDREN'S IRON 497 CHILD COMPLETE MULTIVITAMIN 511 CHILDREN'S MAPAP 200 CHILD COUGH-COLD-SORE THROAT 471 CHILDREN'S MOTRIN 4 CHILD COUGH-SORE THROAT 471 CHILDREN'S MUCINEX COUGH 471 CHILD FEVER REDUCER 200 CHILDREN'S MUCUS RELIEF 472 CHILD FEVER REDUCER-PAIN RELVR 200 CHILDREN'S MULTIVITAMIN 345,511 CHILD LITTLE ANIMALS VITAMINS 511 CHILDREN'S NON-ASPIRIN 200 CHILD MUCINEX CHEST MINI-MELTS 471 CHILDREN'S PAIN AND FEVER 200 CHILD MUCINEX COUGH MINI-MELTS 471 CHILDREN'S PAIN RELIEF 200,201 CHILD MUCUS RELIEF COUGH 471 CHILDREN'S PAIN RELIEVER 201 CHILD MUCUS-COUGH RELIEF 471 CHILDREN'S PAIN-FEVER 201 CHILD MULTI-SYMPTOM COLD-FEVER 471 CHILDREN'S PEPTO 252 CHILD MULTIVITAMINS 511 CHILDREN'S PROFEN IB 4 CHILD PAIN REL-FEVER REDUCER 200 CHILDREN'S PROFENIB 4 CHILD TRIAMINIC COLD-ALLERGY 471 CHILDREN'S SALINE NASAL SPRAY 345 CHILD WAL-TAP COLD-ALLERGY 471 CHILDREN'S SILAPAP 201 CHILD'S DIBROMM COLD-ALLERGY 471 CHILDREN'S SILFEDRINE 345 CHILDREN'S SOOTHE 252 CHOLBAM 252 CHILDREN'S STUFFY NOSE-COLD 472 CHOLECAL DF 550 CHILDREN'S TACTINAL 201 cholecalciferol (vitamin d3) 346,497,511 CHILDREN'S VITAMINS WITH IRON 511 cholesterol 346 CHILDREN'S WAL-DRYL ALLERGY 454 cholesterol and blood glucose meter 346 CHILDREN'S WAL-FEX 454 cholestyramine 346 CHILDREN'S WAL-ZYR 454 cholestyramine (with sugar) 189 CHILDRN COLD-COUGH-SORE THROAT 472 cholestyramine/aspartame 189 CHIRHOSTIM 345 choline bitartrate 346 CHLOR-TRIMETON 454 choline chloride 346 345 choline salicylate/magnesium salicylate 4,346 chlorambucil 345 chondroitin sulfate a sodium 346 chloramphenicol 345 chorionic gonadotropin, human 346 chloramphenicol palmitate 345 chromic chloride 497 chloramphenicol sod succinate 42 chromium picolinate 346,497 CHLORASEPTIC 209 chromium polynicotinate 346 chlordiazepoxide hcl 143 chromium potassium sulfate dodecahydrate 346 chlordiazepoxide/clidinium bromide 247 chrysin 346 chlorhexidine 345 chymotrypsin 347 chlorhexidine acetate 345 CIALIS 276 chlorhexidine gluconate 209,345 CICLODAN 79 CHLORHIST 454 ciclopirox 79 chloroallyl methenamine chloride 345 ciclopirox olamine 79,347 chlorobutanol 346 ciclopirox/urea/camphor/menthol/eucalyptol 79 chlorophyllin copper complex 346 cidofovir 130,347 chloroprocaine hcl/pf 34 cilostazol 163 chloroquine phosphate 116,346 CILOXAN 434 chlorothiazide 185 CIMDUO 550 chlorothiazide sodium 185 cimetidine 262,347 chloroxine 346 cimetidine hcl 262 chloroxylenol 346 CIMZIA 308 CHLORPHEN SR 454 cinacalcet hcl 303 chlorpheniramine maleate 346,454 cinnamon 511 chlorpromazine hcl 120,346 cinnamon bark 347 chlorpropamide 147 CINQAIR 472 CHLORTABS 454 CINRYZE 307 chlorthalidone 185 CINVANTI 550 chlorzoxazone 488,550 CIPRO 53 chocolate flavor 346 CIPRO HC 448 chocolate hazelnut flavor 346 CIPRODEX 448 CHOCOLATED LAXATIVE 264 ciprofloxacin 53,54 ciprofloxacin hcl 54,347,434 CLINDACIN PAC 42 ciprofloxacin hcl/fluocinolone acetonide 448 CLINDAGEL 218 ciprofloxacin lactate/dextrose 5 % in water 54 clindamycin hcl 42,347 ciprofloxacin/ciprofloxacin hcl 54 clindamycin palmitate hcl 42 cisplatin 98 clindamycin phosphate 43,218,219,347 citalopram hydrobromide 67 clindamycin phosphate in 0.9 % sodium CITRACAL + D MAXIMUM 497 chloride 43 CITRACAL-D3 MAXIMUM PLUS 497 clindamycin phosphate/benzoyl peroxide 219 CITRANATAL B-CALM 511 clindamycin phosphate/dextrose 5 % in water 43 citrate phosphate dextros soln 155 clindamycin phosphate/tretinoin 219 citric acid 347 CLINDESSE 43 citric acid monohydrate 347 CLINIMIX 512 citric acid/sodium citrate 277 CLINIMIX E 512 CITROMA 264 CLINIMIX N14G30E 550 CITRUCEL 264 CLINIMIX N9G15E 550 citrulline 347 CLINIMIX N9G20E 512 cladribine 95 CLINISOL 512 CLAFORAN 49 CLINOLIPID 550 CLARAVIS 218 CLINPRO 5000 209 CLARINEX 454 clioquinol 347 CLARINEX-D 12 HOUR 472 clobazam 58,59 CLARISPRAY 449 clobetasol propionate 219,347 clarithromycin 52,347 clobetasol propionate/calcipotriene 550 CLASSIC PRENATAL 512 clobetasol propionate/emollient base 219 CLEANSING WASH 218 CLOBEX 219 CLEARASIL ULTRA 218 219 CLEARLAX 264 CLODAN 219 clemastine fumarate 347,454 CLODERM 219 clemizole hcl 347 clofarabine 95 CLENPIQ 550 clofazimine 347 CLEOCIN 42 CLOLAR 95 CLEOCIN HCL 42 clomiphene citrate 347 CLEOCIN PEDIATRIC 42 clomipramine hcl 72,347 CLEOCIN PHOSPHATE 42 clonazepam 144,347 CLEOCIN T 218 clonidine 164 CLEVIPREX 173 clonidine hcl 165,196,347 clidinium bromide 347 clonidine hcl/pf 165 CLIMARA 289 clopidogrel bisulfate 163,347 CLIMARA PRO 289 clorazepate dipotassium 144 CLINDACIN ETZ 42,218 clotrimazole 79,348 CLINDACIN P 218 CLOTRIMAZOLE AF 79 clotrimazole/betamethasone dipropionate 79,219 COLD-SINUS RELIEF 473 clove oil 348 colesevelam hcl 189 CLOVERINE 348 COLESTID 189 CLOVIQUE 493 colestipol hcl 190 clozapine 129 colistin (as colistimethate sodium) 43,348 CLOZARIL 129,130 colistin sulfate 348 COAGADEX 160 collagen, hydrolysate (bovine) 348 348 collagenase clostridium histolyticum 348 COARTEM 116 collodion 348 cobamamide 348 collodion, flexible 348 cocaine hcl 348 COLOCORT 321 cocamide dea 348 colostomy bag, non-sterile 349 cocoa butter 348 colostomy bags 349 cocoa extract 348 colostomy belt 349 coconut flavor 348 colostomy washer 349 coconut oil 348 colostomy-ileostomy sets, sterile 349 coconut oil/beeswax/safflower oil 348 COLY-MYCIN M PARENTERAL 43 cod liver oil 512 COLY-MYCIN S 448 COD LIVER OIL 512 COLYTE WITH FLAVOR PACKETS 265 codeine phosphate 348 COMBIGAN 445 codeine phosphate/butalbital/aspirin/caffeine 13 COMBIPATCH 289 codeine phosphate/guaifenesin 472 COMBIVENT RESPIMAT 473 codeine sulfate 13 COMBIVIR 136 coffee flavor 348 COMETRIQ 107 COGENTIN 117 COMFORT GEL 253 COL-RITE 265 COMPANION 512 cola flavor 348 COMPAZINE 73 COLAZAL 320 COMPLERA 135 colchicine 85,348 COMPLETE 262,512 COLCRYS 85 COMPLETE 50 PLUS 512 COLD & SINUS PAIN RELIEF 472 COMPLETE ALLERGY 454,455 COLD HEAD CONGESTION 472 COMPLETE MEN 512 COLD MULTI-SYMPTOM 472 COMPLETE MULTI 512 COLD MULTI-SYMPTOM SEVERE 472 COMPLETE MULTI 50+ 512 COLD RELIEF HEAD CONGESTION 472 COMPLETE MULTI-VIT-MINERAL 512 COLD RELIEF MULTI-SYMPTOM 472 COMPLETE MULTIVITAMIN 512 COLD-ALLERGY 472 COMPLETE MV ADULT 50 PLUS 512 COLD-ALLERGY PE 472 COMPLETE NATAL DHA 512 COLD-COUGH 473 COMPLETE PREMIUM VITAMIN 513 COLD-COUGH DM 473 COMPLETE SENIOR 513 COLD-FLU RELIEF 473 COMPLETE WOMEN 513 COMPLEX B-100 513 compression stocking,thigh high,long length,x- compound vehicle solution sugar-free no.1 349 small circumf. 350 compound vehicle suspension no.7 349 compression stocking,thigh high,reg length,x- compound vehicle suspension sugar-free no.1 349 large circumfer 351 compound vehicle suspension sugar-free compression stocking,thigh high,regular no.12 349 length,large circumf 351 compounding vehicle no.8 349 compression stocking,thigh high,regular compounding vehicle sugar-free no.9 349 length,medium circum 351 compounding vehicle suspension no.17 349 compression stocking,thigh high,regular compounding vehicle suspension no.19 349 length,small circumf 351 compounding vehicle suspension sugar-free compression stocking,thigh high,regular length,x- no.18 349 small circ. 351 compounding vehicle suspension sugar-free compression stocking,thigh high,short no.20 350 length,large circumfer 351 compounding vehicle syrup no.10 350 compression stocking,thigh high,short compounding vehicle syrup no.13 350 length,medium circumf. 351 compounding vehicle syrup no.23 350 compression stocking,thigh high,short compression stocking, knee high, regular length, length,small circumfer 351 medium 350 compressor, for nebulizer 351 compression stocking, knee high, regular length, COMPRO 73 small 350 COMTAN 117 compression stocking,knee high,long length, large conception assistance supplies combination circumfer. 350 no.1 351 compression stocking,knee high,long length, x- CONCERTA 196 large circumf. 350 condoms, latex, lubricated 351 compression stocking,knee high,long CONDYLOX 220 length,medium circumfer. 350 CONEX 473 compression stocking,knee high,long length,small CONRAY 351 circumferen 350 CONRAY-30 351 compression stocking,knee high,regular CONRAY-43 351,550 length,large circumf. 350 CONSENSI 550 compression stocking,knee high,regular length,x- CONSTULOSE 265 large circum 350 container,empty 351 compression stocking,thigh high,long CONTROLLED DELIVERY PROBIOTIC 253 length,extra-large circ 350 CONZIP 9 compression stocking,thigh high,long length,large COPAXONE 206 circumfer. 350 copper gluconate 351 compression stocking,thigh high,long copper glycinate 351 length,medium circumfer 350 CORDRAN 220 compression stocking,thigh high,long length,small COREG 170 circumfer. 350 COREG CR 170 COREMINO 55 COUGH DM 473 CORGARD 170 COUGH DM ER 473 CORICIDIN HBP COLD AND FLU 473 COUGH DROPS 209 CORIFACT 160 COUGH RELIEF 473 CORLANOR 178 COUGH SYRUP 473 CORLOPAM 192 COUGH-CHEST CONGEST DM 473 CORMAX 220 COUGH-CHEST CONGESTION DM 473 corn extract 550 COUGH-COLD 473 corn oil 351 COUGH-COLD HBP 473 corn starch 351 COUGH-COLD RELIEF HBP 473 corn syrup/sucrose 352 COUMADIN 155 CORRECTOL 265 coumarin 352 CORTAID 220 COVARYX 289 CORTANE-B 220 COVARYX H.S. 289 CORTEF 280 covid-19 antigen immunoassay test 550 CORTENEMA 321 covid-19 molecular nucleic acid test assay 550 corticotropin 352 COZAAR 166 CORTIFOAM 321 crab extract 352 CORTISONE 220 cran-raspberry flavor 352 cortisone acetate 280,352 cranberry fruit extract 352 CORTISONE WITH ALOE 220 cream base no. 9 352 CORTISPORIN 220 cream base no.103 352 CORTIZONE-10 220 cream base no.105 352 CORTIZONE-10 PLUS 220 cream base no.108 352 CORTROSYN 283 cream base no.109 352 CORVERT 168 cream base no.110 352 CORZIDE 178 cream base no.111 352 COSAMIN DS 352 cream base no.115 352 COSENTYX (2 SYRINGES) 220 cream base no.126 221 COSENTYX PEN 220 cream base no.127 352 COSENTYX PEN (2 PENS) 221 cream base no.128 352 COSENTYX SYRINGE 221 cream base no.130 352 COSMEGEN 98 cream base no.135 352 COSOPT 445 cream base no.142 353 COSOPT PF 446 cream base no.148 353 cosyntropin 283 cream base no.157 353 COTELLIC 107 cream base no.159 353 COTEMPLA XR-ODT 550 cream base no.161 353 cotton candy flavor 352 cream base no.165 353 cottonseed oil 352 cream base no.170 353 COUGH & COLD MUCUS RELIEF CF 473 cream base no.171 353 cream base no.174 353 cream base no.78 354 cream base no.175 353 cream base no.81 354 cream base no.176 353 cream base no.82 354 cream base no.177 353 cream base no.83 355 cream base no.181 353 cream base no.84 355 cream base no.185 353 cream base no.87 355 cream base no.186 353 cream base no.88 355 cream base no.189 353 cream base no.96 355 cream base no.190 353 cream base no.97 355 cream base no.191 353 cream base no.98 355 cream base no.192 353 cream de menthe 355 cream base no.193 353 cream or lotion base no.74 355 cream base no.195 353 creatine 355 cream base no.201 353 creatine monohydrate 355 cream base no.206 79 creatinine 355 cream base no.208 353 CREON 245 cream base no.210 354 CRESEMBA 79 cream base no.220 550 CRESTOR 188 cream base no.221 550 CRINONE 300 cream base no.222 550 CRITIC-AID 221 cream base no.226 551 CRITIC-AID CLEAR AF 79 cream base no.228 551 CRIXIVAN 139 cream base no.29 354 CROFAB 314 cream base no.31 354 cromolyn sodium 253,355,442,473 cream base no.34 354 crotamiton 355 cream base no.37 354 croton oil 355 cream base no.39 354 CRYSELLE 289 cream base no.40 354 CUBICIN 43 cream base no.42 354 CUBICIN RF 43 cream base no.43 354 CULTURELLE 253 cream base no.47 354 CULTURELLE DIGESTIVE HEALTH 253 cream base no.49 354 CULTURELLE HEALTH-WELLNESS 253 cream base no.52 354 CULTURELLE KIDS 253 cream base no.56 354 CULTURELLE KIDS GENTLE-GO 253 cream base no.58 354 CULTURELLE KIDS PURELY PROB 253 cream base no.64 354 cupric chloride 497 cream base no.68 354 cupric sulfate 355 cream base no.69 354 cupric sulfate pentahydrate 355 cream base no.70 354 CUPRIMINE 277 cream base no.73 354 CURITY 277,355 cream base no.77 354 CUROSURF 473 CUTIVATE 221 CYSTOGRAFIN-DILUTE 356 CUTTER BACKWOODS 355 cytarabine 95 CUTTER BACKWOODS DRY 355 cytarabine/pf 95 CUTTER SKINSATIONS 355 CYTOGAM 314 CUVITRU 314 CYTOMEL 302 CUVPOSA 247 CYTOTEC 272 cyanocobalamin (vitamin b-12) 355,497,513 CYTOVENE 130 CYANOKIT 356 CYTRA-2 277 CYCLAFEM 289 CYTRA-3 277 cyclandelate 356 CYTRA-K 277 CYCLINEX-1 513 cyclobenzaprine hcl 356,488 D CYCLOGYL 434 d and c green no.6 356 CYCLOMYDRIL 434 d-mannose 356 cyclopentolate hcl 356,434 D-PENAMINE 551 cyclopentolate hcl/lidocaine d-xylose 356 hcl/phenylephrine/tropicamide 434 D.H.E.45 86 cyclopentolate hcl/tropicamide/phenylephrine hcl D3-2000 513 in water 434 D3-50 513 cyclophosphamide 90,356,551 dacarbazine 91 cycloserine 89,356 DACOGEN 98 CYCLOSET 147 dactinomycin 98 cyclosporine 309,356 DAFLONEX-XL 513 cyclosporine, modified 309 DAILY FIBER 265 CYKLOKAPRON 160 DAILY GUMMIES 513 CYMBALTA 205 DAILY MULTIPLE 513 cyproheptadine hcl 356,455 DAILY MULTIPLE VITAMIN 513 CYRAMZA 98 DAILY MULTIVITAMIN 513 CYRED 289 DAILY MULTIVITAMIN-IRON 513 CYRED EQ 289 DAILY PRENATAL 513 CYSTADANE 245 DAILY PROBIOTIC 551 CYSTAGON 245 DAILY VALUE 513 CYSTARAN 434 DAILY VITAMIN FORMULA 513 cysteamine hcl 356 DAILY VITAMIN FORMULA-IRON 513 cysteine 356 DAILY VITAMIN FORMULA-MINERALS 513 cysteine hcl 356,513 DAILY VITE 514 CYSTEX CRANBERRY 356 DAILY VITE WITH IRON 514 CYSTEX PLUS 43 DAILY-VITE 514 cystine 356 DAKIN'S 221 CYSTO-CONRAY II 356 DAKLINZA 132 CYSTOGRAFIN 356 dalfampridine 206,356 DALIRESP 464 deferoxamine mesylate 357 danazol 285,356 DEFINITY 163 DANTRIUM 488 DELESTROGEN 290 dantrolene sodium 356,488 DELFLEX WITH 1.5% DEXTROSE 497 dapiprazole hcl 356 DELFLEX WITH 2.5% DEXTROSE 497 dapsone 89,221,357 DELFLEX WITH 4.25% DEXTROSE 497 DAPTACEL DTAP 318 DELFLEX-2.5% DEXTROSE 551 daptomycin 43 DELSTRIGO 551 DARAPRIM 116 DELSYM COUGH+CHEST CONGEST DM 474 darifenacin hydrobromide 274 DELTA D3 514 DARZALEX 113 DELZICOL 320 DASETTA 290 DEMADEX 184 DATSCAN 357 demecarium bromide 357 daunorubicin hcl 98 demeclocycline hcl 55 DAY TIME 473 DEMEROL 13 DAY TIME COLD-FLU 473 DEMSER 178 DAY TIME COLD-FLU RELIEF 473 DENAVIR 141 DAY TIME PE 473 DENTA 5000 PLUS 209 DAYHIST ALLERGY 455 DENTAGEL 209 DAYPRO 4 deoxycholic acid 357 DAYSEE 290 DEPACON 59 DAYTIME COLD AND FLU RELIEF 474 DEPAKENE 59 DAYTIME COLD MULTI-SYMPTOM 474 DEPAKOTE 59 DAYTIME COLD-FLU 474 DEPAKOTE ER 59 DAYTIME COLD-FLU RELIEF 474 DEPAKOTE SPRINKLE 59 DAYTRANA 196 DEPEN 277 DAYVIGO 551 DEPLIN-ALGAL OIL 514 DDAVP 283 DEPO-ESTRADIOL 290 deanol 357 DEPO-MEDROL 280 deanol bitartrate 357 DEPO-PROVERA 300 deanol/glycolic acid 357 DEPO-SUBQ PROVERA 104 300 DEBACTEROL 209 DEPO-TESTOSTERONE 285 DEBLITANE 300 DERMA-SMOOTHE-FS 221 DECADRON 280 DERMACINRX FOLIXAPURE 514 decamethylcyclopentasiloxane 357 DERMACINRX LEXITRAL 221 DECARA 514 DERMACINRX SILAPAK 221 decitabine 98 DERMACINRX THERAZOLE PAK 221 DECUBI VITE 514 DERMAGRAFT 357 DEEP SEA 357 DERMAREST ECZEMA 221 deferasirox 493,551 DERMAREST PSORIASIS 221 deferiprone 493 DERMASEPTIN 221 DERMATOP 221 dexamethasone isonicotinate 357 DERMAZENE 221 dexamethasone sodium phosphate 281 DERMAZINC 221 dexamethasone sodium phosphate in 0.9 % DERMOTIC 448 sodium chloride 281 DESCOVY 136 dexamethasone sodium phosphate/pf 281,551 DESENEX 79 dexamethasone, micronized 357 DESFERAL 357 dexchlorpheniramine maleate 551 DESFERAL MESYLATE 357 DEXEDRINE 194 desflurane 34 DEXERYL 222 DESGEN DM 474 DEXILANT 273 desipramine hcl 72,357 dexmedetomidine hcl 358 desloratadine 455 dexmedetomidine hcl in 0.9 % sodium desmopressin acetate 283,357 chloride 358 desmopressin acetate (non-refrigerated) 283 dexmethylphenidate hcl 196,197 desogestrel-ethinyl estradiol 290 DEXPAK 281 desogestrel-ethinyl estradiol/ethinyl estradiol 290 dexpanthenol 358 DESONATE 221 dexrazoxane hcl 98 desonide 221 DEXTENZA 551 desonide, micronized 357 dextroamphetamine sulf- DESOWEN 222 saccharate/amphetamine sulf-aspartate 195 desoximetasone 222 dextroamphetamine sulfate 195 desoximetasone, micronized 357 dextromethorphan hbr 358 desoximetasone/niacinamide 551 dextromethorphan polistirex 474 desoxycorticosterone acetate 357 dextrose 358 DESOXYN 194 dextrose 10 % and 0.2 % sodium chloride 497 DESPEC DM 474 dextrose 10 % and 0.45 % sodium chloride 497 DESPEC DM-G 474 dextrose 10 % in water 514 desvenlafaxine 68 dextrose 2.5 % and 0.45 % sodium chloride 497 desvenlafaxine succinate 68 dextrose 20 % in water 514 DETROL 275 dextrose 25 % in water 514 DETROL LA 275 dextrose 30 % in water 514 devil's claw extract 357 dextrose 40 % in water 514 DEXABLISS 551 dextrose 5 % and 0.2 % sodium chloride 497 dexamethasone 280,281 dextrose 5 % and 0.3 % sodium chloride 497 dexamethasone acetate 357 dextrose 5 % and 0.45 % sodium chloride 497 dexamethasone acetate and sodium phosphate in dextrose 5 % and 0.9 % sodium chloride 497 sterile water 551 dextrose 5 % in lactated ringers 498 dexamethasone acetate in sodium chloride, iso- dextrose 5 % in ringer's 498 osmotic 551 dextrose 5 % in water 514 dexamethasone acetate, micronized 357 dextrose 50 % in water 514 DEXAMETHASONE INTENSOL 281 dextrose 70 % in water 514 DHS SAL 222 dichloroacetic acid 358 DIABETES HEALTH FORMULA 514 DICLEGIS 73 DIABETIC SILTUSSIN DAS-NA 474 diclofenac epolamine 222 DIABETIC SILTUSSIN-DM 474 diclofenac potassium 4 DIABETIC SILTUSSIN-DM MAX STR 474 diclofenac sodium 4,222,358,443 diabetic supplies,miscell 358 diclofenac sodium, micronized 358 DIABETIC SUPPORT FORMULA 492 diclofenac sodium/misoprostol 4 DIABETIC TUSSIN DM 474 DICLOFEX DC 222 DIABETIC TUSSIN EX 474 DICLOVIX M 551 DIACOMIT 551 dicloxacillin sodium 51 DIALYVITE 514 dicumarol 358 DIALYVITE 800 514 dicyclomine hcl 247,248,358 DIALYVITE 800 PLUS D 358 didanosine 137 DIALYVITE 800 WITH IRON 514 diethanolamine 358 DIALYVITE 800 WITH ZINC 514 diethylcarbamazine citrate 358 DIALYVITE 800-ULTRA D 515 diethylpropion hcl 358 DIALYVITE SUPREME D 515 diethylstilbestrol 359 DIALYVITE VITAMIN D 515 diethyltoluamide 359 DIALYVITE VITAMIN D3 MAX 515 DIFF-STAT 253 DIAMODE 253 DIFFERIN 222 DIANEAL PD-2 W-1.5% DEXTROSE 498 DIFICID 52 DIANEAL PD-2 W-2.5% DEXTROSE 498 222 DIANEAL PD-2 W-4.25% DEXTROSE 498 DIFLUCAN 79 DIANEAL WITH 1.5% DEXTROSE 498 diflunisal 5 DIANEAL WITH 2.5% DEXTROSE 498 DIGESTIVE ADVANTAGE INT BOWEL 359 DIANEAL WITH 4.25% DEXTROSE 498 DIGESTIVE ADVANTAGE LACTOS DEF 359 DIAPER RASH 222 DIGESTIVE ADVANTAGE PROBIOTIC 253 DIAPER RASH OINTMENT 222 DIGESTIVE PROBIOTIC 253 diaper,brief,adult, disposable 358 DIGESTIVE RELIEF 253 diaper/brief,infant-toddler, disposable 358 DIGIFAB 178 diaphragms, wide seal 358 DIGITEK 178 DIARRHEA RELIEF 253 DIGOX 178 DIASTAT 59 digoxin 178,359 DIASTAT ACUDIAL 59 digoxin, micronized 552 diazepam 59,144,358 dihydrocodeine bitartrate 359 diazolidinyl urea/iodopropynyl dihydroergotamine mesylate 86,359 butylcarbamate 358 dihydroxyacetone (1,3) dimer 359 diazoxide 152,358 diindolylmethane 359 DIBENZYLINE 165 DILANTIN 63 dibucaine hcl 358 DILANTIN-125 63 dichloralphenazone 358 DILATRATE-SR 192 DILAUDID 13,14,552 diphenhydramine hcl 360,455 DILT-XR 173 diphenhydramine hcl in 0.9 % sodium chloride 455 diltiazem hcl 173,174,359 diphenidol hcl 360 diltiazem hcl in 0.9 % sodium chloride 174,552 diphenoxylate hcl/atropine sulfate 253 diltiazem hcl/dextrose 5 % in water 174 DIPRIVAN 34 diluent for dexrazoxane (sodium lactate) 552 DIPROLENE 222 DILUENT FOR ELITEK 552 dipyridamole 164,360 diluent for epoprostenol sodium (glycine) 359 DISCOVISC 434 DILUENT FOR FLOLAN 359 DISKETS 30 DILUENT FOR IXEMPRA 552 disopyramide phosphate 168 DILUENT FOR LEFAMULIN(XENLETA) 498 disulfiram 38,360 DILUENT FOR ROTARIX 359 DITROPAN XL 275 diluent for treprostinil (glycine) 359 DIURIL 185 DILUENT-MERCK LIVE VIRUS VACC 359 divalproex sodium 59 DILUTING MEDIUM FOR NOVOLOG 359 DIVIGEL 290 DIMAPHEN 474 dl-3-hydroxybutyric acid, sodium salt 552 DIMAPHEN DM 474 dl-leucine 360 dimenhydrinate 73,359 DMSA 360 DIMENTHO 552 dobutamine hcl 179 dimethyl fumarate 359 dobutamine hcl in dextrose 5 % in water 179 359 DOCEFREZ 99 dimethylacetamide 359 docetaxel 99,552 dimethylglycine hcl 359 docosanol 360 dinitrochlorobenzene (2,4) 359 DOCU LIQUID 265 DINO-LIFE 515 DOCUPRENE 265 DINO-LIFE EXTRA C MULTIVITAMIN 515 docusate calcium 265 DINO-LIFE MULTIVITAMIN 515 docusate sodium 265,360 DIOCTO 265 DOCUSIL 265 DIOCTYL 265 dofetilide 168 diosgenin 360 DOJOLVI 552 diosmin 360 DOK 265 DIOTAME 253 DOK PLUS 265 DIOVAN 166 DOLOPHINE HCL 9 DIOVAN HCT 178,179 donepezil hcl 64 dioxybenzone 360 DONNATAL 248 DIPENTUM 320 dopamine hcl 179,360 DIPHEDRYL 455 dopamine hcl in dextrose 5 % in water 179 DIPHEDRYL ALLERGY 455 DOPRAM 474 DIPHEN 455 DOPTELET 552 diphencyprone 360 DORAL 490 DIPHENHIST 455 doripenem 49 DORYX 55 DSUVIA 553 DORYX MPC 55 DUAC 223 dorzolamide hcl 446 DUAKLIR PRESSAIR 553 dorzolamide hcl/timolol maleate 446 DUAL ACTION 262 dorzolamide hcl/timolol maleate/pf 446 DUAL ACTION COMPLETE 262 DOTAREM 360,552 DUAVEE 290 DOTHELLE DHA 515 DUCODYL 265 DOUBLE ANTIBIOTIC 222 DUET DHA 400 515 DOVATO 552 DUET DHA BALANCED 515 DOVONEX 223 DUETACT 147 doxapram hcl 474 DUEXIS 5 doxazosin mesylate 165,360 DULCOEASE 265 doxepin hcl 72,223,360,491 DULCOLAX 265 doxercalciferol 322 DULCOLAX STOOL SOFTENER 265 DOXIL 99 DULERA 474,553 doxorubicin hcl 99 duloxetine hcl 205,361 doxorubicin hcl pegylated liposomal 99 DUOBRII 553 DOXY 100 55 DUOCAL 515 doxycycline hyclate 56,360,552 DUODOTE 361 doxycycline monohydrate 56,360 DUOPA 119 doxylamine succinate 360 DUOVISC 434 doxylamine succinate/pyridoxine hcl (b6) 73 DUPIXENT PEN 553 drainage bag 360 DUPIXENT SYRINGE 553 DRAMAMINE LESS DROWSY 73 DURACLON 165 DRAXIMAGE DTPA 360 DURAGESIC 9 dressing, collagen/sodium DURAMORPH 14 alginate/carboxymethylcellulose 361 DUREZOL 443 dressing,collagen/silver/sod DURLAZA 498 alginate/carboxymethylcellulose 361 DUROLANE 553 DRIMINATE 73 DURYSTA 553 DRISDOL 515 dutasteride 276,553 DRITHOCREME HP 223 dutasteride/tamsulosin hcl 276 DRIZALMA SPRINKLE 553 DUTOPROL 179 dronabinol 75 DUZALLO 553 droperidol 120,361 DVORAH 553 drospirenone/ethinyl estradiol/levomefolate DXEVO 554 calcium 290 DYANAVEL XR 195 DROXIA 95 DYAZIDE 179 DRY EYE RELIEF 434 dyclonine hcl 361 DRYSOL 223 DYMISTA 475 DSS 265 dyphylline 361 DYRENIUM 185 efavirenz 135 DYSPORT 488 efavirenz/emtricitabine/tenofovir disoproxil fumarate 135 E EFFACLAR DUO 223 E-Z DISK 361 EFFER-K 498 E-Z-HD 361 EFFEXOR XR 68 E-Z-PAQUE 361 EFFIENT 164 E-Z-PASTE 361 EFUDEX 95 E.E.S. 200 52 EGATEN 554 E.E.S. 400 52 egg extract 361 EAA 515 egg yolk extract 361 EAR DROPS 448 EGG-PRO 515 EAR SYSTEM 448 EGRIFTA SV 304 EAR WAX REMOVAL 448 ELAPRASE 245 EAZZZE THE PAIN 492 ELECARE 515 EC-NAPROSYN 5 ELECARE JR 515 ECONASIL 80 ELECTROLYTE 498 econazole nitrate 80,361 electrolyte-48 solution/dextrose 5 % in water 498 ECONTRA EZ 290 ELELYSO 245 ECONTRA ONE-STEP 290 ELESTAT 442 ECOTRIN 5 ELESTRIN 290 ECOZA 80 ELETONE 223 ECPIRIN 5 eletriptan hydrobromide 86 ED A-HIST 475 ELIDEL 223 ED A-HIST PSE 475 ELIGARD 304 ED CHLORPED JR 455 ELIMITE 223 ED-A-HIST DM 475 ELINEST 290 ED-APAP 201 ELIQUIS 155,554 ED-SPAZ 248 ELITE-OB 515 EDARBI 166 ELITEK 95 EDARBYCLOR 179 ELIXOPHYLLIN 464 EDECRIN 184 ELLA 300 edetate calcium disodium 361 ELLENCE 99 edetate disodium 361 ELLIOTTS B 498 edetate tetrasodium tetrahydrate 361 ELLZIA PAK 554 edetic acid 361 ELMIRON 278 EDLUAR 490 ELOCON 223 edrophonium chloride 361 ELOCTATE 160 EDURANT 135 ELURYNG 290 EEMT 290 EMADINE 442 EEMT H.S. 290 EMBEDA 30 EMCYT 94 ENGERIX-B ADULT 318 EMEND 75,76 ENGERIX-B PEDIATRIC-ADOLESCENT 318 EMFLAZA 554 ENHERTU 554 EMGALITY PEN 554 enoxaparin sodium 155 EMGALITY SYRINGE 554 ENPRESSE 290 emollient combination no. 15 361 ENSKYCE 290 emollient combination no. 2 361 ENSTILAR 223 emollient combination no.112 362 ENSURE 515 emollient combination no.37 362 ENSURE ACTIVE HEART HEALTH 515 emollient combination no.59 362 ENSURE ACTIVE HIGH PROTEIN 515 emollient combination no.64 362 ENSURE ACTIVE LIGHT 515 emollient combination no.79 362 ENSURE ACTIVE MUSCLE HEALTH 516 EMOQUETTE 290 ENSURE ACTIVE PROTEIN-MUSCLE 516 EMPRICAINE-II 223 ENSURE CLEAR 516 EMSAM 67 ENSURE CLEAR THERAPEUTIC 516 emtricitabine 137 ENSURE COMPACT 516 emtricitabine/tenofovir disoproxil fumarate 137 ENSURE ENLIVE 516 EMTRIVA 137 ENSURE HIGH PROTEIN 516 emu oil 362 ENSURE LIQUID 516 emulsifying wax 362 ENSURE MUSCLE HEALTH 516 emulsion base no.54 362 ENSURE ORIGINAL 516 EMULSION SB 223 ENSURE PLUS 516 EMVERM 115 ENSURE POWDER 516 ENABLEX 275 entacapone 117 enalapril maleate 167,362 entecavir 131,132 enalapril maleate/hydrochlorothiazide 179 ENTEREG 253 enalaprilat dihydrate 167 ENTERO VU 362 ENBREL 309,554 ENTOCORT EC 321 ENBREL MINI 309 ENTRESTO 179 ENBREL SURECLICK 309 ENTTY 362 ENDACOF-DM 475 ENTYVIO 309 ENDARI 515 ENULOSE 266 ENDO-AVITENE 362 ENVARSUS XR 309 ENDOCET 14 ENZYMATIC DIGESTANT 253 ENDOFORM 362 EOVIST 362 ENDOMETRIN 300 EPANED 167 ENDUR-ACIN 190 EPCLUSA 132,554 ENEMA 266,362 ephedrine hcl 362 ENEMA DISPOSABLE 266 ephedrine sulfate 179,362 ENEMEEZ 266 ephedrine sulfate in 0.9 % sodium chloride/pf 179 ENFAMIL ENFALYTE 498 EPHRINE NOSE DROPS 362 EPICERAM 223 ERIVEDGE 107 EPIDIOLEX 554 ERLEADA 555 EPIDUO 223 ERRIN 300 EPIDUO FORTE 224 ERTACZO 80 EPIFIX AMNIOTIC MEMBRANE 224 ertapenem sodium 49 EPIFOAM 224 ERWINAZE 99 epigallocatechin gallate 362 ERY 224 epinastine hcl 442 ERY-TAB 52 epinephrine 362,460 ERYGEL 224 epinephrine bitartrate 362 ERYPED 200 52 epinephrine hcl in 0.9 % sodium chloride 460,555 ERYPED 400 52 epinephrine hcl in dextrose 5 % in water 460,555 ERYTHROCIN LACTOBIONATE 52 epinephrine hcl/pf 460 ERYTHROCIN STEARATE 52 EPINEPHRINESNAP-EMS 460 erythromycin base 52,363,434 EPINEPHRINESNAP-V 460 erythromycin base in ethanol 224 EPIPEN 461 erythromycin base/benzoyl peroxide 224 EPIPEN 2-PAK 461 erythromycin estolate 363 EPIPEN JR 461 erythromycin ethylsuccinate 52,363 EPIPEN JR 2-PAK 461 erythrosine sodium 363 epirubicin hcl 99 ESBRIET 475,555 EPISIL 209 ESCAVITE LQ 516 EPISNAP 461 escitalopram oxalate 68 EPITOL 63 ESGIC 201 EPIVIR 137 esmolol hcl 170 EPIVIR HBV 132 esmolol hcl in sodium chloride, iso-osmotic 171 eplerenone 185 ESOMEP-EZS 273 EPOGEN 157 esomeprazole magnesium 273 epoprostenol sodium (glycine) 465 esomeprazole sodium 273 eprosartan mesylate 166 esomeprazole strontium 273 eptifibatide 164 ESPEROCT 555 EPZICOM 137 ESSENTIA 516 EQ GENTLE 434 ESSENTIAL BALANCE 516 EQUACARE JR 555 ESSENTIAL CARE JR 555 EQUETRO 145 ESSENTIAL DAILY 516 ERAXIS (WATER DILUENT) 80 ESSENTIAL MAN 516 ERBITUX 113 ESSENTIAL MAN 50+ 516 ergocalciferol (vitamin d2) 362,516 ESSENTIAL WOMAN 50+ 516 ergoloid mesylates 64,362 ESTARYLLA 290 ERGOMAR 86 estazolam 490 ergotamine tartrate 363 ESTRACE 291 ergotamine tartrate/caffeine 86 estradiol 291,363 estradiol benzoate 363 EUFLEXXA 364 estradiol cypionate 363 eugenol 364 estradiol hemihydrate, micronized 363 EURAX 117 estradiol micronized 363 EVAMIST 291 estradiol valerate 291,363 evans blue 364 estradiol/norethindrone acetate 291 EVARREST 364 ESTRING 291 EVEKEO 195 estriol 363 EVEKEO ODT 555 estriol micronized 363 everolimus 107,310 ESTROGEL 291 EVICEL 364 estrogens,esterified/methyltestosterone 291 EVISTA 302 estrone 363 EVOCLIN 224 ESTROSTEP FE 291 EVOMELA 91 eszopiclone 490 EVOTAZ 139 ethacrynate sodium 184 EVOXAC 209 ethacrynic acid 185 EVRYSDI 555 ethambutol hcl 89 EVZIO 40 ETHAMOLIN 363 EXALGO 31 ethanolamine 363 EXELDERM 80 ether 363 EXELON 64 ethinyl estradiol 363 exemestane 105 ethinyl estradiol/drospirenone 291 EXFORGE 179 ethosuximide 58,363 EXFORGE HCT 180 ethoxydiglycol 363 EXJADE 493 ethyl acetate 363 EXODERM 80 ethyl alcohol 363,516 EXONDYS-51 364 ethyl chloride 224 EXPAREL 34 ethyl oleate 363 EXPECTORANT 475 ethylenediamine 364 EXPECTORANT COUGH SYRUP 475 ethynodiol diacetate-ethinyl estradiol 291 EXPECTORANT DM 475 ETHYOL 99 EXTAVIA 206 etidronate disodium 322 EXTINA 80 etodolac 5 EXTRA ACTION COUGH 475 etomidate 34 EXTRA PAIN RELIEF 5 etonogestrel/ethinyl estradiol 291 EXTRANEAL ICODEXTRIN DIALYSIS 498 ETOPOPHOS 105 EXTRAPRIN 5 etoposide 105 EYE DROP TEARS 435 eucalyptol 364 EYE DROPS 435 364 EYE HEALTH AND LUTEIN 517 EUCERIN 224 EYE HEALTH PLUS LUTEIN 517 EUCRISA 555 EYE ITCH RELIEF 442 EYE-STREAM 435 feeder container with pump set 365 EYESCRUB 364 feeder irrigation kit 365 EYLEA 435 FEIBA NF 160 EZALLOR SPRINKLE 555 felbamate 61 ezetimibe 190 FELBATOL 61 ezetimibe/simvastatin 190 FELDENE 5 felodipine 174 F FEM PH 278 FA-8 517 FEMARA 105 FABIOR 224 FEMHRT 292 FABRAZYME 246 FEMRING 292 facial mask 364 FEMYNOR 292 FACTIVE 54 FENESIN DM IR 475 FALMINA 292 FENESIN IR 266 famciclovir 141 fenofibrate 186 famotidine 40,262,364,555 fenofibrate nanocrystallized 186 famotidine in 0.9 % sodium chloride 262,556 fenofibrate,micronized 186 famotidine in sodium chloride, iso-osmotic/pf 262 fenofibric acid 186 famotidine/pf 262 fenofibric acid (choline) 187 FANAPT 122 FENOGLIDE 187 FARESTON 94 fenoprofen calcium 5 FARXIGA 147 fenoprofen calcium, dihydrate 365 FARYDAK 99 FENORTHO 5 FASENRA 556 fentanyl 9,31 FASENRA PEN 556 fentanyl citrate 15,365 FASLODEX 94 fentanyl citrate in 0.9 % sodium chloride/pf15,556 FAST RELIEF LAXATIVE 266 fentanyl citrate in dextrose 5% in water/pf 15 FAYOSIM 292 fentanyl citrate/bupivacaine hcl in 0.9 % sodium FAZACLO 130 chloride/pf 15,556 fd and c blue no.1 364 fentanyl citrate/pf 16,556 fd and c green no.3 364 fentanyl citrate/ropivacaine hcl/sodium chloride fd and c no.2 (indigotine) 364 0.9%/pf 16 fd and c no.5 (tartrazine) 364 FENTORA 16 fd and c red no.40 364 FEOSOL 498 fd and c yellow no.6 (sunset yellow fcf) 364 FERAHEME 517 FE C 498 FERATE 498 FE C PLUS 498 FEROCON 498 febuxostat 85 FEROSUL 499 feeder container 364 FERREX 150 517 feeder container with gravity set 364 FERREX 150 FORTE 499 feeder container with gravity set, enfit 556 ferric ammonium citrate 365 ferric chloride 365 FIORINAL WITH CODEINE #3 16 ferric subsulfate 365 FIRAZYR 307 ferric sulfate 365 FIRMAGON 304 FERRIC X-150 517 FIRST AID ANTIBIOTIC 224 FERRIPROX 493,556 FIRST AID ANTIBIOTIC-PAIN RLF 224 FERRIPROX (2 TIMES A DAY) 556 FIRST AID ANTISEPTIC 365 FERRLECIT 517 FIRVANQ 557 FERRO-TIME 499 FISH OIL 517 FERROCITE 499 FLAC OTIC OIL 448 FERROCITE PLUS 499 FLAGYL 43 ferrous fumarate 365,499 FLANAX 5 ferrous gluconate 365,499 FLAREX 443 ferrous sulfate 365,499 flash glucose scanning reader 557 ferrous sulfate, dried 365,499 flash glucose sensor 557 FERROUSUL 499 FLAVOR CHEWS ANTACID 253 ferulic acid 365 flavoring agent 365 FETROJA 556 flavoxate hcl 275 FETZIMA 68 flaxseed oil 365,517 FEVER REDUCER-PAIN RELIEVER 201 FLEBOGAMMA DIF 314 FEVERALL 201 flecainide acetate 169 feverfew extract 365 FLECTOR 225 FEXMID 488 FLEXBUMIN 365 fexofenadine hcl 365,455 flibanserin 365 fexofenadine hcl/pseudoephedrine hcl 475 FLINTSTONES 517 FIASP 556 FLINTSTONES COMPLETE 517 FIASP FLEXTOUCH 556 FLINTSTONES GUMMIES 517 FIASP PENFILL 556 FLINTSTONES PLUS CALCIUM 517 FIBER 266 FLINTSTONES WITH EXTRA C 517 FIBER LAXATIVE 266 FLOLAN 465 FIBER SMOOTH 266 FLOLIPID 557 FIBER TABS 266 FLOMAX 276 FIBER THERAPY 266 FLONASE SENSIMIST 557 FIBER-LAX 266 FLORAJEN 253 FIBRICOR 187 FLORAJEN BIFIDOBLEND 253 FIBRYGA 556 FLORAJEN3 254 FINACEA 224 FLORAJEN4KIDS 254 finasteride 276,365 FLORANEX 254 FINTEPLA 557 FLORASTOR 254 FIORICET 201 FLORASTORKIDS 254 FIORICET WITH CODEINE 16 FLORAVANCE 254 FIORINAL 201 FLOVENT DISKUS 449 FLOVENT HFA 449 fluorouracil 95,225,366 floxuridine 95,365 FLUOVIX PLUS 225 FLU RELIEF THERAPY DAYTIME 475 fluoxetine 366 FLU-SEVERE COLD 475 fluoxetine hcl 68 FLUAD 2019-2020 557 fluphenazine decanoate 120,366 FLUAD 2020-2021 557 fluphenazine hcl 121 FLUAD QUAD 2020-2021 557 FLURA-DROPS 499 FLUARIX QUAD 2019-2020 557 flurandrenolide 225 FLUARIX QUAD 2020-2021 557 flurazepam hcl 491 FLUBLOK QUAD 2019-2020 557 flurbiprofen 5,366 FLUBLOK QUAD 2020-2021 557 flurbiprofen sodium 443 FLUCAINE 435 flutamide 92 FLUCELVAX QUAD 2019-2020 557 fluticasone propionate 225,366,449 FLUCELVAX QUAD 2020-2021 557 fluticasone propionate, micronized 366 fluconazole 80,365 fluticasone propionate/salmeterol fluconazole in sodium chloride, iso-osmotic 80 xinafoate 475,558 flucytosine 80,366 fluvastatin sodium 188 fludarabine phosphate 100 fluvoxamine maleate 68,69 fludrocortisone acetate 281,366 FLUZONE HIGH-DOSE 2019-2020 558 FLULAVAL QUAD 2019-2020 557 FLUZONE HIGH-DOSE QUAD 2020-21 558 FLULAVAL QUAD 2020-2021 558 FLUZONE QUAD 2019-2020 558 FLUMADINE 140 FLUZONE QUAD 2020-2021 558 flumazenil 366 FML 443 FLUMIST QUAD 2019-2020 558 FML FORTE 443 FLUMIST QUAD 2020-2021 558 FML S.O.P. 443 flunisolide 366,449 foam bandage 366 fluocinolone acetonide 225,366 foam base no.129 366 fluocinolone acetonide oil 448 foam base no.99 366 fluocinolone acetonide/shower cap 225 FOAMING ANTACID 254 fluocinonide 225 FOCALIN 197 fluocinonide, micronized 366 FOCALIN XR 197 fluocinonide/emollient base 225 FOLBEE 517 FLUOPAR 558 FOLBEE PLUS 517 FLUORABON 517 FOLBEE PLUS CZ 517 fluorescein sodium 366 FOLBIC 518 FLUORESCITE 435 FOLBIC RF 518 fluoride (sodium) 209,366,499,517 folic acid 366,518 FLUORIDEX 209 FOLIC ACID-VIT B-6-VIT B-12 367 FLUORITAB 517 folic acid/multivit with minerals/lutein 518 fluorometholone 443 folic acid/vitamin b complex and c/rice bran 518 FLUOROPLEX 225 folic acid/vitamin b complex and vitamin c 518 FOLIKA-NC 558 frovatriptan succinate 87 FOLINIC-PLUS 518 fructose 367 FOLITAB 500 499 FRUIT C-500 518 FOLIVANE-PLUS 499 FRUITIVITS 518 FOLOTYN 96 fuchsin,basic 367 FOLPLEX 2.2 499 FUL-GLO 435 FOLTANX 518 FULL SPECTRUM B 518 FOLTANX RF 518 fuller's earth 367 fomepizole 367 FULPHILA 558 fondaparinux sodium 155 fulvestrant 94 FOOT & SNEAKER 80 FUNGI CURE 80 FORANE 34 FUNGOID TINCTURE 80 FORAXA 558 FUNGOID-D 80 FORFIVO XL 66 FURADANTIN 43 FORMA-RAY 225 furazolidone 367 FORMADON 367 furosemide 185,367 formaldehyde 367 furosemide in 0.9 % sodium chloride 185 formoterol fumarate 367 furosemide/dextrose 5 % in water 185 formoterol fumarate dihydrate, micronized 367 FUSILEV 100 FORMULA 3 80 FUSION PLUS 499 FORTAMET 147,201 FUSION SPRINKLES 500 FORTAVIT 518 FUZEON 138 FORTAZ 49 FYAVOLV 292 FORTEO 322 FYCOMPA 57 FORTESTA 285 FOSAMAX 322 G FOSAMAX PLUS D 322 G TUSSIN AC 475 fosamprenavir calcium 139 G-FENESIN 266 fosaprepitant dimeglumine 76 G-FENESIN DM 476 FOSCAVIR 130 GA 518 FOSFREE 499 GA EXPRESS 15 518 fosinopril sodium 167 GA GEL 518 fosinopril sodium/hydrochlorothiazide 180 GABACAINE 558 fosphenytoin sodium 63 GABAPAL 558 FOSRENOL 279 gabapentin 59,367 FRAGMIN 155 GABITRIL 59 FREAMINE HBC 518 GABLOFEN 488 FREAMINE III 518 GADAVIST 367 FREEDAVITE 518 galactose 367 FRESHKOTE 435 galantamine hbr 64 FROVA 86 GALZIN 493 GAMASTAN 314 gel base no.30 368 GAMASTAN S-D 314 gel base no.41 368 GAMIFANT 558 gel base no.46 368 gamma-aminobutyric acid 367 gel base no.72 368 GAMMAGARD LIQUID 314 gel base no.79 368 GAMMAGARD S-D 314 gel base no.80 368 GAMMAKED 314 gel base no.86 368 GAMMAPLEX 315,558 gel base no.92 368 GAMUNEX-C 315 gel dressing 368 ganciclovir 131 gel-matrix pad dressing, silicone 559 ganciclovir sodium 131,558 GEL-ONE 368 GARDASIL 9 318 gelatin 369 gardenia fragrance 367 gelatin capsules (empty) 369 garlic 518 gelatin troche base no.53 369 GAS RELIEF 254 GELFILM 435 GAS-X 254 GELFOAM 369 GAS-X ULTRA STRENGTH 255 GELFOAM COMPRESSED 369 GASTROCROM 255 GELFOAM JMI 559 GASTROGRAFIN 367 GELNIQUE 275 GASTROMARK 367 gemcitabine hcl 96,559 gatifloxacin 367,435 gemfibrozil 187,369 GATTEX 255 GEMZAR 96 gauze bandage 367 GENADUR 225 GAVILAX 266 GENERESS FE 292 GAVILYTE-C 266 GENERLAC 267 GAVILYTE-G 266 GENGRAF 310 GAVILYTE-N 267 GENICIN 369 GAVISCON 255 genistein 369 GAZYVA 113 GENOTROPIN 283 gel base no.102 367 GENTAK 435 gel base no.107 368 gentamicin sulfate 41,225,369,435 gel base no.117 368 gentamicin sulfate in sodium chloride, iso- gel base no.120 368 osmotic 41 gel base no.133 368 gentamicin sulfate/pf 41 gel base no.137 368 gentamicin sulfate/sodium citrate 559 gel base no.153 368 GENTEAL TEARS 435 gel base no.162 368 GENTEAL TEARS SEVERE 435 gel base no.180 368 gentian violet 369 gel base no.184 368 GENTLE LAXATIVE 267 gel base no.197 368 GENTLELAX 267 gel base no.225 368 GENVISC 850 369 GENVOYA 135 glucosamine hcl/msm/chondroitin sulfate GEODON 122 a/ 370 geranium oil 369 glucosamine sulfate 370 GERBER SOOTHE 255 glucosamine sulfate (dipotassium chloride) 370 GERI-DRYL 455 glucosamine sulfate dipotassium GERI-HYDROLAC 225 chlor/chondroitin sulfate a 370 GERI-KOT 267 glucosamine sulfate sodium cl 370 GERI-LANTA 255 GLUCOSAMINE-CHONDROITIN 370 GERI-MOX 255 GLUCOSAMINE-CHONDROITIN COMPLX 370 GERI-PECTATE 255 GLUCOSAMINE-MSM COMPLEX 370 GERI-TUSSIN 476 glucosamine/chondroit-msm GERI-TUSSIN DM 476 no.1/c/manganese/boswellia serrata 370 GIANVI 292 glucosamine/chondroitin sulfate a 370 GILENYA 207,559 GLUCOTROL 148 GILOTRIF 108 GLUCOTROL XL 148 GILPHEX TR 476 GLUMETZA 148 GILTUSS TR 476 glutamic acid 370 ginger root 369 glutamine 370 GIVLAARI 559 glutaraldehyde 370 GLASSIA 476 GLUTAREX-1 518 glatiramer acetate 207 GLUTAREX-2 519 GLATOPA 207 glutathione 370 GLEEVEC 108 glyburide 148,370 GLENMAX PEB DM 476 glyburide,micronized 148 GLEOSTINE 91 glyburide/metformin hcl 148 GLIADEL 91 glycerides c12-18 371 glimepiride 147 glycerin 267,371 glipizide 147,369 glycerol formal 371 glipizide/metformin hcl 147 glyceryl oleate 371 GLOPERBA 559 glycine 371 gloves 369 glycine carbonate sodium 371 gloves, latex 369 GLYCINE SOYA PROTEIN 371 GLUCAGEN 152 glycine urologic solution 278 GLUCAGON EMERGENCY KIT 152 glycocyamine 371 glucagon hcl 152 glycofurol 371 gluconolactone 369 GLYCOLAX 267 GLUCOPHAGE 147,148 glycolic acid 371 GLUCOPHAGE XR 148 GLYCOPHOS 500 glucosamine hcl 369 glycopyrrolate 248,371,559 glucosamine hcl/chondroitin sulfate a 369 glycopyrrolate in sterile water/pf 248,559 glucosamine hcl/chondroitin sulfate a sodium 370 GLYCOSADE 519 glycosaminoglycans,mixed 371 GUAICON DMS 476 glycyrrhizin 371 guaifenesin 267,372,476 GLYDO 226 GUAIFENESIN AC 476 GLYNASE 148 GUAIFENESIN DAC 476 GLYRX-PF 248 guaifenesin/dextromethorphan hbr 476 GLYSET 148 guaifenesin/pseudoephedrine hcl 476 GLYTACTIN 15 PE BETTERMILK 519 guanabenz acetate 372 GLYTACTIN BURST 10-10 559 guanethidine sulfate 372 GLYTACTIN BURST 20-20 559 guanfacine hcl 165,197 GLYTACTIN RTD 10 PE 519 guanidine hcl 88 GLYTACTIN RTD 15 PE 519 guar gum 372 GLYXAMBI 148 guarana seed extract 372 GOCOVRI 559 guava flavor 372 gold sodium thiomalate 371 GUMMI BEAR MULTIVITAMIN 519 GOLYTELY 267 GUMMIES CHILDREN MULTIVITAMIN 519 GONIOTAIRE 435 GUMMY 519 GONIOVISC 435 GUMMY DINOS 519 GONITRO 192 GVOKE PFS 1-PACK SYRINGE 559 GOODY'S EXTRA STRENGTH 5 GVOKE PFS 2-PACK SYRINGE 560 GORMEL 226 gymnema leaf 372 GRAFIX CORE 226 GYNAZOLE 1 80 GRAFIX PRIME 226 GYNE-LOTRIMIN 81 GRALISE 59 GYNE-LOTRIMIN-7 81 gramicidin d 371 granisetron hcl 76 H granisetron hcl/pf 76 H-CHLOR 12 226 GRANIX 158,559 H2Q 519 grape flavor 371 HAEGARDA 560 grape seed oil 371 HAILEY 292 GRASTEK 476 HAILEY 24 FE 292 green (food color) 371 HAILEY FE 292 green soap 371 HAIR VITAMIN 519 green tea extract 371 HAIR, SKIN AND NAILS 519 green tea oil 371 HALAVEN 100 griseofulvin 371 halcinonide 226 griseofulvin ultramicrosize 80 HALCION 490 griseofulvin, microsize 80 HALDOL 120 GRX HEMORRHOIDAL 226 HALDOL DECANOATE 100 120 guaiacol 371 HALDOL DECANOATE 50 120 GUAIASORB DM 476 halobetasol propionate 226,560 GUAIATUSSIN AC 476 HALOG 226,560 haloperidol 121,372 HEMMOREX-HC 281 haloperidol decanoate 120,372 HEMOCYTE PLUS 500 haloperidol lactate 120,560 HEMOCYTE-F 500 HALUCORT 560 HEMOFIL M 160 HARVONI 132,560 HEMORRHOIDAL COOLING GEL 226 HAVRIX 318 HEMORRHOIDAL CREAM 226 hawthorn berry 372 HEMORRHOIDAL MEDICATED WIPES 226 HCU EXPRESS POWDER 519 HEMORRHOIDAL OINTMENT 226 HCU EXPRESS20 519 HEMORRHOIDAL PADS 226 HCU GEL 519 HEMORRHOIDAL SUPPOSITORIES 226 HCY 1 519 HEMORRHOIDAL SUPPOSITORY 226 HCY 2 519 HEPAGAM B 315 HEADACHE PM 492 heparin sodium,porcine 155 HEADACHE PM FORMULA 492 heparin sodium,porcine in 0.45 % sodium HEADACHE RELIEF 5 chloride 155 HEADACHE RELIEF PM 492 heparin sodium,porcine in 0.45 % sodium HEALON 435 chloride/pf 560 HEALON GV PRO 560 heparin sodium,porcine in 0.9 % sodium HEALON5 435 chloride 156,560 HEALTHY EYES 519 heparin sodium,porcine in 0.9 % sodium HEALTHY EYES SUPERVISION 519 chloride/pf 156 HEALTHYLAX 267 heparin sodium,porcine/dextrose 5 % in water156 HEARTBURN & ACID REFLUX 519 heparin sodium,porcine/pf 156,560 HEARTBURN ANTACID 255 HEPATAMINE 519 HEARTBURN PREVENTION 262 hepes 372 HEARTBURN RELIEF 255,262,263 HEPLISAV-B 561 HEARTBURN RELIEF 150 263 HEPSERA 132 HEARTBURN TREATMENT 273 heptaminol 372 HEARTBURN TREATMENT 24 HOUR 273 HERCEPTIN 113 HEATHER 300 HERCEPTIN HYLECTA 561 HECTOROL 322 HESPAN 372 HELIDAC 560 hetastarch in 0.9 % sodium chloride 372 HELIXATE FS 160 HETLIOZ 492 HEMABATE 278 HEXTEND LACTATED ELECTROLYTE 372 HEMANGEOL 171 HI-CAL 500 HEMATINIC PLUS 500 HIBERIX 318 HEMATINIC WITH FOLIC ACID 500 HICON 372 hematoxylin, c.i. 75290 372 HIDEX 281 HEMAX 500 HIGH POTENCY CAPSAICIN 226 HEMENATAL OB + DHA 519 HIGH POTENCY IRON 500 HEMLIBRA 560 HIPREX 43 histamine phosphate 372 HUMULIN R 153 HISTEX-AC 17 HUMULIN R U-500 153 histidine hcl 372 HUMULIN R U-500 KWIKPEN 148 HIZENTRA 315,561 huperzine serrate a 373 HOMATROPAIRE 435 HYALGAN 373 homatropine hbr 435 hyaluronate sodium 373 homatropine methylbromide 372 hyaluronidase, bovine 373 HOMINEX-1 520 HYCAMTIN 105 HOMINEX-2 520 HYCLODEX 562 HOMOCYSTEINE FORMULA 372 hydralazine hcl 192,373 honey almond fragrance 372 hydrazine sulfate 373 HONEY BEARS 520 HYDREA 96 HONEY BEARS MULTIVITAMIN 520 HYDRO 40 227 honey flavor 372 hydrochloric acid 373 HORIZANT 201 hydrochlorothiazide 185,373 HPR 226 hydrocodone bitart/chlorpheniramine HPR PLUS 226,373 maleate/pseudoephedrine 476 HUMALOG 152 hydrocodone bitartrate 9,373 HUMALOG JUNIOR KWIKPEN 561 hydrocodone bitartrate/acetaminophen 17 HUMALOG KWIKPEN U-100 152 hydrocodone bitartrate/homatropine HUMALOG KWIKPEN U-200 152 methylbromide 476,477 HUMALOG MIX 50-50 152 hydrocodone polistirex/chlorpheniramine HUMALOG MIX 50-50 KWIKPEN 152 polistirex 477 HUMALOG MIX 75-25 152 hydrocodone/ibuprofen 17 HUMALOG MIX 75-25 KWIKPEN 152 hydrocolloid dressing 373 HUMATE-P 160 hydrocortisone 227,281,321,373 HUMATROPE 283 hydrocortisone acetate 227,281,373 HUMIRA 310 hydrocortisone acetate/iodoquinol/aloe vera 227 HUMIRA PEDIATRIC CROHN'S 310 hydrocortisone acetate/lidocaine hcl/aloe HUMIRA PEN 310 vera 227 HUMIRA PEN CROHN'S-UC-HS 310 hydrocortisone acetate/pramoxine hcl 227 HUMIRA PEN PSOR-UVEITS-ADOL HS 310 hydrocortisone butyrate 227 HUMIRA(CF) 311,561 hydrocortisone butyrate/emollient base 227 HUMIRA(CF) PEDIATRIC CROHN'S 561 hydrocortisone valerate 227 HUMIRA(CF) PEN 561 hydrocortisone/acetic acid 448 HUMIRA(CF) PEN CROHN'S-UC-HS 561 hydrocortisone/aloe vera 227 HUMIRA(CF) PEN PSOR-UV-ADOL HS 562 hydrocortisone/iodoquinol 227 HUMULIN 70-30 152 hydrocortisone/mineral oil/petrolatum,white 227 HUMULIN 70/30 KWIKPEN 153 HYDROCREAM 227 HUMULIN N 153 373 HUMULIN N KWIKPEN 153 hydrogen peroxide 373 hydrogenated vegetable oil 373 HYPERRAB S-D 315 HYDROMET 477 HYPERRHO S-D 315 hydromorphone hcl 17,18,31,373 HYPERTET S-D 315 hydromorphone hcl in 0.9 % sodium hypromellose 374 chloride 18,562 HYQVIA 315 hydromorphone hcl in 0.9 % sodium HYQVIA HY COMPONENT 374 chloride/pf 18,19,562 HYQVIA IG COMPONENT 315 hydromorphone hcl in dextrose 5 %-water/pf 19 HYSEPT 227 hydromorphone hcl/bupivacaine hcl in 0.9% HYSINGLA ER 31 sodium chloride/pf 19 HYZAAR 180 hydromorphone hcl/pf 19 hydromorphone hcl/ropivacaine in 0.9 % sodium I chloride/pf 19 I-PRIN 5 hydroxocobalamin 373,520 I-VALEX-1 520 hydroxyamphetamine hydrobromide 373 I-VALEX-2 520 hydroxyapatite 373 I-VITE 520 hydroxychloroquine sulfate 116,374 ibandronate sodium 323 hydroxyethyl acrylate/sod acryloyldimethyl IBRANCE 108,562 taurate copolymer 374 IBU 5 hydroxyethyl methacrylate 374 IBU-200 5 hydroxyethylcellulose 374 IBUDONE 19 hydroxyprogesterone caproate 300 IBUPAK 5 hydroxyprogesterone caproate/pf 300 ibuprofen 6,374 hydroxypropyl betadex 374 IBUPROFEN COLD & SINUS 477 hydroxypropyl cellulose 374 IBUPROFEN COLD-SINUS 477 hydroxyurea 96,374 ibuprofen lysine/pf 6 hydroxyzine hcl 374,456 ibuprofen/oxycodone hcl 20 hydroxyzine pamoate 374,456 ibutilide fumarate 169 HYGEL 227 IC GREEN 374 HYGIENIC CLEANSING PADS 227 ICAPS 520 HYLAGUARD 374 ICAPS AREDS 520 HYLATOPICPLUS 227,374 ICAPS MV 520 HYLENEX 374 icatibant acetate 307 HYMOVIS 374 ICE BLUE GEL 227 HYOPHEN 43 ichthammol 374 hyoscyamine sulfate 248,374 ICLUSIG 108 HYOSYNE 248 IDAMYCIN PFS 100 HYPER-SAL 477,500 idarubicin hcl 100 HYPERHEP B S-D 315 idebenone 374 HYPERLYTE CR 500 IDELVION 161 HYPERRAB 562 IDHIFA 562 idoxuridine 374 indomethacin sodium 6 IFEREX 150 520 indomethacin, submicronized 6 IFEX 91 INFANRIX DTAP 318 ifosfamide 91 INFANT FEVER-PAIN RELIEVER 201 ifosfamide/mesna 91 INFANT GAS RELIEF 255 ILARIS 317 INFANT PAIN RELIEF 201,202 ILEVRO 443 INFANT PAIN-FEVER 202 ILIDERM 562 INFANT'S MOTRIN 6 ILUMYA 562 INFANT'S PAIN RELIEF 202 ILUVIEN 443 INFANTS PROFENIB 6 imatinib mesylate 108 INFANTS' ADVIL 6 IMBRUVICA 109,563 INFANTS' FEVER-PAIN RELIEVER 202 imidurea 375 INFANTS' GAS RELIEF 255 imipenem/cilastatin sodium 49 INFANTS' MOTRIN 6 imipramine hcl 72,375 INFANTS' PAIN RELIEF 202 imipramine pamoate 72 INFANTS' PAIN RELIEVER 202 imiquimod 228,375 INFANTS' PAIN-FEVER 202 IMITREX 87 INFASURF 477 IMMULIFE 520 INFED 520 IMODIUM A-D 563 INFLAMMACIN 375 IMOGAM RABIES-HT 315 INFLATHERM(DICLOFENAC-MENTHOL) 563 IMOVAX RABIES VACCINE 318 INFLECTRA 311 IMPAVIDO 116 INFUMORPH 20 IMPOYZ 563 infusion set for insulin pump 563 IMURAN 311 INFUVITE ADULT 520 IMVEXXY 563 INFUVITE PEDIATRIC 520 INAVIX 375 INGREZZA 563 INCASSIA 300 INGREZZA INITIATION PACK 563 INCRELEX 283 inhaler, assist devices 375 INCRUSE ELLIPTA 459 inhaler, assist devices, accessories 375 indapamide 186 inhaler,assist device with large mask 375 INDERAL LA 171 inhaler,assist device with medium mask 375 INDERAL XL 171 inhaler,assist device with small mask 375 INDICLOR 375 INJECTAFER 520 INDIGO CARMINE 375 INLYTA 109 INDIUM IN-111 DTPA 375 INNOPRAN XL 171 indium in-111 oxyquinoline 375 inositol 375 INDOCIN 6 inositol niacinate 375 indocyanine green 375 INQOVI 564 indole-3-carbinol 375 INSPRA 185 indomethacin 6,375 insulin aspart 153 insulin aspart protamine human/insulin aspart153 irbesartan 166 insulin lispro 153,564 irbesartan/hydrochlorothiazide 180 insulin lispro protamine and insulin lispro 153 IRESSA 109 insulin pump cartridge 564 irinotecan hcl 100 insulin pump controller 564 IRO-PLEX 376 insulin syringe-needle,safety,disposal unit,0.5 IRON 500 ml 375 IRON 100 PLUS 500 INTEGRILIN 164 iron,carbonyl/ascorbic acid 500 INTELENCE 135 irrigation set 376 INTERMEZZO 490 ISENTRESS 135 INTESTINEX 255 ISENTRESS HD 564 INTRALIPID 520 ISIBLOOM 292 INTRAROSA 564 ISOCHRON 192 INTRON A 133 isoflurane 34 INTROVALE 292 isoleucine 376 INTUNIV 197 ISOLYTE P WITH DEXTROSE 500 INVANZ 49 ISOLYTE S 500 INVEGA 122,123 isomalt 376 INVEGA SUSTENNA 123 isometheptene mucate 376 INVEGA TRINZA 123 isoniazid 89,376 INVELTYS 564 isopropamide iodide 376 INVIRASE 139 isopropyl alcohol 376 INVOKAMET 148 isopropyl myristate 376 INVOKAMET XR 148 isopropyl palmitate 376 INVOKANA 148,149 isoproterenol hcl 376,461 INZO ANTIFUNGAL 81 ISOPTO CARPINE 446 iodine 375 ISOPTO TEARS 435 iodine/potassium iodide 375 ISORDIL 192 iodine/sodium iodide 228,375 ISORDIL TITRADOSE 192 IODOFLEX 376 isosorbide 376 iodoform 376 isosorbide dinitrate 192,193 IODOPEN 500 isosorbide mononitrate 193 iodoquinol 376 isosulfan blue 376 IODOSORB 376 isotretinoin 228,376 IONOSOL B WITH DEXTROSE 5% 500 ISOVUE-200 376 IONOSOL MB-DEXTROSE 5% 500 ISOVUE-250 377 iopanoic acid 376 ISOVUE-300 377 IOPIDINE 446 ISOVUE-370 377 IPOL 318 ISOVUE-M 200 377 ipratropium bromide 376,459 ISOVUE-M 300 377 ipratropium bromide/albuterol sulfate 477 isoxsuprine hcl 64,377 isradipine 174 JR PAIN & FEVER 202 ISTALOL 446 JR. STR NON-ASPIRIN PAIN 202 ISTODAX 100 JUBLIA 81 ISTURISA 564 JULEBER 292 ISUPREL 461 JULUCA 564 ITCH RELIEF 81,228 JUNEL 293 ITCHY EYE 442 JUNEL FE 293 itraconazole 81,377 JUNEL FE 24 293 itraconazole, micronized 377 JUNIOR PAIN RELIEVER 202 ivermectin 115,228,377 juniper tar 377 IXEMPRA 100 JUXTAPID 190 IXIARO 318 JYNARQUE 494,565 IXINITY 161 K J K EFFERVESCENT 500 JADENU 493 K-PAX 520 JADENU SPRINKLE 564 K-PAX IMMUNE BOOSTER 520 JAIMIESS 292 K-PAX IMMUNE SUPPORT 521 JAKAFI 109 K-PEC 255 JALYN 276 K-PHOS NO.2 278 JANTOVEN 156 K-PHOS ORIGINAL 500 JANUMET 149 K-TAB ER 500 JANUMET XR 149 KADCYLA 114 JANUVIA 149 KADIAN 9,10 JARDIANCE 149 kahlua flavor 377 JASMIEL 292 KAITLIB FE 293 jasmine fragrance 377 KALA 255 JATENZO 564 KALBITOR 308 JENCYCLA 300 KALETRA 140 JENTADUETO 149 KALLIGA 293 JENTADUETO XR 149 KALYDECO 462,565 JEUVEAU 564 kanamycin sulfate 377 JEVTANA 100 KANJINTI 565 JINTELI 292 KAO-TIN 255,267 JIVI 564 kaolin 377 JOCK ITCH 81 KAOPECTATE 255 JOCK ITCH RELIEF 81 KAPSPARGO SPRINKLE 565 jojoba oil 377 KAPVAY 197 JOLESSA 292 karaya gum 377 JOLIVETTE 300 KARBINAL ER 456 JORNAY PM 564 KARIVA 293 KATERZIA 565 KINERET 311 KAZANO 149 kinetin 378 KCENTRA 161 KINEVAC 378 KEDRAB 316 KINRIX 318 KEFLEX 49 KIONEX 494 KELNOR 1-35 293 KISQALI 565,566 KELNOR 1-50 293 KISQALI FEMARA CO-PACK 109 KENALOG 228 kit for prep tc-99m/mertiatide (betiatide) 566 KENALOG-10 281 KITABIS PAK 462 KENALOG-40 281 kiwi fragrance 378 KENGREAL 164 KLARON 228 KEPIVANCE 209 KLONOPIN 144 KEPPRA 58 KLOR-CON 500 KEPPRA XR 58 KLOR-CON 10 500 KERAFOAM 228 KLOR-CON 8 501 KERALAC 228 KLOR-CON M10 501 KERALYT 228 KLOR-CON M15 501 KERYDIN 81 KLOR-CON M20 501 KETALAR 34 KLOR-CON-EF 501 ketamine hcl 34,377 KOATE 161 ketamine hcl in 0.9 % sodium chloride 35 KOBEE 521 KETOCAL 2.5:1 565 KOGENATE FS 161 KETOCAL 3:1 521 kojic acid 378 KETOCAL 4:1 521 KOMBIGLYZE XR 149 ketoconazole 81,377 KONSYL 267 ketoconazole, micronized 377 KONSYL FIBER 267 ketoconazole/niacinamide 565 KORLYM 281 KETODAN 81 KOSELUGO 566 KETONEX-1 521 KOSHER PRENATAL PLUS IRON 521 KETONEX-2 521 KOVALTRY 161 ketoprofen 6,377,565 KPN 521 ketoprofen, micronized 377 krill oil/omega-3 fatty ketorolac tromethamine 6,7,377,443 acids/dha/epa/phospholipids 378 ketotifen fumarate 377,442 KRINTAFEL 566 KETOVOLVE 521 KRISTALOSE 267 KEVEYIS 184 KRYSTEXXA 85 KEVZARA 565 kudzu root 378 KEYTRUDA 114 KURVELO 293 KHAPZORY 565 KUVAN 246 KHEDEZLA 69 KYLEENA 301 KIDKARE 477 KYNMOBI 566 KYPROLIS 109,566 LAMISIL AT 81 lamivudine 132,137 L lamivudine/zidovudine 137 L-METHYL-B6-B12 521 lamotrigine 62,378 L-METHYLFOLATE FORTE 521 LANAFLEX 521 labetalol hcl 171,378,566 lancets 378 labetalol in dextrose 5 % in water 566 lancing device 378 LAC-HYDRIN FIVE 228 lancing device, vacuum/lancets 566 LACRISERT 436 lancing device/lancets 152 lactase 378 lanolin 378 lactic acid 378 lanolin alcohols 378 LACTINEX 256 lanolin,anhydrous 378 LACTO-PECTIN 256 LANOXIN 180 lactobacillus acidophilus 256,378,566 LANOXIN PEDIATRIC 180 lactobacillus lansoprazole 273,378 acidophilus,salivarius/b.bifidum/s.thermophil 256 lansoprazole/amoxicillin lactobacillus acidophilus/bifidobacterium trihydrate/clarithromycin 256 longum 256 lanthanum carbonate 279 lactobacillus LANTUS 153 acidophilus/fructooligosaccharides 256 LANTUS SOLOSTAR 153 lactobacillus acidophilus/lactobacillus bifidus 256 LARIN 293 lactobacillus acidophilus/lactobacillus LARIN 24 FE 293 sporogenes 256 LARIN FE 293 lactobacillus acidophilus/pectin 256 LARISSIA 293 lactobacillus acidophilus/pectin, citrus 256 LASIX 185 lactose 378 LASTACAFT 442 lactulose 267 latanoprost 378,447 LAMICTAL 61 LATISSE 228 LAMICTAL (BLUE) 61 LATUDA 123 LAMICTAL (GREEN) 61 laureth 9 378 LAMICTAL (ORANGE) 61 laureth-23 379 LAMICTAL ODT 61 lauric acid 379 LAMICTAL ODT (BLUE) 61 lavender oil 521 LAMICTAL ODT (GREEN) 61 LAX STOOL SOFTENER WITH SENNA 267 LAMICTAL ODT (ORANGE) 61 LAXACLEAR 267 LAMICTAL XR 61 LAXATIVE 268 LAMICTAL XR (BLUE) 62 LAXATIVE FEMININE 268 LAMICTAL XR (GREEN) 62 LAXATIVE MAXIMUM STRENGTH 268 LAMICTAL XR (ORANGE) 62 LAXATIVE SUPPOSITORY 268 LAMISIL 81 LAYOLIS FE 293 LAMISIL AF 81 LAZANDA 20 LC-5 228 levofloxacin/dextrose 5 % in water 54 lead acetate trihydrate 379 levoleucovorin calcium 101,566 lead tetroxide 379 levomefolate calcium 380,521 lecithin 379,521 levomefolate calcium/schizochytrium algal oil 521 lecithin, soy 379,521 LEVONEST 293 lecithin/isopropyl palmitate 379 levonorgestrel 293 lecithin/sorbic acid/isopropyl palmitate 379 levonorgestrel/ethinyl estradiol 293,294 ledipasvir/sofosbuvir 133 levonorgestrel/ethinyl estradiol and ethinyl LEENA 293 estradiol 294 leflunomide 317 LEVOPHED 180 lemon flavor extract 379 LEVOPHED BITARTRATE 180 lemon oil 379 LEVORA-28 294 lemonade flavor oil 379 levorphanol tartrate 31,380,566 LENVIMA 109,566 levothyroxine sodium 302,380,567 LESCOL 188 LEVOXYL 303 LESCOL XL 188 LEVSIN 248 LESSINA 293 LEVSIN-SL 248 LETAIRIS 465 LEVULAN 228 letrozole 105,379 LEXAPRO 69 leucine 379 LEXETTE 567 leucovorin calcium 101,379,566 LEXISCAN 164 LEUKERAN 91 LEXIVA 140 LEUKINE 158 LIALDA 320 leuprolide acetate 304,379 LIBRAX 248 levalbuterol hcl 461 LICART 567 levalbuterol tartrate 461 LICE KILLING 228 levamisole hcl 379 LICE PYRINYL SHAMPOO 228 LEVAQUIN 54 LICE TREATMENT 228,229 LEVBID 248 licorice flavor 380 LEVEMIR 153 licorice root extract 380 LEVEMIR FLEXTOUCH 153 licorice,deglycyrrhizinated 380 levetiracetam 58,379 lidocaine 229,380 levetiracetam in sodium chloride, iso-osmotic 58 lidocaine hcl 35,209,229,380,567 LEVO-T 302 lidocaine hcl buffered with 8.4 % sodium levobunolol hcl 446 bicarbonate 35,567 levocarnitine 379,521 lidocaine hcl in 0.9 % sodium chloride 35 levocarnitine (with sugar) 521 lidocaine hcl in 0.9 % sodium chloride/pf 35,567 levocarnitine hcl 379 lidocaine hcl in dextrose 5% in water/pf 35 levocetirizine dihydrochloride 379,456 lidocaine hcl in dextrose 7.5 % in water/pf 35 levodopa 379 lidocaine hcl in sodium chloride, iso-osmotic/pf 35 levofloxacin 54,379,436 lidocaine hcl/epinephrine 35 lidocaine hcl/epinephrine bitartrate 35 liquid base no.154 380 lidocaine hcl/epinephrine/pf 35 liquid base no.178 380 lidocaine hcl/hydrocortisone acetate 229 liquid base no.223 567 lidocaine hcl/pf 35,567 liquid base no.57 380 lidocaine/prilocaine 229 liquid base no.71 380 lidocaine/tetracaine 229 LIQUID E-Z PAQUE 380 LIDODERM 229 LIQUID POLIBAR PLUS 380 LIDODOSE 229 LIQUIGEN 521 LIDOPIN 229 LIQUITEARS 436 LIDOPRIL 229 LIQUITUSS GG 477 LIDOPURE PATCH 229 lisinopril 167,380 LIDORX 229 lisinopril/hydrochlorothiazide 180 LIDOTIN 567 lithium carbonate 145,380 LIDOTRAL 36 lithium citrate 145 LIDOTREX 36,567 lithium citrate tetrahydrate 380 LIDOVEX 229 LITHOBID 146 LIDTOPIC MAX 567 LITHOSTAT 278 LILETTA 301 LITTLE ANIMALS PLUS IRON 522 LILLOW 294 LITTLE ANIMALS WITH IRON 522 lime green (food color) 380 LITTLE REMEDIES 380 lime oil 380 LITTLE REMEDIES FEVER-PAIN 202 LINCOCIN 43 LITTLE REMEDIES STUFFY NOSE 380 lincomycin hcl 43 LIVALO 188 lindane 229 LIVER WITH IRON 501 linezolid 43 LMD 522 linezolid in 0.9 % sodium chloride 43 LMD 10% WITH 0.9% SOD CHLORIDE 381 linezolid in dextrose 5 % in water 43 LMD 10% WITH 5% DEXTROSE 381 linoleic acid 380 LO LOESTRIN FE 294 LINZESS 263,567 LO-ZUMANDIMINE 294 LIORESAL INTRATHECAL 488 LOCOID 229 liothyronine sodium 303,380 LOCOID LIPOCREAM 229 LIPIODOL 567 LODINE 7 LIPISTART 521 LODOSYN 119 LIPITOR 188 LOESTRIN 294 LIPODOX 101 LOESTRIN FE 294 LIPODOX 50 101 LOHIST-DM 477 LIPOFEN 187 LOJAIMIESS 294 LIPRITIN 567 LOKELMA 567 LIPRITIN II 567 lollipop base no.232 567 LIQUACEL 567 lollipop base no.233 567 LIQUID ANTACID 256 LOMOTIL 256 LONG ACTING NASAL DECONGESTANT 381 LOTRIMIN AF 81,82 LONHALA MAGNAIR REFILL 568 LOTRISONE 82 LONHALA MAGNAIR STARTER 568 LOTRONEX 264 LONSURF 96 LOUTREX 229 loperamide hcl 256,381 lovastatin 188 LOPID 187 LOVAZA 522 lopinavir/ritonavir 140 LOVENOX 156 LOPREEZA 294 LOW-OGESTREL 294 LOPRESSOR 171 loxapine succinate 120 LOPRESSOR HCT 180 LUBRICANT EYE 268,436 LOPROX 81 LUBRICANT EYE DROP 436 LORADAMED 456 LUBRICANT EYE DROPS 436 LORATA-D 477 LUBRICANT GEL DROPS 436 LORATA-DINE D 477 LUBRICANT PM 436 loratadine 381,456 LUBRICATING EYE 268 loratadine, micronized 381 LUBRICATING EYE DROPS 436 LORATADINE-D 477 LUBRICATING PLUS 436 lorazepam 144,381 LUBRICATING RELIEF 436 lorazepam in 0.9 % sodium chloride 145 LUBRICATING TEARS 436 lorazepam in 5 % dextrose and water 145 LUBRIFRESH PM 436 LORAZEPAM INTENSOL 145 LUCEMYRA 568 LORCET 20 LUCENTIS 436,568 LORCET HD 20 LUDENT FLUORIDE 501,522 LORCET PLUS 20 LUGOL'S 381 LORMATE 568 luliconazole 82 LORTAB 20 LUMIGAN 447 LORTUSS EX 477 LUMIZYME 246 LORTUSS LQ 478 LUNESTA 490 LORYNA 294 LUPANETA PACK 304 LORZONE 488 LUPRON DEPOT 304 losartan potassium 166 LUPRON DEPOT (LUPANETA) 305 losartan potassium/hydrochlorothiazide 180 LUPRON DEPOT-PED 305 LOSEASONIQUE 294 lutein 381 LOTEMAX 444 LUTERA 294 LOTEMAX SM 568 LUXAMEND 230 LOTENSIN 167 LUXIQ 230 LOTENSIN HCT 180 LUZU 82 loteprednol etabonate 444 LYMPHAZURIN 381 lotion base no.203 381 LYNPARZA 568 lotion base no.48 381 LYRICA 205 LOTREL 180 LYRICA CR 568 lysine 522 magnesium gluconate 381,501 lysine hcl 381 magnesium glycinate 382,568 LYSIPLEX PLUS 492 magnesium hydroxide 268,382 LYSODREN 101 magnesium malate 382 LYSTEDA 161 magnesium oxide 257,382,501 LYUMJEV 568 magnesium oxide/magnesium amino acid LYUMJEV KWIKPEN U-100 568 chelate 501 LYUMJEV KWIKPEN U-200 568 magnesium phosphate 382 LYZA 301 magnesium stearate 382 magnesium sulfate 382,501 M magnesium sulfate in 0.9 % sodium M-CLEAR WC 478 chloride 502,568 m-cresol acetate 381 magnesium sulfate in lactated ringers solution 502 M-END PE 478 magnesium sulfate in sterile water 502 M-HIST DM 478 magnesium sulfate/dextrose 5 % in water 502,569 M-M-R II VACCINE 318 MAGNEVIST 382 M-NATAL PLUS 522 MAGONATE 502 M.V.I. ADULT 522 MAJOR-PREP HEMORRHOIDAL 230 M.V.I. PEDIATRIC 522 MAKENA 301,569 M.V.I.-12 522 MALARONE 116 MAALOX ADVANCED 256 malathion 117 MAALOX MAXIMUM STRENGTH 256 maleic acid 382 maca 381 malic acid 382 MACROBID 44 maltodextrin 382 MACRODANTIN 44 mandelic acid 382 MACUGEN 437 manganese chloride 382,502 MAG-AL 257 manganese gluconate 382 MAG-AL PLUS 257 manganese sulfate 382,502 MAG-AL PLUS XS 257 mango flavor 382 MAG-G 501 mannitol 181,382 MAGBID ER 501 mannitol/sorbitol solution 278 MAGIC BULLET 268 MAPAP 202 MAGLOX 257 MAPAP ARTHRITIS PAIN 202 magnesium 501 MAPAP COLD FORMULA 478 magnesium aluminum silicate 381 MAPAP PM 492 magnesium amino acid chelate 381,501 MAPAP SINUS 478 magnesium ascorbate 381 maple flavor 382 magnesium aspartate dihydrate 381 maprotiline hcl 69 magnesium carbonate 381 MAR-COF BP 478 magnesium chloride 381,501 MAR-COF CG 478 magnesium citrate 268,381,501 MARCAINE 36 MARCAINE SPINAL 36 MEDICATED PADS 230 MARCAINE-EPINEPHRINE 36 MEDIPROXEN 7 MARINOL 76 medium chain triglycerides 383 MARLISSA 294 MEDROL 281 MARNATAL-F 522 medroxyprogesterone acetate 301 MARPLAN 67 medroxyprogesterone acetate, micronized 383 MARQIBO 101 MEDTYCHOLL-B COMPLEX W-LIVER 522 marshmallow flavor 382 mefenamic acid 7,383 MASANTI 257 mefloquine hcl 116 MASOPHEN 202 MEGA MULTI 522 masterwort extract 382 MEGA MULTI W-CHELATED MINERALS 522 MATULANE 91 MEGA PROBIOTIC 383 MATZIM LA 174 MEGACE ES 301 MAVENCLAD 569 MEGAVITE 492 MAVYRET 569 MEGAVITE GOLDEN YEARS 55+ 492 MAXALT 87 megestrol acetate 301 MAXALT MLT 87 megestrol acetate,micronized 383 MAXI-TUSS AC 478 MEKINIST 109,110 MAXI-TUSS CD 569 MELATIN 383 MAXIDEX 444 melatonin 383 MAXIMUM DAILY MULTIVITAMIN 522 melatonin/chamomile flower 383 MAXIPIME 49 melatonin/pyridoxine 383 MAXITROL 437 melatonin/pyridoxine hcl (vit b6) 383 MAXZIDE 181 MELODETTA 24 FE 294 MAXZIDE-25 MG 181 meloxicam 7,383 MAYZENT 569 melphalan 91 MCT OIL 522 melphalan hcl 91 MCT PRO-CAL 522 memantine hcl 65,383 MD-76 R 382 MEMBRANEBLUE 437 MD-GASTROVIEW 382 MEN 50 PLUS ADVANCED ONE DAILY 522 mebendazole 382 MEN'S DAILY FORMULA 522 mecamylamine hcl 383 MEN'S DAILY GUMMIES 522 mechlorethamine hcl 383 MEN'S DAILY MULTIVIT-MINERAL 522 meclizine hcl 73,383 MEN'S MULTIVITAMIN 522 meclofenamate sodium 7,383 MEN'S ONE DAILY 523 meclofenoxate hcl 383 MENACTRA 318 mecobalamin 383 menadione 383 MEDI-MECLIZINE 73 menadione sodium bisulfite 383 MEDI-PADS 230 MENEST 294 medical supply, miscellaneous 383 MENOSTAR 294 MEDICATED DOUCHE 278 MENTAX 82 menthol 230,384 methanol 384 MENVEO A-C-Y-W-135-DIP 318 methazolamide 384,446 MENVEO MENA COMPONENT 318 methenamine 384 MENVEO MENCYW-135 COMPONENT 318 methenamine hippurate 44 meperidine hcl 21,384 methenamine mandelate 44,384 meperidine hcl in 0.9 % sodium chloride/pf 21 methenamine/sod phosph,monobasic/methylene meperidine hcl/pf 21 blue/hyoscyamine 44 MEPHYTON 523 METHERGINE 384 mepivacaine hcl/pf 36 methimazole 307,384 meprobamate 142 METHIONAID 523 MEPRON 116 methionine 384 mequinol 384 METHITEST 285 mercaptopurine 96,384 methocarbamol 384,489 meropenem 49 methohexital sodium in sterile water for meropenem in 0.9 % sodium chloride 50 injection/pf 570 MERREM 50 methotrexate 384 mesalamine 320,384 methotrexate sodium 311 mesalamine with cleansing wipes 320 methotrexate sodium/pf 311 mesna 101 methoxsalen 230 MESNEX 101 methscopolamine bromide 248,384 MESTINON 88 methyclothiazide 186 meta-cresol 384 methyl aminolevulinate hcl 384 METABIOTIC 257 methyl salicylate 230 METADATE ER 197 methylcellulose 385 METAFOLBIC 523 methylcellulose 1500cps 385 METAFOLBIC PLUS RF 523 methylcellulose 4000cps 385 METAMUCIL MULTIHEALTH FIBER 268 methyldopa 165 METANX 523 methyldopa/hydrochlorothiazide 181 metaproterenol sulfate 384,461 methyldopate hcl 165 METAXALL 489 methylene blue 385 metaxalone 489 methylene blue/gentian violet/foam bandage 385 metformin hcl 149,150,202,384 methylergonovine maleate 385 methacholine chloride 384,569 METHYLIN 197 methacrylic acid copolymer type a 384 methylparaben 385 methadone hcl 10,31,32,384,570 methylphenidate hcl 197,198,385,570 methadone hydrochloride in 0.9 % sodium methylprednisolone 281 chloride 22,570 methylprednisolone acetate 281 METHADONE INTENSOL 32 methylprednisolone acetate in sodium METHADOSE 32 chloride,iso-osmotic/pf 570 methamphetamine hcl 195 methylprednisolone acetate in sterile water for methanesulfonic acid 384 injection 570 methylprednisolone acetate, micronized 385 MICRO-GUARD 82 methylprednisolone sodium succinate 281 MICROCYN 230 methylprednisolone, micronized 385 MICROCYN HYDROGEL 230 methylscopolamine nitrate 385 MICROGESTIN 295 methylsulfonylmethane 385 MICROGESTIN 24 FE 295 methyltestosterone 286,385 MICROGESTIN FE 295 methyltestosterone, micronized 385 MICROLIPID 523 methyltetrahydrofolate glucosamine 385 microplegic solution no.1/citrate phosphate methysergide maleate 385 double dextrose 570 metipranolol 446 MICROZIDE 186 metoclopramide hcl 73,385 midazolam 386 metolazone 186 midazolam hcl 142 METOPIRONE 385 midazolam hcl in 0.9 % sodium chloride 142,570 metoprolol succinate 171 midazolam hcl in 0.9 % sodium chloride/pf 142 metoprolol tartrate 171,385 midazolam hcl in dextrose 5% in water 570 metoprolol tartrate/hydrochlorothiazide 181 midazolam hcl/pf 143 METRO IV 44 midazolam in sodium chloride, iso-osmotic/pf 570 METROCREAM 230 middle ear inflation device 386 METROGEL 230 MIDNITE FOR MENOPAUSE 268 METROGEL-VAGINAL 44 MIDNITE MENOPAUSE 268 METROLOTION 230 MIDNITE PM 386 metronidazole 44,230,385 midodrine hcl 165 metronidazole benzoate 386 MIDOL 7 metronidazole in sodium chloride 44 MIFEPREX 282 mexiletine hcl 169,386 mifepristone 282 MGO 502 MIGERGOT 86 MI ACID 257 miglitol 150 MI-ACID 257 miglustat 246 MIACALCIN 323 MIGRAINE FORMULA 7 MIBELAS 24 FE 295 MIGRAINE RELIEF 7 MICARDIS 166 MIGRANAL 86 MICARDIS HCT 181 MIGRANOW 87 MICATIN 82 MILI 295 miconazole 386 milk thistle 386 miconazole nitrate 82,386 MILLIPRED 282 miconazole nitrate/skin cleanser no.17 on wipe 82 MILLIPRED DP 282 miconazole nitrate/zinc MILLTRIUM SENIOR 523 oxide/petrolatum,white 82 milrinone lactate 181 MICONAZORB AF 82 milrinone lactate/dextrose 5 % in water 181 MICORT-HC 230,281 MIMVEY 295 MICRHOGAM ULTRA-FILTERED PLUS 316 MIMVEY LO 295 MINASTRIN 24 FE 295 MOISTURE BARRIER OINTMENT 230 MINERAL FREEZ 230 MOISTURIZING CREAM 230 mineral oil 268,386 MOISTURIZING LOTION 230 MINERAL OIL HEAVY 386 molindone hcl 121 mineral oil, light sterile 386 molybdenum 387 mineral oil, light/petrolatum,white/cetyl mometasone furoate 231,387,449 alc/stearyl alc 386 MONDOXYNE NL 56 mineral oil/petrolatum/emulsifying wax 386 MONISTAT 3 82 mineral oil/polyethylene glycol 386 MONISTAT 7 82 mineral oil/polyethylene/butylated MONJUVI 570 hydroxytoluene 386 MONO-LINYAH 295 MINI PRENATAL 523 monobenzone 387 MINIPRESS 165 MONOCAPS 523 MINITRAN 193 monochloroacetic acid 387 MINIVELLE 295 MONODOX 56 MINOCIN 56 MONOJECT 0.9% SODIUM CHLORIDE 502 minocycline hcl 56,386,570 MONOJECT PREFILL ADVANCED 502 minoxidil 192,230,386 MONOJECT SODIUM CHLORIDE FLUSH 502 mint chocolate chip flavor 386 MONONESSA 295 MINTOX 257 MONONINE 161 MINTOX MAXIMUM STRENGTH 257 monosodium glutamate, monohydrate 387 MINTOX PLUS 257 MONOVISC 387 MIOCHOL-E 437 MONSEL'S 161 MIOSTAT 446 montelukast sodium 387,458 MIRAPEX 118 MONUROL 44 MIRAPEX ER 118 MORE-DOPHILUS 257 MIRCERA 158,570 MORGIDOX 56 MIRCETTE 295 MORPHABOND ER 570 MIRENA 301 morphine sulfate 10,22,23,32,387 mirtazapine 66 morphine sulfate in 0.9 % sodium chloride 23,571 MIRVASO 230 morphine sulfate in 0.9 % sodium misoprostol 272,386 chloride/pf 23,571 mite-dermatophagoides farinae, standardized 386 morphine sulfate/dextrose 5 % in water 571 MITIGARE 85 morphine sulfate/pf 23 mitomycin 101,386,570 MOTEGRITY 571 mitotane 386 MOTION RELIEF 73 mitoxantrone hcl 101 MOTION SICKNESS 73,74 MOBIC 7 MOTION SICKNESS II 74 modafinil 492 MOTION SICKNESS RELIEF 74,571 MODERIBA 133 MOTION-TIME 74 moexipril hcl 167 MOTOFEN 257 MOTRIN IB 7 MUCUS RELIEF SEVERE COLD 479 MOVANTIK 257 MUCUS RELIEF SINUS PRES-PAIN 479 MOVE IT ALONG 268 MUCUS RLF COLD-FLU-SORE THROAT 479 MOVIPREP 268 MUCUS RLF SEVERE SINUS CONGEST 479 MOXATAG 51 MUCUS-ER MAX 479 MOXEZA 437 MULPLETA 571 moxifloxacin hcl 54,387,437 MULTAQ 169 moxifloxacin hcl in sodium acetate and MULTI COMPLETE-IRON 523 sulfate,water,iso-osm 54 MULTI FOR HER 523 moxifloxacin hcl in sodium chloride, iso- MULTI-BETIC 523 osmotic 54 MULTI-DAY PLUS IRON 523 moxifloxacin hcl in sodium chloride,iso- MULTI-DELYN 523 osmotic/pf 571 MULTI-SYMPTOM COLD 479 moxisylyte hcl 387 MULTI-VITAMIN DAILY 523 MOZOBIL 158 MULTIGEN FOLIC 502 MS CONTIN 11,33 MULTIGEN PLUS 502 MTERYTI 523 MULTIHANCE 387 MTERYTI FOLIC 5 523 MULTIHANCE MULTIPACK 387 MUCINEX FAST-MAX COLD-SINUS 478 MULTILEX 523 MUCINEX FAST-MAX CONGEST-HEAD 478 MULTILEX T-M 523 MUCINEX SINUS-MAX SEV CONGEST 478 MULTITRACE-4 502 MUCOSA 268 MULTITRACE-5 503 MUCOSA DM 478 multivit with calcium, iron, and other minerals523 MUCOSITISRX 209 multivitamin 523 mucus clearing device 387 multivitamin combination no.51/ferrous MUCUS D 478 fumarate/folic acid 523 MUCUS DM ER 478 multivitamin with iron 524 MUCUS DM MAX ER 478 MULTIVITAMIN WITH IRON 524 MUCUS ER 478 multivitamin with minerals 524 MUCUS RELIEF 268,478 multivitamin with minerals/ferrous gluconate 524 MUCUS RELIEF CHEST 268 multivitamin,therapeutic with minerals 524 MUCUS RELIEF CHEST CONGESTION 478 multivitamin- MUCUS RELIEF COLD-SINUS 478 mins/calcium/biotin/cholecalciferol/folic acid 524 MUCUS RELIEF COLD-SINUS MAX 456 mupirocin 231,387 MUCUS RELIEF COUGH 478 mupirocin calcium 231 MUCUS RELIEF D 478 MURINE EAR DROPS 448 MUCUS RELIEF DM 479 MURINE EAR WAX REMOVAL SYSTEM 448 MUCUS RELIEF DM ER 479 MURO-128 437 MUCUS RELIEF DM MAX 479 MUSCLE RUB 231 MUCUS RELIEF DM MAX ER 479 MUSCLE RUB ULTRA STRENGTH 231 MUCUS RELIEF ER 479 MUSTARGEN 91 MUTAMYCIN 102 nafcillin sodium 51 MVASI 571 naftifine hcl 82 MVC-FLUORIDE 524 NAFTIN 82 MVW COMPLETE FORMLTN PEDIATRIC 524 NAGLAZYME 246 MVW COMPLETE FORMULATION D3000 524 nalbuphine hcl 23,388 MVW COMPLETE FORMULTN MULTIVIT 524 NALFON 7 MY CHOICE 295 nalidixic acid 388 MY FAVORITE MULTIPLE 524 NALOCET 571 MY WAY 295 naloxone hcl 40,388 MYALEPT 387 naltrexone 572 MYAMBUTOL 89 naltrexone hcl 38,388 MYCAMINE 82 naltrexone hydrochloride dihydrate 388 MYCAPSSA 571 NAMENDA 65 MYCOBUTIN 89 NAMENDA XR 65 mycophenolate mofetil 311 NAMZARIC 64,202 mycophenolate mofetil hcl 311 388 mycophenolate sodium 311 NAPRELAN 7 MYDAYIS 571 NAPROSYN 7 MYDRIACYL 437 naproxen 7,388 MYFORTIC 311 naproxen sodium 7,388 MYLERAN 91 naproxen/esomeprazole magnesium 8 MYNATAL 524 NARAMIN 456 MYNATAL PLUS 524 naratriptan hcl 87 MYNATAL-Z 524 NARCAN 40 MYOBLOC 387 NARDIL 67 MYORISAN 231 NAROPIN 36 MYRBETRIQ 275 NASAL ALLERGY 449 MYSOLINE 60 NASAL ALLERGY SPRAY 388 MYTESI 257 NASAL DECON (PSEUDOEPHEDRINE) 388 MYVITALIFE 524 NASAL DECONGESTANT 388 MYXREDLIN 571 NASAL DECONGESTANT PE 388 MYZILRA 295 nasal exhalation resistance device 388 NASAL FOUR 388 N NASAL MIST 388 NABI-HB 316 NASAL MOISTURIZING 389 nabumetone 7,387 NASAL RELIEF 389 nabumetone, micronized 387 NASAL SPRAY 389 nadide 387 NASAL SPRAY EXTRA MOISTURIZING 389 nadolol 171,387 NASAL SPRAY ORIGINAL 389 nadolol/bendroflumethiazide 181 NASAL SPRAY SINUS 389 nafcillin in dextrose, iso-osmotic 51 NASCOBAL 524 nasogastric tube 389 nefazodone hcl 69 NASONEX 449 NEMBUTAL SODIUM 60 NATACHEW 524 NEO-POLYCIN 437 NATACYN 82 NEO-POLYCIN HC 437 NATAZIA 295 NEO-SYNALAR 231 nateglinide 150 NEO-SYNEPHRINE 391 NATESTO 286 NEO-TUSS 479 NATPARA 323 NEOKE MCT70 524 NATRECOR 181 neomycin sulfate 41,391 NATROBA 231 neomycin sulfate/bacitracin zinc/polymyxin NATURA-LAX 268 b/hydrocortisone 437 NATURAL BALANCE TEARS 437 neomycin sulfate/bacitracin/polymyxin b 437 NATURAL BALANCED B-100 524 neomycin sulfate/polymyxin b sulfate 44 NATURAL DAILY FIBER 269 neomycin sulfate/polymyxin b sulfate/gramicidin NATURAL FIBER 269 d 438 NATURAL FIBER LAXATIVE 269 neomycin sulfate/polymyxin b NATURAL FIBER POWDER 269 sulfate/hydrocortisone 438,448 NATURAL LAXATIVE 269 neomycin/polymyxin b NATURAL TEARS 437 sulfate/dexamethasone 438 NATURAL VEGETABLE LAXATIVE 269 NEOPROFEN 8 NATURAL VEGETABLE POWDER 269 NEORAL 311 NATURE'S TEARS 437 NEOSALUS 231 NATURE-THROID 303 NEOSALUS CP 231 NAVELBINE 102 neostigmine methylsulfate 88,391 NAYZILAM 572 neostigmine methylsulfate in sterile water for nebulizer 389 injection 88 nebulizer accessories 389 NEOTUSS PLUS 479 nebulizer and compressor 389 NEOVITE 572 NEBUPENT 116 NEPHRAMINE 524 NEBUSAL 479,503 NEPHRO-VITE RX 524 NECON 295 NEPHROCAPS 524 needle clipping and storage device 389 NEPHRONEX 525 needles, blood collection 389 NEPHRONEX-SL 525 needles, disposable 390 NERLYNX 572 needles, filter 390 NESACAINE 36 needles, huber disposable 390 NESACAINE-MPF 36 needles, pharmacy compound 390 NESINA 150 needles, reusable 390 NESTABS 525 needles, safety 390,391 NESTABS ABC 525 needles, safety huber, disposable 391 NESTABS DHA 525 needles, spinal-anesthetic 391 nettle leaf 391 NEUAC 231 NICOTROL NS 41 NEULASTA 158 nifedipine 174,175,392 NEULASTA ONPRO 158 nifedipine, micronized 572 NEUPOGEN 158 NIGHT TIME COLD-FLU 479 NEUPRO 118 NIGHT TIME PAIN MEDICINE 492 NEURONTIN 60 NIGHTTIME ALLERGY RELIEF 456 NEUT 503 NIGHTTIME COLD-FLU 479 NEVANAC 444 NIGHTTIME COLD-FLU RELIEF 479 nevirapine 135 NIGHTTIME DRY-EYE RELIEF 438 NEW DAY 295 NIKKI 295 NEWGEN 525 NILANDRON 92 NEXAFED 391 nilutamide 92 NEXAVAR 110 NIMBEX 203 NEXAVIR 391 nimodipine 175 NEXIUM 273 NINJACOF-XG 479 NEXIUM I.V. 273 NINLARO 110 NEXLETOL 572 NIPENT 96 NEXLIZET 572 nisoldipine 175 NEXPLANON 301 NITHIODOTE 392 NEXTERONE 169 nitisinone 246 niacin 181,190,391,525 nitric acid 392 NIACIN 525 NITRO-BID 193 niacin (inositol niacinate) 525 NITRO-DUR 193 niacinamide 190,391 NITRO-TIME 193 NIACOR 190 nitrofurantoin 44,392 niaouli oil 391 nitrofurantoin macrocrystal 44,392 NIASPAN 190 nitrofurantoin monohydrate/macrocrystals 44 nicardipine hcl 174 nitrofurazone 392 nicardipine hcl in 0.9 % sodium chloride 174,572 nitroglycerin 193 nicardipine in 5 % dextrose in water 174 nitroglycerin in 5 % dextrose in water 193 nicardipine in sodium chloride, iso-osmotic 174 NITROLINGUAL 193 niclosamide 391 NITROMIST 193 NICODERM CQ 40 NITROPRESS 194 NICORELIEF 40 nitroprusside sodium 194 NICORETTE 40 NITROSTAT 194 nicotinamide-adenine dinucleotide, reduced, NITYR 572 disodium 391 NIVA-FOL 525 nicotine 40 NIVA-HIST DM 480 nicotine bitartrate 391 NIVA-PLUS 525 nicotine polacrilex 41,392 NIVATOPIC PLUS 392 NICOTROL 41 NIVESTYM 572 nizatidine 263 NORMOSOL-R PH 7.4 503 NIZORAL 83 NORPACE 169 NO DRIP 392 NORPACE CR 169 NO DRIP NASAL SPRAY 392 NORPRAMIN 72 NOBLE FORMULA 231 NORTEMP 203 NOBLE FORMULA HC 231 NORTHERA 181 NOCTIVA 572 NORTREL 296 NOHIST-DM 480 nortriptyline hcl 72,392 NOHIST-LQ 480 NORVASC 175 NOLIX 231 NORVIR 140,572 NON-ASPIRIN 203 NOSE DROPS 392 NON-ASPIRIN EXTRA STRENGTH 203 NOURIANZ 573 NON-ASPIRIN PAIN RELIEF 203 NOVAREL 573 NON-ASPIRIN PM 492 NOVOEIGHT 161 NON-ASPIRIN PM EX-STRENGTH 492 NOVOLIN 70-30 153 NON-DROWSY ALLERGY 456 NOVOLIN 70-30 FLEXPEN 153 NOPIOID-TC KIT 572 NOVOLIN N 153 NORA-BE 301 NOVOLIN N FLEXPEN 153 NORCO 24 NOVOLIN R 153 NORDITROPIN FLEXPRO 283 NOVOLIN R FLEXPEN 573 norepinephrine bitartrate 181,392 NOVOLOG 153 norepinephrine bitartrate in 0.9 % sodium NOVOLOG FLEXPEN 153 chloride 181,572 NOVOLOG MIX 70-30 153 norepinephrine bitartrate in 0.9 % sodium NOVOLOG MIX 70-30 FLEXPEN 154 chloride/pf 572 NOVOSEVEN RT 161 norepinephrine bitartrate in 5 % dextrose in NOXAFIL 83 water 181,572 NP THYROID 303 norethindrone 301,392 NPLATE 158,573 norethindrone acetate 301,392 NU-IRON 150 525 norethindrone acetate-ethinyl estradiol 295,296 NU-MAG 503 norethindrone acetate-ethinyl estradiol/ferrous NUCALA 480,573 fumarate 296 NUCARACLINPAK 573 norethindrone-ethinyl estradiol/ferrous NUCARARXPAK 573 fumarate 296 NUCYNTA 24 NORGESIC FORTE 572 NUCYNTA ER 33 norgestimate-ethinyl estradiol 296 NUEDEXTA 203 NORITATE 231 NULEV 248 NORLYDA 301 NULOJIX 311 NORMOSOL-M AND DEXTROSE 503 NULYTELY WITH FLAVOR PACKS 269 NORMOSOL-R 503 NUMBONEX 36 NORMOSOL-R AND DEXTROSE 503 NUMBRINO 573 NUMOISYN 209 octreotide acetate 305 NUOX 231 OCUCOAT 438 NUPLAZID 117,573 OCUFLOX 438 NURTEC ODT 573 OCUVITE ADULT 50 PLUS 525 NUTRILIPID 525 OCUVITE EYE HEALTH 525 NUTRILYTE 503 OCUVITE LUTEIN-ZEAXANTHIN 526 NUTRIVIT 525 OCUVITE WITH LUTEIN 526 NUTROPIN AQ NUSPIN 283 ODACTRA 573 NUVAIL 231 ODEFSEY 136 NUVAKAAN-II 231 ODOMZO 110 NUVARING 296 ODOR CONTROL FOOT-SNEAKER 83 NUVESSA 44 OFEV 480 NUVIGIL 492 OFF ACTIVE 393 NUWIQ 162 OFF DEEP WOODS 393 NYAMYC 83 OFF DEEP WOODS DRY 393 nylidrin hcl 392 OFF DEEP WOODS SPORTSMEN 393 NYMALIZE 175,573 OFF FAMILYCARE INSCT RPLNT III 393 nystatin 83,392 OFF FAMILYCARE INSECT RPLNT 393 nystatin/triamcinolone acetonide 83 OFF FAMILYCARE INSECT RPLNT II 393 NYSTOP 83 OFIRMEV 203 ofloxacin 54,438 O OGESTREL 296 O-CAL PRENATAL 525 OGIVRI 574 oats extract 573 OIL-FREE ACNE WASH 232 OB COMPLETE 525 ointment base no.104 393 OB COMPLETE ONE 525 ointment base no.198 393 OB COMPLETE PETITE 525 ointment base no.75 393 OB COMPLETE PREMIER 525 OKEBO 57 OB COMPLETE WITH DHA 525 olanzapine 123,124 OBIZUR 162 olanzapine/fluoxetine hcl 66 OBREDON 480 oleic acid 393 OBTREX DHA 573 olive oil 393 OC8 232 olive oil/macadamia nut oil ethoxy/peg-6 caprylic- OCALIVA 257 capric gly 393 OCELLA 296 olmesartan medoxomil 166 OCTAGAM 316 olmesartan medoxomil/amlodipine octanoic acid 392 besylate/hydrochlorothiazide 181 OCTAPLAS 392 olmesartan medoxomil/hydrochlorothiazide 182 octinoxate 392 olopatadine hcl 442,456 octoxynol 9 393 OLUMIANT 574 OCTREOSCAN 393 OLUX 232 OLUX-E 232 ONE DAILY FOR WOMEN 527 OMECLAMOX-PAK 258 ONE DAILY FOR WOMEN 50+ ADV 527 OMEGA 3-6-9 FATTY ACIDS 393 ONE DAILY HEALTHY WEIGHT 527 omega-3 acid ethyl esters 526 ONE DAILY MAXIMUM 527 omega-3 fatty acids 526 ONE DAILY MEN'S 527 omega-3 fatty acids/dha/epa/other omega- ONE DAILY MEN'S 50+ 527 3s/fish oil 526 ONE DAILY MEN'S HEALTH 527 omega-3 fatty acids/docosahexaenoic ONE DAILY MULTIVITAMIN 527 acid/epa/fish oil 526 ONE DAILY MULTIVITAMIN-IRON 527 omega-3 fatty acids/docosahexanoic ONE DAILY MULTIVITAMIN-MINERAL 527 acid/epa/fish oil 526 ONE DAILY PLUS IRON 527 omega-3 fatty acids/fish oil 393,526 ONE DAILY PLUS MINERALS 528 OMEGA-3 FISH OIL 526 ONE DAILY PRENATAL 528 OMEGAVEN 574 ONE DAILY WITH CALCIUM-IRON 528 omeprazole 273,393,574 ONE DAILY WITH IRON 528 omeprazole magnesium 273 ONE DAILY WOMEN'S 528 omeprazole/sodium bicarbonate 274 ONE DAILY WOMEN'S 50 PLUS ADV 528 OMIDRIA 438 ONE DAILY WOMEN'S 50+ 528 OMNARIS 449 ONE DAILY WOMEN'S HEALTH 528 OMNICAP 526 ONE DAILY WOMENS 50 PLUS 528 OMNICT 526 ONE-A-DAY 528 OMNIPAQUE 393,574 ONE-A-DAY ENERGY 528 OMNIPRED 444 ONE-A-DAY ESSENTIAL 528 OMNISCAN 393 ONE-A-DAY MAXIMUM FORMULA 528 OMNISCAN PREFILL PLUS 394 ONE-A-DAY MEN VITACRAVES 528 OMNITROPE 284 ONE-A-DAY MEN'S 528 ONCASPAR 102 ONE-A-DAY MEN'S 50 PLUS 528 ONCE DAILY 526 ONE-A-DAY MENOPAUSE FORMULA 528 ONCOVITE 526 ONE-A-DAY TEEN ADVANTAGE 528 ondansetron 76 ONE-A-DAY TEEN HIM VITACRAVES 528 ondansetron hcl 76,394 ONE-A-DAY TRUBIOTICS 258 ondansetron hcl in 0.9 % sodium chloride 76,574 ONE-A-DAY VITACRAVES 528 ondansetron hcl in dextrose 5% in water 574 ONE-A-DAY VITACRAVES IMMUNITY 528 ondansetron hcl/pf 77 ONE-A-DAY VITACRAVES OMEGA-3 529 ONE A DAY WOMEN'S PRENATAL DHA 526 ONE-A-DAY VITACRAVES SOUR 529 ONE DAILY 526,527 ONE-A-DAY WEIGHTSMART 529 ONE DAILY COMPLETE 527 ONE-A-DAY WOMEN VITACRAVES 529 ONE DAILY ENERGY 527 ONE-A-DAY WOMEN'S 529 ONE DAILY ESSENTIAL 527 ONE-A-DAY WOMEN'S HEALTHY SKIN 529 ONE DAILY FOR MEN 527 ONE-A-DAY WOMEN'S PETITES 529 ONE DAILY FOR MEN 50+ ADVANCED 527 ONE-A-DAY WOMEN'S PRENATAL 1 529 ONE-DAILY MULTI-VITAMIN 529 ORAPEUTIC 575 ONE-DAILY MULTI-VITAMIN-IRON 529 ORAPRED ODT 282 ONEXTON 232 ORASEP 210 ONFI 60 ORAVIG 83 ONGLYZA 150 ORAZINC 503 ONMEL 83 ORENCIA 312,575 ONTRUZANT 574 ORENCIA CLICKJECT 312 ONZETRA XSAIL 87 ORENITRAM ER 465,575 OPANA 24 ORFADIN 246 OPCICON ONE-STEP 296 ORIAHNN 575 OPDIVO 114,574 origanum oil 394 opium tincture 258 ORIGINAL NASAL SPRAY 394 opium/belladonna alkaloids 24 ORILISSA 575 OPSUMIT 465 ORKAMBI 463,575 OPTI-CLEAR 438 ornithine hcl 394 OPTI-VITAMIN 529 orphenadrine citrate 394,489 OPTIMAL D3 529 orphenadrine citrate/aspirin/caffeine 575 OPTION 2 296 ORPHENGESIC FORTE 575 OPTIRAY 240 574 ORSYTHIA 296 OPTIRAY 300 394 ORTHO MICRONOR 301 OPTIRAY 320 394 ORTHO TRI-CYCLEN 296 OPTIRAY 350 394 ORTHO TRI-CYCLEN LO 296 OPTISON 164 ORTHO-CYCLEN 296 OPTISOURCE 529 ORTHO-NOVUM 296 OPURITY MULTIVITAMIN 529 ORTHOVISC 394 ORA RELIEF 209 OS-CAL 500-VIT D3 503 ORABLOC 36 OSCIMIN 248 ORACEA 57 OSCIMIN SL 248 ORACIT 278 OSCIMIN SR 248 ORAFATE 209 oseltamivir phosphate 141 oral dosing devices 394 OSENI 150 ORAL RELIEF 210 OSMITROL 182 ORALAIR 394,480 OSMOLEX ER 575 ORALONE 210 OSMOPREP 269 ORALYTE 503 OSPHENA 302 orange (food color) 394 ostomy barrier seal 394 orange cream flavor 394 ostomy kit 394 orange extract 574 ostomy supply 395 orange flavor 394 OTEZLA 317 orange oil 394 OTIPRIO 54 ORAP 121 OTOVEL 448 OTREXUP 312 OZOBAX 575 OVACE 232 OZURDEX 444 OVACE PLUS 232 OVACE PLUS WASH 232 P OVEEZA 575 PACERONE 169 OVIDE 117 paclitaxel 102 oxacillin sodium 51 PACNEX 232 oxacillin sodium in iso-osmotic dextrose 51 PACNEX HP 233 oxalic acid 395 PACNEX LP 233 oxaliplatin 102 PADCEV 575 OXANDRIN 286 PAIN & FEVER 203 oxandrolone 286,395 PAIN & SLEEP 492 oxaprozin 8 PAIN EASE MEDIUM STREAM SPRAY 233 OXAYDO 24 PAIN EASE MIST SPRAY 233 oxazepam 145 PAIN RELIEF 203 OXBRYTA 575 PAIN RELIEF ADULT 203 oxcarbazepine 63 PAIN RELIEF EXTRA STRENGTH 203 oxiconazole nitrate 83 PAIN RELIEF PM 492 OXISTAT 83 PAIN RELIEVER 8,204 OXSORALEN-ULTRA 232 PAIN RELIEVER ADULT 204 OXTELLAR XR 63 PAIN RELIEVER JUNIOR STRENGTH 204 oxybenzone 395 PAIN RELIEVER PLUS 8 oxybutynin chloride 275,395 PAIN RELIEVER PM 492 oxycodone hcl 25,33,395 PAIN RELIEVING CREAM 233 oxycodone hcl/acetaminophen 25,575 PAIN-OFF 8 oxycodone hcl/aspirin 25 PALFORZIA 576 OXYCONTIN 33 paliperidone 124 oxymetazoline hcl 395 palmarosa oil 395 oxymorphone hcl 26,33 palmitoyl pentapeptide-4 395 oxyquinoline sulfate 395 palonosetron hcl 77,576 oxytetracycline hcl 395 PALYNZIQ 576 oxytocin 395 PAMELOR 72 oxytocin in 0.9 % sodium chloride 395 pamidronate disodium 323 oxytocin in 5 % dextrose in water 395 panax ginseng root 395 oxytocin/ringer's solution,lactated 395 pancreatin 396 OXYTROL 275 PANCREAZE 246 OXYTROL FOR WOMEN 275 PANDEL 233 OYSCO 500-VIT D3 503 PANHEMATIN 576 OYSCO-500 503 PANOXYL 233 OYSTERCAL-D 503 PANRETIN 115 OZEMPIC 575 panthenol 396 pantoprazole sodium 274 PEDIA-LAX ENEMA 269 PANZYGA 576 PEDIA-LAX PROBIOTIC YUMS 258 papain 396 PEDIACARE FEVER REDUCER 204 papaverine hcl 64,396 PEDIARIX 319 paraben/cetyl alcohol/stearyl alc/prop gly/sod PEDIASURE 529 lauryl sulf 233 PEDIASURE 1.5 529 parachlorophenol 396 PEDIASURE 1.5 WITH FIBER 529 paraffin 396 PEDIASURE ENTERAL 529 PARAGARD T 380-A 396 PEDIASURE ENTERAL WITH FIBER 529 PARAPLATIN 102 PEDIASURE GROW-GAIN 529 paregoric 258 PEDIASURE PEPTIDE 1.0 CAL 529 PAREMYD 438 PEDIASURE PEPTIDE 1.5 CAL 529 paricalcitol 323 PEDIASURE SIDEKICKS 530 PARLODEL 118 PEDIASURE WITH FIBER 530 PARNATE 67 PEDIATRIC COUGH-COLD 480 PAROEX 210 PEDIATRIC ELECTROLYTE 503 paromomycin sulfate 41,396 PEDIATRIC ENEMA 269 paroxetine hcl 69 PEDIATRIC FREEZER POPS 503 paroxetine mesylate 70 pediatric multivit with a,c,d3 no.21/sodium PARSABIV 577 fluoride 530 PARVLEX 529 pediatric multivitamin no.136 396 PASER 89 pediatric multivitamin no.16/sodium fluoride 530 passion fruit flavor 396 pediatric multivitamin no.2/sodium fluoride 530 PATADAY 442,577 pediatric multivitamins no.17 with sodium PATANASE 456 fluoride 530 PATANOL 442 PEDITRACE 503 PAXIL 70 PEDIZOL PAK 577 PAXIL CR 70 PEDVAXHIB 319 PAZEO 442 peg 100 stearate/glyceryl monostearate 396 peach flavor 396 peg 3350/mannitol/sodium bicarbonate/citric peak flow meter 396 acid/sucrose 396 peak flow meter/inhaler, assist devices 396 peg 3350/sod sulf/sod bicarb/sod peanut butter flavor 396 chloride/potassium chloride 269 peanut extract 577 peg 400 monostearate 396 peanut oil 396 peg-40 castor oil 396 pecan extract 577 PEG-PREP 269 pectin 396 PEGANONE 63 PEDIA POLY-VITE 529 PEGASYS 133 PEDIA RELIEF COUGH-COLD 480 PEGASYS PROCLICK 133 PEDIA RELIEF INFANT 396 PEGINTRON 133 PEDIA-LAX 269 PEMAZYRE 577 pen needle, diabetic 397 perphenazine 74,397 pen needle, diabetic disposable, safety 397 perphenazine/amitriptyline hcl 66 pen needle, diabetic, safety 397,577 PERRY PRENATAL 530 penicillamine 278,397 PERSERIS 577 penicillin g potassium 51 PERTZYE 246,577 penicillin g potassium/dextrose-water 51 petrolatum, yellow 397 penicillin g procaine 51 petrolatum,white 397,398 penicillin g sodium 51 petrolatum,white/carboxymethylcellulose 398 penicillin v potassium 51 petrolatum,white/lanolin 233 PENLAC 83 PEXEVA 70 PENNSAID 233 PFIZERPEN 51 pennyroyal oil 397 PH 12 DILUENT FOR FLOLAN 398 PENTACEL 319 PHARBECHLOR 456 PENTACEL ACTHIB COMPONENT 319 PHARBEDRYL 456 PENTACEL DTAP-IPV COMPONENT 319 PHARBETOL 204 PENTAM 300 116 PHENADOZ 457 pentamidine isethionate 116 PHENAGIL CH 480 PENTASA 320 PHENASEPTIC 210 pentazocine hcl/naloxone hcl 26 phenazopyridine hcl 278,398 pentetate calcium trisodium 397 phenelzine sulfate 67,398 pentetate zinc trisodium 397 PHENERGAN 457 PENTICAN 577 phenethylamine hcl 398 pentobarbital sodium 60 phenindione 398 pentosan polysulfate sodium 397 pheniramine maleate 577 pentoxifylline 182,397 phenobarbital 60,398 pentylenetetrazol 397 phenobarbital sodium 60 PEP-T-MED 258 phenobarbital/hyoscyamine sulf/atropine PEPCID 263 sulf/scopolamine hb 248 peppermint oil 530 PHENOHYTRO 249 pepsin 397 phenol 398 PEPTIC RELIEF 258 phenolsulfonic acid 398 PERCOCET 26 phenoxybenzamine hcl 165,398 PERDIEM 269 phenoxyethanol 398 perfluorodecalin 397 phentermine hcl 398 PERFOROMIST 461 phentolamine mesylate 165,398 PERIDEX 210 phenyl salicylate 398 PERIGUARD 233 PHENYLADE GMP 530 perindopril erbumine 167 PHENYLADE GMP MIX-IN 577 PERIOGARD 210 phenylalanine 398 PERJETA 114 phenylalanine,dl- 398 permethrin 233,397 phenylbutazone 398 phenylephrine hcl 182,398,438 pimecrolimus 233 phenylephrine hcl in 0.9 % sodium pimozide 121 chloride 182,577 PIMTREA 297 phenylephrine hcl in dextrose 5 % in pina colada flavor 399 water 182,577 pindolol 171 phenylephrine hcl in sterile water for injection577 pine needle oil 399 phenylephrine hcl/promethazine hcl 480 pine oil 399 phenylephrine hcl/pyrilamine maleate 480 pine tar 233 phenylmercuric acetate 398 pineapple flavor 399 phenylmercuric nitrate 398 pineapple fruit extract 399 phenyltoloxamine citrate (dihydrogen) 578 pink (food color) 399 PHENYTEK 63 PINK BISMUTH 258 phenytoin 63,399 pioglitazone hcl 150 phenytoin sodium 63,399 pioglitazone hcl/glimepiride 150 phenytoin sodium extended 63 pioglitazone hcl/metformin hcl 150 PHESGO 578 piperacillin sodium/tazobactam sodium 51 PHEXXI 578 piperine 399 PHILITH 297 PIQRAY 578 PHILLIPS 503 PIRMELLA 297 PHILLIPS' COLON HEALTH 258 piroxicam 8,399 PHILLIPS' LAXATIVE 269 pistachio nut extract 578 PHILLIPS' MILK OF MAGNESIA 258,269 PITOCIN 399 PHOS-NAK 503 PLAN B ONE-STEP 297 PHOSLYRA 279 PLAQUENIL 116 PHOSPHA 250 NEUTRAL 278 PLASBUMIN-25 399 PHOSPHASAL 44 PLASBUMIN-5 399 phosphatidyl serine 399 PLASMA-LYTE 148 504 phosphatidylcholine 399 PLASMA-LYTE A PH 7.4 504 PHOSPHOLINE IODIDE 446 PLASMANATE 399 phosphoric acid,diluted 399 PLAVIX 164 PHOTOFRIN 102 PLEGISOL 182 PHRENILIN FORTE 204 PLEGRIDY 207 PHYSIOLYTE 504 PLEGRIDY PEN 208 PHYSIOSOL 504 PLENAMINE 530 physostigmine salicylate 399 PLEXION 233 phytic acid 399 PLIAGLIS 233 phytonadione (vit k1) 399,530 PNEUMOVAX 23 319 PICATO 233 PNV 29-1 530 PIFELTRO 578 PNV OB+DHA 530 pilocarpine hcl 210,399,446 PNV-OMEGA 530 pilocarpine nitrate 399 PNV-SELECT 530 PNV-VP-U 530 polysorbate 60 401 PODOCON-25 233 polysorbate 80 401 podofilox 234,399 POLYSPORIN 234 podophyllum resin 400 POLYTRIM 438 POLIBAR ACB 400 polyvinyl alcohol 401,438 POLOCAINE 36 polyvinyl alcohol/gentian violet/methylene POLOCAINE-MPF 36 blue 401 poloxalene 400,578 POLYVITAMIN WITH IRON 530 poloxamer 400 POMALYST 93 poloxamer 188/poloxamer 407/xylitol 400 PONTOCAINE 234 POLY-IRON 530 porcine acell submucosa,meshed 401 POLY-TUSSIN AC 480 porcine acellular small intestine submucosa, POLY-VI-FLOR 530 fenestrated 401 POLY-VI-FLOR WITH IRON 530 pork extract 578 POLY-VI-SOL WITH IRON 530 PORTIA 297 POLY-VITAMIN 530 posaconazole 83 POLYCIN 438 POTABA 531 polyethylene glycol 400 potassium acetate 401,504 polyethylene glycol 1000 400 potassium alum 401 polyethylene glycol 1450 400 potassium aminobenzoate 401 polyethylene glycol 300 400 potassium aspartate 401 polyethylene glycol 3350 269,400 potassium azeloyl diglycinate 401 polyethylene glycol 3350/polyethylene glycol potassium bicarbonate 401 400 400 potassium bicarbonate/citric acid 504 polyethylene glycol 400 400 potassium bitartrate 401 polyethylene glycol 400/peg 8000/polysorbate potassium bromide 401 80 400 potassium chloride 401,504 polyethylene glycol 4500 578 potassium chloride in 0.45 % sodium chloride 504 polyethylene glycol 600 400 potassium chloride in 0.9 % sodium polyethylene glycol 8000 400 chloride 504,578 polyhexamethylene biguanide 400 potassium chloride in 5 % dextrose in water 504 polyhexamethylene biguanide/gauze bandage 400 potassium chloride in dextrose 5 % and 0.9 % polymyxin b sulfate 44 sodium chloride 504 polymyxin b sulfate,micronized 400 potassium chloride in dextrose 5 %-0.2 % sodium polymyxin b sulfate/trimethoprim 438 chloride 504 polyoxyl (100) stearyl ether 401 potassium chloride in dextrose 5 %-0.45 % sodium polyoxyl 10 oleyl ether 401 chloride 504 polyoxyl 40 stearate 401 potassium chloride in dextrose 5% and 0.3 % polyquaternium-6/gauze bandage 401 sodium chloride 504 polysorbate 20 401 potassium chloride in lactated ringers and 5 % polysorbate 40 401 dextrose 504 potassium chloride in water for injection, PRANDIN 150 sterile 505 prasterone (dhea) 403 potassium chloride/lidocaine hcl in 0.9 % sodium prasterone (dhea), micronized 403 chloride 505 prasugrel hcl 164 potassium chloride/potassium bicarbonate/citric PRAVACHOL 189 acid 505 pravastatin sodium 189 potassium citrate 278,401 praziquantel 403 potassium citrate monohydrate 402 prazosin hcl 165,403 potassium citrate/citric acid 278 PRE B2 258 potassium gluconate 402 PRE-ATTACHED LTA KIT 234 potassium hydroxide 402 PRE-MOISTENED HEMORRHOIDAL 234 potassium iodide 402 PRE-PEN 403 potassium iodide/iodine 402 PRECEDEX 403 potassium metabisulfite 402 PRECOSE 150,151 potassium nitrate 402 PRED FORTE 444 402 PRED MILD 444 402 PRED-G 438 potassium phosphate in 0.9 % sodium prednicarbate 234 chloride 505 prednisolone 282,403 potassium phosphate, dibasic 402 prednisolone acetate 444 potassium phosphate,monobasic 402 prednisolone acetate, micronized 403 potassium phosphate,monobasic-dibasic 505 prednisolone sodium phosphate 282,403,444 potassium sorbate 402 prednisolone, micronized 403 potassium sulfate 402 prednisone 282,403 povidone 402 PREDNISONE INTENSOL 282 povidone-iodine 278,402,438 prednisone micronized 403 powder base no.200 402 PREFEST 297 powder scent fragrance 402 pregabalin 205 POWDERLAX 269 pregnenolone 403 PR NATAL 400 531 pregnenolone, micronized 403 PR NATAL 400 EC 531 PREMARIN 297 PR NATAL 430 531 PREMASOL 531 PR NATAL 430 EC 531 PREMPHASE 297 PRADAXA 156 PREMPRO 297 pralidoxime chloride 402 PRENA1 CHEW 531 pralines and cream flavor 402 PRENA1 PEARL 531 PRALUENT PEN 190 PRENA1 TRUE 505 pramipexole di-hcl 118 PRENATABS FA 531 PRAMOSONE 234 PRENATABS RX 531 PRAMOSONE E 234 PRENATAL FORMULA-DHA 531 pramoxine hcl 234,402 PRENATAL ONE 403 prenatal vit with calcium 95/ferrous prenatal vits, calcium no.91/ferrous fumarate/folic acid/dha 531 fumarate/folic acid/dha 532 prenatal vit with calcium no.122/ferrous PRENATE DHA 532 fumarate/folic acid 531 PRENATE ELITE 532 prenatal vit with calcium no.129/ferrous PRENATE ENHANCE 532 fumarate/folic acid 531 PRENATE MINI 532 prenatal vit with calcium no.130/ferrous PRENATE PIXIE 532 fumarate/folic acid 531 PRENATE RESTORE 532 prenatal vitamins no.121/ferrous fumarate/folic PRENATE STAR 532 acid 531 PREORBOTIC 258 prenatal vitamins no.40/ferrous fumarate/folic PREPARATION H 234 acid/dha 531 PREPIDIL 278 prenatal vitamins no.62/folic acid/omega- PREPLUS 533 3s/dha/epa/fish oil 531 PREPOPIK 269 prenatal vitamins with calcium/ferrous PRES GEN 480 fumarate/folic acid 531 PRESERA 234 prenatal vits no.151/iron fum/folic PRESERVISION AREDS 533 acid/omega3/dha/epa/fish 531 PRESERVISION LUTEIN 533 prenatal vits with calcium 118/ferrous PRESSURE-PAIN PE PLUS MUCUS 457 fumarate/folic acid 532 PRESTALIA 182 prenatal vits with calcium 133/ferrous PRETAB 533 fumarate/folic acid 532 pretomanid 578 prenatal vits with calcium 137/ferrous PREVACID 274 fumarate/folic acid 532 PREVACID 24HR 274 prenatal vits with calcium 95/ferrous PREVALITE 191 fumarate/folic acid 532 PREVIDENT 210 prenatal vits with calcium no.124/ferrous PREVIDENT 5000 210 fumarat/folic acid 532 PREVIDENT 5000 ENAMEL PROTECT 210 prenatal vits with calcium no.21/ferrous PREVIDENT 5000 PLUS 210 fumarate/folic acid 532 PREVIDENT 5000 SENSITIVE 210 prenatal vits with calcium no.72/ferrous PREVIFEM 297 fumarate/folic acid 532 PREVNAR 13 319 prenatal vits with calcium PREVYMIS 578 no.72/iron,carbonyl/folic acid 532 prezatide copper 403 prenatal vits with calcium no.74/ferrous PREZCOBIX 139 fumarate/folic acid 532 PREZISTA 140 prenatal vits with calcium no.93/ferrous PRIALT 403 fumarate/folic acid 532 PRIFTIN 89 prenatal vits with calcium no.96/ferrous PRIKAAN 234 fumarate/folic acid 532 PRIKAAN LITE 234 PRILO PATCH 579 prilocaine hcl 403 PROCALAMINE 533 PRILOSEC 274 procarbazine hcl 404 PRILOVIX PLUS 234 PROCARDIA 175 PRIMACARE 579 PROCARDIA XL 175 primaquine phosphate 116 PROCENTRA 195 PRIMATENE MIST 579 PROCERV HP 533 PRIMAXIN 50 prochlorperazine 74 primidone 60,403 prochlorperazine edisylate 74,404 PRIMLEV 26,27 prochlorperazine maleate 74,404 PRIMSOL 44 PROCORT 234 PRINIVIL 167 PROCRIT 158 PRISMASOL 403 PROCTO-MED HC 234 PRISTIQ 70 PROCTO-PAK 321 PRIVIGEN 316 PROCTOCORT 282,321 PRIZOPAK II 234 PROCTOFOAM-HC 234 PRIZOTRAL-II 579 PROCTOSOL-HC 321 PRO-RED AC 480 PROCTOZONE-HC 321 PROAIR DIGIHALER 461 PROCYSBI 246,579 PROAIR HFA 461 PROFENO 8 PROAIR RESPICLICK 461 PROFERRIN-FORTE 505 probenecid 85 PROFILNINE 162 probenecid/colchicine 85 progesterone 301,404 PROBIOTIC 258,579 progesterone, micronized 302,404 PROBIOTIC & ACIDOPHILUS 258 PROGLYCEM 152 PROBIOTIC 4X 258 PROGRAF 312,579 PROBIOTIC ACIDOPHILUS 259,579 PROHANCE 404 PROBIOTIC ACIDOPHILUS BIOBEADS 259 PROHANCE MULTIPACK 404 PROBIOTIC ACIDOPHILUS-PECTIN 259 PROLASTIN C 480 PROBIOTIC COLON CARE 259 PROLATE 27 PROBIOTIC COLON SUPPORT 259 PROLENSA 444 PROBIOTIC COMPLEX 259 PROLEUKIN 102 PROBIOTIC DIGESTIVE CARE 259 PROLIA 323 PROBIOTIC FORMULA 259 proline 404 PROBIOTIC GOLD ACIDOPHILUS 259 PROMACTA 159,579 PROBIOTIC PEARLS 259 PROMELLA 579 PROBIOTIC PEARLS COMPLETE 259 promethazine hcl 404,457 PROBIOTIC PLUS COLOSTRUM 579 promethazine hcl in 0.9 % sodium chloride 74 PROBIOTIC WITH PREBIOTIC 259 promethazine hcl/codeine 480 PROBUPHINE 39 promethazine hcl/dextromethorphan hbr 481 procainamide hcl 169,404 promethazine/phenylephrine hcl/codeine 481 procaine hcl 404 PROMETHEGAN 457 PROMETRIUM 302 PROTOPAM CHLORIDE 405 PROMISEB 234 PROTOPIC 234,235 PROMOD 533 protriptyline hcl 72 PROMOLAXIN 270 PROVELLA 259 propafenone hcl 169 PROVENGE 102 propantheline bromide 249,404 PROVENTIL HFA 461 proparacaine hcl 404,439 PROVERA 302 proparacaine hcl/fluorescein sodium 439 PROVIDA DHA 533 propofol 36 PROVIDA OB 533 PROPOVEN (EUA) 579 PROVIGIL 492 propranolol hcl 171,404 PROVIL 8 propranolol hcl/hydrochlorothiazide 182 PROVISC 439 propyl gallate 404 PROVOCHOLINE 405 propylene glycol 404 PROZAC 70 propylene glycol monostearate 404 PRUCLAIR 235 propylene glycol/carbomer 940 404 PRUDOXIN 235 propylparaben 404 PRUMYX 235 propylthiouracil 307,404 PRUTECT 235 PROQUAD 319 pseudoephedrine hcl 405 PRORENAL 533 PSORCON 235 PRORENAL QD 533 PSORIASIS MEDICATED 235 PROSCAR 276 psyllium husk 270,405 PROSHIELD PLUS 234 PULMICORT 450 PROSIGHT 533 PULMICORT FLEXHALER 450 PROSIGHT WITH LUTEIN 533 PULMOSAL 481 PROSILK GEL 579 PULMOZYME 481 PROSOL 533 pumice 405 PROSOURCE TF 533 pump set 405 PROSTIN E2 VAGINAL SUPPOSITORY 278 PURALUBE 439 PROSTIN VR PEDIATRIC 182 PURE & GENTLE EYE DROPS 439 protamine sulfate 156,404 PURE AND GENTLE SALINE ENEMA 270 PROTECT CARDIO AF 533 PURELAX 270 PROTECT IRON 533 PURIXAN 96 PROTECT PLUS SO 533 PYLERA 259 PROTECTIVE OINTMENT 404 pyrantel pamoate 405 PROTEOLIN 533 pyrazinamide 89,405 PROTHELIAL 210 PYRIDIUM 278 prothrombin time/inr test meter 404 pyridostigmine bromide 88,89,405 protirelin 405 pyridoxal phosphate 405 PROTONIX 274 pyridoxine hcl (vitamin b6) 405,533 PROTONIX IV 274 pyrilamine maleate 405 pyrimethamine 116,405 QUIT 4 41 pyrithione zinc 405 QUTENZA 235 pyrogallol 405 QUZYTTIR 580 pyruvic acid 405 QVAR REDIHALER 450

Q R Q-SORB CO Q-10 533 R-GENE 10 406 QBRELIS 168 R-NATAL OB 534 QBREXZA 579 RABAVERT 319 QINLOCK 579 rabeprazole sodium 274 QMIIZ ODT 579 racemethionine 406 QNASL 450 racepinephrine hcl 406 QNASL CHILDREN 450 RADIAGUARD 235 QTERN 579,580 RADIAPLEXRX 235 QUADRACEL DTAP-IPV 319 RADIOGARDASE 494 QUADRAMET 405 RAGWITEK 481 QUALAQUIN 116 raloxifene hcl 302 QUARTETTE 297 ramelteon 491 QUASENSE 297 ramipril 168 quazepam 490 RANEXA 182 QUDEXY XR 62 ranitidine hcl 263,406 QUELICIN 204 ranolazine 183 quercetin dihydrate 405 RAPAFLO 277 QUESTRAN 191 RAPAMUNE 312 QUESTRAN LIGHT 191 rapeseed oil 406 quetiapine fumarate 124,125 rasagiline mesylate 119,406 QUFLORA 533 raspberry flavor 406 QUILLICHEW ER 198 raspberry flavor, artificial 406 QUILLIVANT XR 198 RASUVO 312 QUIN B STRONG 534 rauwolfia serpentina 406 quinacrine hcl 405 RAVICTI 246 quinapril hcl 168 RAYALDEE 323 quinapril hcl/hydrochlorothiazide 182 RAYOS 282 quinidine gluconate 169 RAZADYNE 64 quinidine sulfate 169,406 RAZADYNE ER 64 quinine hcl dihydrate 406 READI-CAT 2 406 quinine sulfate 117,406 READY TO USE ENEMA 270 QUINTABS 534 REBETOL 133 QUINTABS-M 534 REBIF 208 QUINTABS-M IRON FREE 534 REBIF REBIDOSE 208 QUIT 2 41 REBINYN 580 REBLOZYL 580 REMEDY NUTRASHIELD 235 RECARBRIO 580 REMEDY PHYTOPLEX ANTIFUNGAL 83 RECEDO 235 REMEDY PHYTOPLEX MOISTURIZER 580 RECLAST 323 REMEDY SKIN REPAIR 235 RECLIPSEN 297 REMERON 66 RECOMBINATE 162 REMICADE 312 RECOMBIVAX HB 319 remifentanil hcl 27 RECOTHROM 162 REMODULIN 465 rectal, vaginal applicator tip 406 RENA-VITE 534 RECTASMOOTHE 235 RENA-VITE RX 534 RECTICARE 235 RENAGEL 280 RECTIV 235 RENAL CAPS 534 red (food color) 406 RENAL VITAMIN 534 red algae 406 RENAL-VITE 534 red yeast rice extract 406 RENFLEXIS 312 REDNESS RELIEVER 439 RENO CAPS 534 REFENESEN 481 RENVELA 280 REFENESEN DM 481 REOPRO 164 REFRESH CELLUVISC 439 repaglinide 151 REFRESH CLASSIC 439 repaglinide/metformin hcl 151 REFRESH LACRI-LUBE 439 REPATHA PUSHTRONEX 191 REFRESH LIQUIGEL 439 REPATHA SURECLICK 191 REFRESH OPTIVE 439 REPATHA SYRINGE 191 REFRESH OPTIVE ADVANCED 439 REPEL HUNTER'S 406 REFRESH OPTIVE SENSITIVE 439 REPEL SPORTSMEN 406 REFRESH P.M. 439 REPEL SPORTSMEN DRY 406 REGENECARE 36 REPEL SPORTSMEN MAX 406 REGLAN 74 REQ49+ 534 REGONOL 89 REQUIP 118 REGRANEX 235 REQUIP XL 118 REGULOID 270 RESCRIPTOR 136 RELAFEN DS 580 RESECTISOL 279 RELAGARD 278 reserpine 406 RELENZA 141 resorcinol 407 RELEXXII 580 RESPA A.R. 481 RELISTOR 259 RESPAIRE-30 481 RELPAX 87 RESTASIS 439 remdesivir 580 RESTASIS MULTIDOSE 439 REMEDIENT 580 RESTORA SPRINKLES 259 REMEDY ANTIFUNGAL 83 RESTORIL 490 REMEDY CALAZIME 235 resveratrol 407 RETACRIT 580 RIFAMATE 89 RETAINE HPMC 439 rifampin 89,407 RETAINE PM 439 RIFATER 90 RETAVASE 156 rifaximin 407 RETEVMO 580 RILUTEK 204 RETIN-A 236 riluzole 204 RETIN-A MICRO 236 rimantadine hcl 141 RETIN-A MICRO PUMP 236,580 RIMSO-50 279 retinal 407 ringer's solution 505,534 RETISERT 445 ringer's solution,lactated 505,534 RETROVIR 137 RINGWORM 83 REVATIO 465 RINVOQ 581 REVLIMID 93 RIOMET 151 REVONTO 489 RIOMET ER 581 REXULTI 125 RISA-BID 259 REYATAZ 140 RISAMINE 236 REYVOW 580,581 RISAQUAD 260 RHOFADE 581 RISAQUAD-2 260 RHOGAM ULTRA-FILTERED PLUS 316 risedronate sodium 323,324 RHOPHYLAC 316 RISPERDAL 125 RHOPRESSA 581 RISPERDAL CONSTA 125 RI-GEL 259 risperidone 125,126 RI-GEL II 259 RITALIN 198 RI-MOX 259 RITALIN LA 198 RI-MOX PLUS 259 ritonavir 140 RI-TUSSIN 481 RITUXAN 114 RI-TUSSIN DM 481 RITUXAN HYCELA 581 RIASTAP 162 rivastigmine 64 RIAX 236 rivastigmine tartrate 64 RIBASPHERE 133,134 RIVELSA 297 RIBASPHERE RIBAPAK 134 RIXUBIS 162 ribavirin 134,481 rizatriptan benzoate 87 riboflavin (vitamin b2) 407,534 ROBAFEN 481 riboflavin 5-phosphate sodium (b2) 407 ROBAFEN CF 481 ribose 407 ROBAFEN COUGH 481 rice extract 581 ROBAFEN DM COUGH 481 rice starch 581 ROBAFEN DM COUGH-CHEST CONGEST 481 RID 236 ROBAFEN-DM 482 RIDAURA 317 ROBAXIN 489 rifabutin 89 ROBAXIN-750 489 RIFADIN 89 ROBITUSSIN COUGH-CHEST CONG DM 581 ROBITUSSIN COUGH-CHEST-CONG DM 482 RYNEX PSE 482 ROCALTROL 324 RYNODERM 236 ROCKLATAN 581 RYTARY 119 rocuronium bromide 407 RYTHMOL SR 169 romidepsin 102 RYVENT 582 ROMPE PECHO MAX MULTI SYMPTOMS 482 root beer flavor 407 S ropinirole hcl 118,119 s-adenosylmethionine sulfate tosylate 407 ropivacaine hcl 407 SABRIL 60 ropivacaine hcl in 0.9 % sodium chloride/pf 36 saccharin 407 ropivacaine hcl/pf 37,581 saccharin sodium 407 ROSADAN 236 SAFETUSSIN DM 482 ROSANIL 236 safety syringe with needle, disposable kit-tray, 1 rose bengal 407 ml 407 rose oil 407 safflower oil 407 rosemary oil 407 SAFYRAL 297 rosin 407 sage leaf 407 ROSULA 236 SAIZEN 284 rosuvastatin calcium 189 SAIZEN-SAIZENPREP 284 ROTARIX 319 SALAGEN 210 ROTATEQ 319 SALEX 236 ROWASA 320 salicylic acid 83,236,408 ROWEEPRA 58 salicylic acid/resorcinol/lactic acid/ethyl ROWEEPRA XR 58 alcohol 408 ROXICODONE 27,28 SALIMEZ FORTE 236 ROXYBOND 28,581 SALINE ENEMA 270 ROZEREM 491 SALINE NASAL MIST 408 rubidium chloride 407 SALIVAMAX 210 RUBRACA 581 SALKERA 236 RUCONEST 308 salsalate 8,408 RUKOBIA 581 SALVAX 236 RULOX 260 SAMSCA 494 rutin 407 SANADERMRX 236 RUXIENCE 581 SANCUSO 77 RUZURGI 582 SANDIMMUNE 312 RYBELSUS 582 SANDOSTATIN 305 RYCLORA 582 SANDOSTATIN LAR DEPOT 305,306 RYDAPT 582 SANTYL 236 RYDEX 482 SAPHRIS 126 RYNEX DM 482 sapropterin dihydrochloride 408 RYNEX PE 482 SARAFEM 70 SARCLISA 582 selenomethionine 408 sarracenia flava 408 SELRX 237 sassafras 408 SELSUN BLUE 41,237 saturated fa glycerides c12-18 408 SELSUN BLUE NATURALS 237 SAVAYSA 156 SELZENTRY 139,582 SAVELLA 205 SEMPREX-D 482 SAVISION 534 SEN-O-TAB 270 saw palmetto 408 SENEXON 270 SCALACORT 236 SENEXON-S 270 SCALPICIN 236 SENIOR PROBIOTIC 260 SCANDONEST PLAIN 37 SENIOR TABS 534 scarlet red 408 SENNA 270 SCENESSE 582 SENNA LAX 270 SCLEROSOL 408 SENNA LAXATIVE 270 SCOOBY-DOO 534 SENNA PLUS 270 scopolamine 74 SENNA-S 270 scopolamine hydrobromide 408 SENNA-S LAXATIVE 270 SCOT-TUSSIN 482 SENNA-TIME S 270 SCOT-TUSSIN EXPECTORANT 482 SENNO 270 SCRUB CARE POVIDONE IODINE 408 sennosides 270 SE-NATAL 19 534 sennosides/docusate sodium 271 SE-NATAL-19 534 SENOKOT 271 SEA-OMEGA 30 534 SENSI-CARE BODY CREAM 237 SEASONIQUE 297 SENSIPAR 304 SEBEX 237 SENSORCAINE 37 SEBUDERM 237 SENSORCAINE WITH DEXTROSE 37 SECONAL SODIUM 493 SENSORCAINE-EPINEPHRINE 37 secretin acetate (human) 408 SENSORCAINE-MPF 37 SECUADO 582 SENSORCAINE-MPF EPINEPHRINE 37 SECURA ANTIFUNGAL 83 SENTRY 534 SECURA DIMETHICONE 237 SENTRY SENIOR 535 SECURA EXTRA PROTECTIVE 237 SEPTOCAINE 37 SECURA PROTECTIVE 237,408 SEREVENT DISKUS 462 SEEBRI NEOHALER 459 serine 408 SEGLUROMET 582 sermorelin acetate 408 SELECT-OB 534 SERNIVO 282 SELECT-OB + DHA 534 SEROQUEL 126 selegiline hcl 119,408 SEROQUEL XR 127 selenium 505 SEROSTIM 284 selenium sulfide 237,408 serotonin hcl 408 selenium yeast 408 sertraline hcl 71,408 sesame oil 409 SILTUSSIN SA 482 sesame seed extract 582 SILVADENE 237 SETLAKIN 298 silver 409 sevelamer carbonate 280 silver nitrate 237,409 sevelamer hcl 280 silver nitrate/potassium nitrate 237 SEVERE COLD AND FLU DAYTIME 482 silver protein,mild 409 SEVERE SINUS 482 silver sulfadiazine 237,409 sevoflurane 37 silver sulfadiazine/foam bandage 409 SF 210 silver sulfate/foam bandage 409 SF 5000 PLUS 210 silver sulfate/non-adherent bandage 410 SFROWASA 320 silver/calcium alginate 410 SHAKE THAT ACHE 204 silver/foam bandage 410 shampoo base no.50 409 silver/silicone/foam bandage 583 shampoo base no.89 409 SILVRSTAT 237 shark cartilage 409 SIMBRINZA 446 SHAROBEL 302 simethicone 260,410 shea butter 409 SIMLIYA 298 SHINGRIX 582 SIMPESSE 298 SHINGRIX ADJUVANT COMPONENT 582 simple syrup 410 SHINGRIX GE ANTIGEN COMPONENT 582 SIMPONI 312 SHOHL'S MODIFIED 279 SIMPONI ARIA 312 shower fresh fragrance 409 SIMULECT 317 shrimp extract 582 simvastatin 189,410,583 siberian ginseng 409 SINEMET 10-100 119 SIDEROL 493 SINEMET 25-100 119 SIGNIFOR 306 SINEMET 25-250 119 SIGNIFOR LAR 306,583 SINEMET CR 119 SIKLOS 583 SINGULAIR 458 SILA III 237 SINOGRAFIN 410 SILACE 271 SINUS 12 HOUR 410 SILADRYL 457 SINUS 12-HOUR 410 SILAZONE-II 237 SINUS CONGESTION & PAIN 482 sildenafil citrate 409,465,466 SINUS CONGESTION-PAIN 482 SILENOR 491 SINUS CONGESTION-PAIN RELIEF 482 silica gel, amorphous synthetic micronized 409 SINUS CONGESTION-PAIN SEVERE 457 silicon dioxide 409 SINUS DECONGESTANT 410 silicon,colloidal 409 SINUS HEADACHE PE 482 SILIQ 583 SINUS MAXIMUM STRENGTH 483 silodosin 277 SINUS NASAL 410 SILTUSSIN DM 482 SINUS NASAL SPRAY 410 SILTUSSIN DM DAS 482 SINUS PAIN RELIEF 483 SINUS PAIN-CONGESTION 483 sodium bicarbonate 260,411,505 SINUS PE DECONGESTANT 410 sodium bicarbonate in dextrose 5%-water 505 SINUS PE PLUS ALLERGY 483 sodium bisulfite 411 SINUS RELIEF 410,483 sodium borate 411 SINUS RELIEF PRESSURE-PAIN 457,483 sodium bromide 411 SINUS RELIEF SEVERE CONGESTION 483 sodium butyrate 411 SINUS RELIEF-CONGESTION & PAIN 483 sodium cacodylate 411 SINUS SEVERE 457 sodium carbonate 411 SINUS-ALLERGY 483 sodium chloride 411,439,505 SINUS-ALLERGY PE 483 sodium chloride 0.45 % 506 SINUS-HEADACHE 483 sodium chloride 0.9 % (flush) 506 sirolimus 313,410 sodium chloride 3 % 506 SIRTURO 90,583 sodium chloride 5 % 506 SITAVIG 141 sodium chloride for inhalation 483,506 SITZMARKS 410 sodium chloride irrigating solution 279 SIVEXTRO 44 sodium chloride/sodium bicarbonate/potassium SKELAXIN 489 chloride/peg 271 skin cleanser 237 sodium chlorite 411 SKIN PROTECTANT A AND D 237 sodium citrate 157,411 SKIN TREATMENT 237 sodium citrate dihydrate 411 SKLICE 115 sodium decanoate 411 SKYLA 302 sodium desoxycholate 411 SKYRIZI 583 sodium dichloroacetate 411 SKYRIZI (2 SYRINGES) KIT 583 SODIUM DIURIL 186 SLO-NIACIN 191 SODIUM EDECRIN 185 SLOW FE 505 sodium ferric gluconate complex in sucrose 535 SLOW RELEASE IRON 505 sodium fluoride f-18 583 SLOW-MAG 505 sodium fluoride/potassium nitrate 210 SLYND 583 sodium gluconate 411 SMOFLIPID 535 sodium hydroxide 411 SMOOTH ANTACID 260 sodium iodide 411 SMOOTH DISSOLVING ANTACID 260 sodium lactate 411,506 SMOOTHLAX 271 sodium laureth sulfate 411 soap 237 sodium lauryl sulfate 411 sodium acetate 410,505 sodium metabisulfite 411 sodium acetate trihydrate 410 sodium monofluorophosphate 412 sodium alginate 410 sodium nitrate 412 sodium ascorbyl phosphate dihydrate 410 sodium nitrite 412 sodium aspartate monohydrate 583 sodium oleate 412 sodium benzoate 411 sodium perborate 412 sodium benzoate/sodium phenylacetate 246 sodium phenylbutyrate 246 sodium phosphate dibasic, heptahydrate 412 SONAFINE 238 sodium phosphate in 0.9 % sodium SOOLANTRA 238 chloride 506,583 SOOTHE 260 sodium phosphate in 5 % dextrose in water 584 SOOTHE HYDRATION 439 sodium phosphate,dibasic 412 SOOTHING CARE 238 sodium phosphate,monobasic 412 SOOTHING PUREWAY-C 535 sodium phosphate,monobasic-dibasic 506 sorbic acid 413 sodium polystyrene sulfonate 494 sorbitan monolaurate 413 sodium propionate 412 sorbitan monooleate 413 sodium pyroglutamate 412 sorbitan monopalmitate 413 sodium pyruvate 412 sorbitol 413 sodium salicylate 412 sorbitol solution 271,279 sodium selenite 412 SORBUGEN NR 483 sodium silicate 412 SORE MUSCLE RUB 238 sodium stearate 412 SORE THROAT LOZENGE 210 sodium stearyl fumarate 412 SORE THROAT SPRAY 210 sodium succinate 412 SORIATANE 238 sodium sulfate 412 SORILUX 238 sodium sulfite 412 SORINE 169 sodium tartrate dihydrate 412 sotalol hcl 169 sodium tetradecyl sulfate 412 SOTRADECOL 413 sodium thiosalicylate 412 SOTYLIZE 169 sodium thiosulfate 413 SOVALDI 134,584 SOF-LAX 271 soybean extract 584 sofosbuvir/velpatasvir 134 413 SOL CARB 535 spearmint oil 413 SOLARAZE 237 SPECTRACEF 49 SOLESTA 413 SPECTRAVITE ADULT 50+ 535 solifenacin succinate 275 SPECTRAVITE ADVANCED FORMULA 535 SOLIQUA 100-33 154 SPECTRAVITE MEN'S 535 SOLIRIS 413 SPECTRAVITE SENIOR 535 SOLO 535 SPECTRAVITE ULTRA MEN 50+ 535 SOLODYN 57 SPECTRAVITE ULTRA MEN'S 535 SOLOSEC 584 SPECTRAVITE ULTRA WOMEN 535 SOLOXIDE 57 SPECTRAVITE ULTRA WOMEN'S 535 SOLTAMOX 94 SPHERUSOL 413 SOLU-CORTEF 282 spinosad 238 SOLU-MEDROL 282 SPIRIVA 459 SOMA 489 SPIRIVA RESPIMAT 459 SOMATULINE DEPOT 306 spirometers and accessories 413 SOMAVERT 306 spironolactone 185,413 spironolactone, micronized 413 STERILE WATER DILUENT-CABLIVI 414 spironolactone/hydrochlorothiazide 183 STERILE WATER FOR KCENTRA 414 SPORANOX 83 steviol glycosides 414 SPRAVATO 584 stevioside 414 SPRAY AND STRETCH 238 stevioside/glycerin 414 SPRINTEC 298 STIMATE 284 SPRITAM 58 STIMULANT LAXATIVE PLUS 271 SPRIX 8 STIOLTO RESPIMAT 483 SPRYCEL 110 STIVARGA 111 SPS 494 STOMACH RELIEF 260 squalane 413 STOMACH RELIEF ORIGINAL 260 squaric acid 413 STOOL SOFTENER 271 squaric acid dibutylester 413 STOOL SOFTENER-LAXATIVE 271 squaric acid dibutylester in butyl alcohol 413 STOOL SOFTENER-STIMULANT LAX 271 SRONYX 298 STOP SMOKING AID 41 SSD 238 STRATTERA 198 SSKI 506 STRAVIX 414 SSS 10-5 238 strawberry extract 584 st. john's wort 413 strawberry flavor 414 ST. JOSEPH ASPIRIN 8 STRENSIQ 247 ST. JOSEPH ASPIRIN EC 8 streptomycin sulfate 41,414 stabilizer for blinatumomab 584 STRESS B WITH ZINC 535 STALEVO 100 117 STRESS FORMULA 535 STALEVO 125 117 STRESS FORMULA WITH IRON 535 STALEVO 150 118 STRESS FORMULA WITH ZINC 535 STALEVO 200 118 STRESS-C 535 STALEVO 50 118 STRIANT 286 STALEVO 75 118 STRIBILD 135 STAMARIL 584 STRIVERDI RESPIMAT 462 stannous chloride dihydrate 414 STROMECTOL 115 stanozolol 414 strontium chloride hexahydrate 414 stanozolol micronized 414 strontium nitrate 414 STARLIX 151 STROVITE ONE 535 stavudine 137 STUART ONE 535 stearic acid 414 STUDIO 35 MOISTURIZING SKIN 238 stearyl alcohol 414 subcutaneous bolus insulin patch pump, 200 unit, STEGLATRO 584 disposable 584 STEGLUJAN 584 SUBLOCADE 584 STELARA 238 SUBOXONE 39,40 STERILE EYE DROPS 439 SUBSYS 28 STERILE HYDROGEL FOR JELMYTO 584 SUBVENITE 62 SUBVENITE (BLUE) 62 sulfisoxazole 415 SUBVENITE (GREEN) 62 sulfosalicylic acid dihydrate 415 SUBVENITE (ORANGE) 62 sulfur 415 succimer 414 sulfur sublimed 415 succinic acid 414 sulfurated potash 415 succinylcholine chloride 414 sulfuric acid 415 SUCRAID 247 sulindac 8,415 sucralfate 272,414 SUMADAN 239 sucrose 414 SUMADAN XLT 239 sucrose octaacetate 414 sumatriptan 87,415 SUDAFED 12 HOUR 414 sumatriptan succinate 87,416 SUDAFED 24-HOUR 415 sumatriptan succinate/naproxen sodium 88 SUDOGEST 415 SUMAVEL DOSEPRO 88 SUDOGEST PE 415 SUMAXIN 239 sufentanil citrate 28,415 SUMAXIN CP 239 SULAR 175 SUMAXIN TS 239 sulconazole nitrate 84 SUMMER'S EVE DOUCHE 279 sulfacetamide 415 SUNOSI 585 sulfacetamide sodium 238,415,439,440 SUPARTZ FX 416 sulfacetamide sodium, monohydrate 415 SUPER B COMPLEX-VITAMIN C 535 sulfacetamide sodium/prednisolone sodium SUPER B-50 COMPLEX 536 phosphate 440 SUPER CALCIUM 506 sulfacetamide sodium/sulfur 239 SUPER GINSENG MULTIVITAMIN 416 sulfacetamide SUPER MULTIPLE 536 sodium/sulfur/avobenzone/octinoxate/octyl SUPER MULTIPLE-LOW IRON 536 sal 239 SUPER MULTIVITAMIN 536 sulfacetamide sodium/sulfur/skin cleanser comb SUPER OMEGA-3 536 no.23 239 SUPER PROBIOTIC 261 sulfacetamide sodium/sulfur/urea 239 SUPER QUINTS 536 SULFACLEANSE 8-4 239 super synersweet flavor 416 sulfadiazine 55,415 SUPER THERAVITE-M 536 sulfadiazine sodium 415 416 sulfamerazine 415 SUPERPLEX-T 536 sulfamethoxazole 415 SUPERVITE 536 sulfamethoxazole/trimethoprim 55 SUPHEDRIN 416 SULFAMYLON 45,239 SUPHEDRINE 416 sulfanilamide 415 SUPHEDRINE 12-HOUR 416 sulfapyridine 415 SUPHEDRINE PE 416 sulfasalazine 321,415 SUPHEDRINE PE COLD-ALLERGY 483 sulfathiazole 415 SUPHEDRINE PE SINUS HEADACHE 483 SULFATRIM 55 SUPHEDRINE PE SINUS-ALLERGY 483 SUPHEDRINE SINUS CONGESTION 416 SYNALAR 239 SUPPORT 536 SYNALAR TS 239 SUPPORT-500 536 SYNAREL 306 SUPPOSITORY 271 SYNDROS 585 suppository base no.119 416 SYNERA 239 suppository base no.234 585 SYNERCID 45 suppository base no.55 416 SYNERDERM 239 suppository base no.85 416 SYNJARDY 151 suppository container, empty 416 SYNJARDY XR 585 suppository mold 416 SYNOVACIN 416 SUPPRELIN LA 306 SYNRIBO 103 SUPRANE 37 SYNTHAMIN 17 WITHOUT ELTYE 536 SUPRAX 49 SYNTHROID 303 SUPREP 271 SYNVISC 416 SURFAK 272 SYNVISC-ONE 416 SURMONTIL 72 SYPRINE 494 SURVANTA 483 syring w-needl 0.5 ml,kit-tray 417 SUSTIVA 136 syringe accessory 417 SUSTOL 77 SYRINGE AVITENE 417 SUTENT 111 syringe cap, enfit,non-sterile 585 SWABFLUSH 506 syringe filter 417 sweetleaf/polyethylene glycol 1450 416 syringe w-needle 0.3 ml,insulin,safety w-self- SYEDA 298 cont.dis.unit 417 SYLATRON 103 syringe with cannula, disposable, 1 ml 417 SYLVANT 114 syringe with cannula, disposable, 10 ml 417 SYMAX 249 syringe with cannula, disposable, 3 ml 417 SYMAX DUOTAB 249 syringe with cannula, disposable, 5 ml 417 SYMAX-SL 249 syringe with cannula, disposable, 6 ml 417 SYMAX-SR 249 syringe with cannula,disposable 12 ml 417 SYMBICORT 483 syringe with needle 1 ml, disposable kit-tray 417 SYMBYAX 66 syringe with needle 1 ml,insulin,safety w-self- SYMDEKO 585 con.disp.unit 417 SYMFI 585 syringe with needle and cannula, disposable, 10 SYMFI LO 585 ml 417 SYMJEPI 585 syringe with needle, insulin, safety, 0.3 ml 417,585 SYMLINPEN 120 151 syringe with needle, insulin, safety, 0.5 ml 417,585 SYMLINPEN 60 151 syringe with needle, insulin, safety, 1 ml 417,586 SYMPAZAN 585 syringe with needle,disposable 418 SYMPROIC 585 syringe with needle,disposable, 0.5 ml 418 SYMTUZA 585 syringe with needle,disposable, 1 ml 418 SYNAGIS 317 syringe with needle,disposable, 10 ml 418 syringe with needle,disposable, 12 ml 418 syringe,safety with needle,12 ml 421 syringe with needle,disposable, 3 ml 419 syringe,safety with needle,3 ml 421 syringe with needle,disposable, 5 ml 419 syringe,safety with needle,5 ml 421 syringe with needle,disposable, 6 ml 419 SYSTANE 440 syringe with needle,disposable,insulin 1 SYSTANE GEL 440 ml 419,586 syringe with needle,insulin 0.3 ml (half unit T mark) 419,586 T-PLUS 239 syringe with needle,insulin 0.5 ml (half unit T-SAL 240 mark) 586 TAB-A-VITE 536 syringe with needle,insulin disposable 419 TAB-A-VITE WITH IRON 536 syringe with needle,insulin,0.3 ml 420,586 tablet rapid dissolve compounding base no. syringe with needle,insulin,0.5 ml 420 163 421 syringe without needle,insulin disposible, 1 ml 420 tablet rapid dissolve compounding base syringe, disposable irrigation, 70 ml 420 no.123 421 syringe, disposable, 1 ml 420 TABLOID 96 syringe, disposable, 10 ml 420 TABRECTA 586 syringe, disposable, 12 ml 420 TACHOSIL 421 syringe, disposable, 20 ml 420 TACLONEX 240 syringe, disposable, 3 ml 420 tacrolimus 240,313,421 syringe, disposable, 30 ml 420 tacrolimus anhydrous 421 syringe, disposable, 35 ml 420 tacrolimus, micronized 421 syringe, disposable, 5 ml 420 TACTINAL 204 syringe, disposable, 6 ml 420 tadalafil 277,466,586 syringe, disposable, 60 ml 420 TAFINLAR 111 syringe, enfit 1 ml, non-sterile 586 TAGITOL 422 syringe, enfit 1 ml, sterile 586 TAGRISSO 111 syringe, enfit 12 ml, non-sterile 586 TAKE ACTION 298 syringe, enfit 12 ml, sterile 586 TAKHZYRO 586 syringe, enfit 3 ml, sterile 586 talc 422 syringe, enfit 35 ml, non-sterile 586 TALICIA 587 syringe, enfit 35 ml, sterile 586 TALTZ AUTOINJECTOR 240 syringe, enfit 6 ml, non-sterile 586 TALTZ AUTOINJECTOR (2 PACK) 240 syringe, enfit 6 ml, sterile 586 TALTZ AUTOINJECTOR (3 PACK) 240 syringe, enfit 60 ml, non-sterile 586 TALTZ SYRINGE 240 syringe, enfit 60 ml, sterile 586 TALWIN 28 syringe, insulin u-500 with needle, disposable, 0.5 TAME THE FLAME 261 ml 420 TAMIFLU 141 syringe,enfit 3 ml,non-sterile 586 tamoxifen citrate 94,422 syringe,safety with needle,1 ml 420,421,586 tamsulosin hcl 277 syringe,safety with needle,10 ml 421 tangerine flavor 422 tangerine oil 422 TEMIXYS 587 tannic acid 422 TEMODAR 92 TAPAZOLE 307 TEMOVATE 240 TAPERDEX 282,587 temozolomide 92 TARCEVA 111 temsirolimus 112 TARGADOX 57 TENCON 204 TARGRETIN 115 TENDERA-OB 587 TARINA 24 FE 298 teniposide 103 TARINA FE 298 TENIVAC 319 TARINA FE 1-20 EQ 298 tenofovir disoproxil fumarate 137 TARKA 183 TENORETIC 100 183 tartaric acid 422 TENORETIC 50 183 TASIGNA 112,587 TENORMIN 171 TASMAR 118 TENSION HEADACHE 422 TASOPROL 587 TENSION HEADACHE PAIN RELIEVER 422 taurine 422 TEPADINA 103,587 tavaborole 84 TEPEZZA 587 TAVALISSE 587 TERA-GEL TAR 240 TAXOTERE 103 terazosin hcl 277 TAYTULLA 298 terbinafine hcl 84 tazarotene 240,422 terbutaline sulfate 422,462 TAZICEF 49 terconazole 84 TAZORAC 240 teriparatide 587 TAZTIA XT 175 terpin hydrate 422 TAZVERIK 587 TERRELL 37 tea tree oil 422 TERSI FOAM 240 teaberry oil flavor 422 TESSALON PERLE 483 TEARS AGAIN 440 TESTIM 286 TECARTUS 587 TESTOPEL 286 TECENTRIQ 114,587 testosterone 286,287,422 TECFIDERA 208 testosterone cypionate 287 TECHNELITE TC-99M GENERATOR 587 testosterone cypionate, micronized 422 TEFLARO 49 testosterone enanthate 287 TEGRETOL 63 testosterone micronized 422 TEGRETOL XR 63 testosterone propionate 422 TEKTURNA 183 TESTRED 287 TEKTURNA HCT 183 tetanus and diphtheria toxoids, adult 319 telmisartan 166 tetanus,diphtheria toxoid ped/pf 319 telmisartan/amlodipine besylate 183 TETCAINE 440 telmisartan/hydrochlorothiazide 183 tetrabenazine 204 temazepam 490 tetracaine 422 tetracaine hcl 422,440 THEREMS-H 537 tetracaine hcl/pf 37,440 THEREMS-M 537 tetracycline hcl 57,422 thermometer for the ear, electronic 423 tetrahydrocurcumin 587 thermometer, electronic,oral 423 tetrahydrozoline hcl 422 thermometer, temple electronic 423 TETRAVISC 440 THEROMEGA SPORT 537 TETRAVISC FORTE 440 thiabendazole 423 TETRIX 423 thiamine hcl 423,537 TEXACORT 240 thiamine thallous chloride tl-201 423 hcl/riboflavin/niacinamide/dexpanthenol/pyridoxi THALOMID 93 ne 537 THAM 506 thiamine mononitrate (vit b1) 537 theanine 423 thioguanine 423 THEO-24 464 THIOLA 279 theobromine 423 THIOLA EC 588 theophylline anhydrous 423,464 thioridazine hcl 121,423 theophylline in dextrose 5 % in water 464 thiotepa 103,423,588 THERA 536 thiothixene 121 THERA M PLUS 536 threonine 423 THERA-D 536 THRIVITE RX 537 THERA-GEL 241 THROAT SPRAY 210 THERA-GESIC 241 THROMBATE III 157 THERA-M 536 THROMBI-GEL 423 THERA-TABS 536 THROMBI-PAD 423 THERA-TABS M 536 THROMBIN-JMI 162 THERADEX M 536 THYMOGLOBULIN 316 THERAFLU EXPRESSMAX COLD DAY 484 thymol 423 THERAFLU EXPRESSMAX COLD-COUGH 484 thymol iodide 423 THERAGRAN-M PREMIER 50 PLUS 536 THYROGEN 423 THERANATAL 536 THYROID 303 THERANATAL OVAVITE 536 thyroid,pork 303,423 THERANATAL PLUS 537 THYROLAR-1 303 THERAPEUTIC DANDRUFF SHAMPOO 241 THYROLAR-1/2 303 THERAPEUTIC M 537 THYROLAR-1/4 303 THERAPEUTIC MINERAL ICE 241 THYROLAR-2 303 THERAPEUTIC SHAMPOO 241 THYROLAR-3 303 THERAPEUTIC T+PLUS 241 TIADYLT ER 175 THERAPEUTIC-M 537 tiagabine hcl 60 THERATRUM COMPLETE 537 TIAZAC 175,176 THERATRUM COMPLETE 50 PLUS 537 TICALAST 588 THEREMS 537 TICANASE 450 ticarcillin disodium/potassium clavulanate 423 tolnaftate 84 TIGAN 74 tolonium chloride 424 tigecycline 45 TOLSURA 588 TIKOSYN 169 tolterodine tartrate 275,276 TILIA FE 298 tolvaptan 494 timolol maleate 171,424,446 TOPAMAX 62 TIMOPTIC 447 topical cream metered-dose device 424 TIMOPTIC OCUDOSE 447 TOPICORT 241 TIMOPTIC-XE 447 topiramate 62,424 TINACTIN 84 TOPOSAR 105 TINDAMAX 45 topotecan hcl 105,106 tinidazole 45,424 TOPROL XL 171 tiopronin 424 toremifene citrate 94 TIROSINT 303 TORISEL 112 TIROSINT-SOL 588 torsemide 185 TISSEEL VHSD 162 TOSYMRA 588 TISSUEBLUE 588 TOTAL ALLERGY 457 titanium dioxide 424 TOTAL B WITH C 537 TIVICAY 135 TOUJEO MAX SOLOSTAR 588 TIVICAY PD 588 TOUJEO SOLOSTAR 154 TIVORBEX 8 TOVET EMOLLIENT 241 tizanidine hcl 424,489 TOVET KIT 241 TNKASE 157 TOVIAZ 276 TOBI 463 TOXICOLOGY SALIVA COLLECTION 424 TOBI PODHALER 463 TPN ELECTROLYTES 506 TOBRADEX 440 TPN ELECTROLYTES II 506 TOBRADEX ST 440 TPOXX (NATIONAL STOCKPILE) 588 tobramycin 424,440 TRACE ELEMENTS-4 506 tobramycin in 0.225 % sodium chloride 463 TRACLEER 466,588 tobramycin sulfate 42,424 TRADJENTA 151 tobramycin sulfate/sodium chloride 42 tragacanth 424 tobramycin/dexamethasone 440 tramadol hcl 11,28,424,588 tobramycin/nebulizer 463 tramadol hcl/acetaminophen 28 TOBREX 440 trandolapril 168 TOFRANIL 72 trandolapril/verapamil hcl 183 TOLAK 241 tranexamic acid 162,163,424 tolazamide 151 tranilast 424 tolazoline hcl 424 transcutaneous electrical nerve stimulators (tens tolbutamide 151 units) 424 tolcapone 118 TRANSDERM-SCOP 74 tolmetin sodium 8 transfer device, closed system 424 TRANXENE T-TAB 145 TRI-VYLIBRA 299 tranylcypromine sulfate 67 TRI-VYLIBRA LO 299 TRAVASOL 537 triacetin 84 TRAVATAN Z 447 triamcinolone 424 TRAVEL SICKNESS 74 triamcinolone acetonide 211,241,242,282,424,450 travoprost 447 triamcinolone acetonide in 0.9 % sodium TRAZIMERA 588 chloride 589 trazodone hcl 71,424 triamcinolone diacetate 425 TREANDA 92 triamcinolone diacetate in 0.9 % sodium TRECATOR 90 chloride 589 TRELEGY ELLIPTA 589 triamcinolone diacetate in 0.9 % sodium TRELSTAR 306 chloride/pf 589 TREMFYA 589 triamcinolone diacetate, micronized 425 treprostinil sodium 466 triamcinolone hexacetonide 425 TRESIBA 589 triamterene 425 TRESIBA FLEXTOUCH U-100 154 triamterene/hydrochlorothiazide 183 TRESIBA FLEXTOUCH U-200 154 TRIANEX 242 TRETIN-X 241 triazolam 490,491 tretinoin 115,241,424 TRIBENZOR 183 tretinoin microspheres 241 TRICARE 537 TRETTEN 163 TRICARE PRENATAL DHA ONE 537 TREXALL 313 trichlormethiazide 425 TREXBROM 484 trichloroacetic acid 242,425 TREXIMET 88 TRICITRASOL 157 TREZIX 29 triclosan 425 TRI FEMYNOR 298 TRICOR 187 TRI-BUFFERED ASPIRIN 8 TRIDERM 242 TRI-CHLOR 241 TRIDESILON 242 TRI-ESTARYLLA 298 trientine hcl 494 TRI-LEGEST FE 298 TRIESENCE 445 TRI-LINYAH 298 triethanolamine 425 TRI-LO-ESTARYLLA 298 triethanolamine lauryl sulfate 425 TRI-LO-MARZIA 298 TRIFERIC 537,589 TRI-LO-MILI 298 trifluoperazine hcl 121 TRI-LO-SPRINTEC 298 trifluridine 142,425 TRI-MILI 298 TRIGLIDE 187 TRI-NORINYL 298 trihexyphenidyl hcl 117 TRI-PREVIFEM 298 TRIJARDY XR 589 TRI-SPRINTEC 299 TRIKAFTA 589 TRI-VI-FLOR 537 TRIKLO 538 TRI-VI-SOL 537 TRILEPTAL 63 TRILIPIX 187,188 tropical punch flavor 426 trilostane 425 tropicamide 426,440 TRILURON 425 trospium chloride 276 TRILYTE WITH FLAVOR PACKETS 272 TRUEPLUS MULTIVITAMIN 538 trimeprazine tartrate 425 TRULANCE 589 trimethobenzamide hcl 74,425 TRULICITY 151 trimethoprim 45,425 TRUMENBA 319 trimethoprim, micronized 425 TRUSOPT 447 trimipramine maleate 72 TRUST NATAL DHA 538 TRIMPEX 45 TRUVADA 138 TRINATAL RX 1 538 TRUXIMA 589 TRINATE 538 trypan blue 426 TRINTELLIX 71 trypsin 426 TRIOSTAT 303 tryptic soy broth 426 trioxsalen 425 tryptophan 426,538 tripelennamine hcl 425 TUBERSOL 426 TRIPHROCAPS 538 TUDORZA PRESSAIR 459 TRIPLE ANTIBIOTIC 242 TUKYSA 590 TRIPLE ANTIBIOTIC EXTRA 242 TULANA 302 TRIPLE ANTIBIOTIC PLUS 242 TUMS 261 TRIPLE ANTIBIOTIC-PAIN RELIEF 242 TUMS DUAL ACTION 263 TRIPLE DYE 84 TUMS FRESHERS 261 triprolidine hcl 425 TUMS SMOOTHIES 261 TRISENOX 589 TUMS ULTRA 261 TRISTART DHA 538 turmeric 426 TRIUMEQ 139 turpentine 426 TRIVEEN-DUO DHA 538 TUSNEL 484 TRIVISC 425 TUSNEL DIABETIC 484 TRIVIX 242 TUSNEL DM PEDIATRIC 484 TRIVORA-28 299 TUSNEL PEDIATRIC 484 TRIZIVIR 137 TUSSI-PRES 484 troche base no.131 425 TUSSICAPS 484 troche base no.168 426 TUSSIN 272,484 troche base no.235 589 TUSSIN CF 484 troche base no.66 426 TUSSIN CF MAX 484 troche mold 426 TUSSIN CHEST CONGESTION 484 TROKENDI XR 62 TUSSIN COUGH 484 tromethamine 426 TUSSIN DM 484,485 tromethamine in sterile water for injection 589 TUSSIN DM CLEAR 485 TROPHAMINE 538 TUSSIN DM COUGH 485 TROPICAL LIQUID NUTRITION 426 TUSSIN DM COUGH-CHEST CONGEST 485 TUSSIN DM MAX 485 ULTANE 37 TUSSIN HONEY 485 ULTIMATE MEN'S COMPLETE 50+ 538 TUSSIN LONG-ACTING 485 ULTIMATE PROBIOTIC-10 590 TUSSIN MUCUS-CHEST CONGESTION 485 ULTIMATE WOMEN'S COMPLETE 50+ 538 TUSSIONEX 485 ULTIVA 29 TUSSLIN 485 ULTRA A-D 261 tutti-frutti flavor 426 ULTRA B-100 COMPLEX 538 TUXARIN ER 590 ULTRA DM FREE & CLEAR 485 TUZISTRA XR 485 ULTRA FLORA PLUS 261 TWINRIX 319 ULTRA FREEDA 538 TWIRLA 590 ULTRA FRESH 440 TWYNSTA 183 ULTRA LUBRICANT EYE 272,440,441 TYBOST 139 ULTRA STRENGTH ANTACID 261 TYDEMY 299 ULTRA TUSS 485 TYGACIL 45 ULTRACET 29 TYKERB 112 ULTRAFOAM 426 TYLENOL COLD MAX 485 ULTRAM 29 TYLENOL COLD MULTI-SYMPTOM 485 ULTRASAL-ER 242 TYLENOL PM EXTRA STRENGTH 493 ULTRATHON INSECT REPELLENT 8 426 TYLENOL-CODEINE NO.3 29 ULTRAVATE 242,283 TYLENOL-CODEINE NO.4 29 ULTRAVATE X 242 TYLOPHEN 204 ULTRAVIST 426 TYMLOS 590 UMECTA 242 TYPHIM VI 319 UNASYN 51 tyrosine 426 undecylenic acid 426 TYSABRI 208 underpads 426 TYVASO 466 UNICOMPLEX-M 538 TYVASO INSTITUTIONAL START KIT 466 unithiol 427 TYVASO REFILL KIT 466 UNITHROID 303 TYVASO STARTER KIT 466 UNITUXIN 114 UNSCENTED COLD CREAM 242 U UPLIZNA 590 ubidecarenone 426,538 UPNEEQ 590 ubidecarenone/vitamin e 538 UPTRAVI 467 ubidecarenone/vitamin e acetate 538 URAMAXIN 242 ubiquinol 426 URE-K 242 UBRELVY 590 urea 243,427 UCERIS 321 UREACIN-20 243 UDAMIN SP 538 URECHOLINE 279 ULESFIA 242 URELLE 45 ULORIC 85 URETRON D-S 45 UREVAZ 243 VALCYTE 131 URIBEL 45 valerian root 428 uridine 427 valganciclovir hcl 131 URIMAR-T 45 valine 428 URIN D.S. 45 VALIUM 145 urinary bag 427 valproic acid 61,428 urinary bag/catheter 427,590 valproic acid (as sodium salt) (valproate urinary bag/catheterization tray 427 sodium) 61,428 urine acetone test,strips 427 valrubicin 103 urine albumin test 427 valsartan 166 urine bilirubin test 427 valsartan/hydrochlorothiazide 184 urine glucose test strip 427 VALSTAR 103 urine glucose-acet test strip 427 VALTOCO 590 urine leukocyte test strips 427 VALTREX 142 urine multiple test strips 427 VALU-TAPP 485 urine phenaphthazine-ph test 427 VALU-TAPP DECONGESTANT 428 URO-458 45 vanadium 428 UROCIT-K 279 VANADOM 489 UROGESIC-BLUE 45 vanadyl sulfate 428 UROMAG 261 VANATOL LQ 204 UROQID-ACID NO.2 506 VANCOCIN HCL 45 urostomy pouch 427 vancomycin hcl 45,46,428,590 UROXATRAL 277 vancomycin hcl in water for injection (peg-400, URSO 261 nada) 46,590 URSO FORTE 261 vancomycin hcl/balanced salt solution no.2/pf 590 ursodiol 261,427 vancomycin in 0.9 % sodium chloride 46,590 URYL 45 vancomycin in 5 % dextrose in water 46,591 USTELL 45 VANDAZOLE 46 UTA 45 VANICREAM HC 243 UTIBRON NEOHALER 485 vanilla butternut flavor 428 UTIRA-C 45 vanilla extract flavor 428 UTOPIC 243 vanillin 428 UVADEX 103 VANOS 243 VANOXIDE-HC 243 V VANTAS 307 V-C FORTE 538 VAPRISOL-5% DEXTROSE 495 vacuum erection device system 427 VAQTA 319 VAGIFEM 299 VARIBAR HONEY 428 vaginal suppository applicator 427 VARIBAR NECTAR 428 valacyclovir hcl 142,427 VARIBAR PUDDING 428 VALCHLOR 92 VARIBAR THIN HONEY 428 VARIBAR THIN LIQUID 428 VELPHORO 280 VARIVAX VACCINE 319 VELTASSA 495 VARIZIG 316 VELTIN 243 VARUBI 77,591 VEMLIDY 132 VASCEPA 191 VENCLEXTA 112 VASELINE WHITE PETROLEUM 243 VENCLEXTA STARTING PACK 112 VASERETIC 184 VENELEX 243 vasopressin 284 venlafaxine hcl 71 vasopressin in 0.9 % sodium chloride 284,591 VENOFER 538 vasopressin in dextrose 5 % in water 284 VENTAVIS 467 VASOTEC 168 VENTOLIN HFA 462 VAXCHORA ACTIVE COMPONENT 319 verapamil hcl 176,429 VAXCHORA BUFFER COMPONENT 428 VERDESO 243 VAXCHORA VACCINE 319 VEREGEN 243 VAZCULEP 184 VERELAN 176 VCF 279 VERELAN PM 176 VECAMYL 184 VERIPRED 20 283 VECTIBIX 114 VERSACLOZ 130 VECTICAL 243 VERTICALM 75 vecuronium bromide 204,428 VERZENIO 591 vehicle base no.10 428 VESICARE 276 vehicle base no.11 428 VFEND 84 vehicle base no.13 428 VFEND IV 84 vehicle base no.144 428 vial,empty 429 vehicle base no.15 428 VIBATIV 46 vehicle base no.18 429 VIBERZI 264 vehicle base no.19 429 VIBRAMYCIN 57 vehicle base no.20 429 VIC-FORTE 538 vehicle base no.22 429 VICKS DAYQUIL 485 vehicle base no.24 429 VICKS DAYQUIL MUCUS CONTROL 486 vehicle base no.4 429 VICKS NYQUIL 486 vehicle base no.5 429 VICKS SINEX 429 vehicle base no.6 429 VICODIN 29 vehicle base no.60 429 VICODIN HP 30 vehicle base no.7 429 VICTOZA 2-PAK 151 vehicle gel base no.61 429 VICTOZA 3-PAK 151 vehicle gel base no.63 429 vidarabine 429 vehicle lozenge base no.14 429 vidarabine monohydrate 429 VELCADE 103 VIDAZA 104 VELETRI 467 VIDEX 138 VELIVET 299 VIDEX EC 138 VIEKIRA PAK 134 VISINE-A 441 VIENVA 299 VISION PLUS LUTEIN 539 vigabatrin 61 VISIPAQUE 430 VIGADRONE 61 VISTARIL 457 VIGAMOX 441 VISTOGARD 430 VIIBRYD 71 VISUDYNE 441 VILTEPSO 591 VIT 3 539 VIMIZIM 247 vit b complex/vit c/folic acid/ferrous fumarate/vit VIMOVO 8 e acet 539 VIMPAT 63,64 VITA-BEE WITH C 539 VINACAL B 539 VITA-RESPA 539 VINATE DHA RF 539 VITACEL 539 VINATE ONE 539 VITAFOL GUMMIES 539 VINATE-M 539 VITAFOL NANO 539 vinblastine sulfate 104 VITAFOL ULTRA 539 VINCASAR PFS 104 VITAFOL-OB 539 vincristine sulfate 104 VITAFOL-OB+DHA 539 vinorelbine tartrate 104 VITAFOL-ONE 539 vinpocetine 429 VITAL-D RX 539 VIOKACE 247 VITALEE 540 violet (food color) 429 VITALETS 540 VIORELE 299 VITAMEDMD ONE RX 540 VIRACEPT 140 VITAMEDMD REDICHEW RX 540 VIRAMUNE 136 vitamin a 540 VIRAMUNE XR 136 vitamin a acetate 430 VIRASAL 243 vitamin a and cholecalciferol (vit d3) in cod liver VIRAZOLE 486 oil 540 VIREAD 138 VITAMIN A AND D GRX 243 VIRT-C DHA 539 vitamin a palmitate 430 VIRT-CAPS 539 vitamin a palmitate/beta-carotene/vit d2/vit VIRT-NATE DHA 539 e/selenium 540 VIRT-PHOS 250 NEUTRAL 279 vitamin b complex 540 VIRT-PN 539 vitamin b complex with vitamin c combination VIRT-PN DHA 539 no.3 540 VIRT-PN PLUS 539 vitamin b complex/folic acid 540 VIRTUSSIN AC 486 VITAMIN D3 COMPLETE 493 VIRTUSSIN DAC 486 vitamin e 243,540 VISBIOME 261 vitamin e (dl-alpha tocopheryl acetate) 430,540 VISCO-3 429 vitamin e acetate 430,540 VISCOAT 441 vitamin e acid succinate 430,540 VISINE TOTALITY 441 vitamin e mixed 430,540 vitamin e(dl-alpha tocopherol) 430 VYTORIN 191 vitamin k2 430 VYVANSE 196,591 vitamins a and d 243 VYZULTA 591 vitamins a and d/white petrolatum/lanolin 243 VITAMINS FOR HAIR 540 W VITAPEARL 540 WAKIX 591 VITATRUE 506 WAL-ACT D COLD & ALLERGY 486 VITATRUM 541 WAL-DRYL 244,457 VITRAKVI 591 WAL-DRYL ALLERGY 457 VITRASE 430 WAL-FEX ALLERGY 457,458 VITRUM 50 PLUS SENIOR 541 WAL-FINATE 458 VITRUM SENIOR 541 WAL-FOUR 430 VIVELLE-DOT 299 WAL-ITIN 458 VIVITROL 38 WAL-ITIN D 486 VIVLODEX 8 WAL-ITIN D 12 HOUR 486 VIVOTIF 320 WAL-MUCIL 272 VOGELXO 287 WAL-NADOL PM 493 VOL-PLUS 541 WAL-PHED 430 VOLNEA 299 WAL-PHED 12 HOUR 430 VOLTAREN 243 WAL-PHED D ER 430 VOLTAREN-XR 9 WAL-PHED PE SINUS HEADACHE 486 VOLUMEN 430 WAL-PHED PE SINUS-ALLERGY 486 VOLUVEN 430 WAL-PHED PE TRIPLE RELIEF 486 VONVENDI 163 WAL-PROFEN 9,486 VORAXAZE 104 WAL-PROFEN D 486 voriconazole 84,430 WAL-PROXEN 9 VOSEVI 134 WAL-TAP 486 VOTRIENT 112 WAL-TAP DM 486 VP-PNV-DHA 541 WAL-TUSSIN 486 VPRIV 247 WAL-TUSSIN COUGH 486 VRAYLAR 127 WAL-TUSSIN COUGH-COLD CF 486 VSL#3 261 WAL-TUSSIN DM 486 VSL#3 DS 261 WAL-ZAN 150 263 VTOL LQ 204 WAL-ZAN 75 263 VUMERITY 591 WAL-ZYR 442,458 VUSION 84 WAL-ZYR D 486 VYEPTI 591 warfarin sodium 157,430 VYFEMLA 299 WART REMOVER 244 VYLIBRA 299 water 430 VYNDAMAX 591 water for inj.,bacteriostatic 431 VYONDYS-53 591 water for injection,sterile 431 water for irrigation,sterile 431 XELJANZ 313,592 watermelon flavor 431 XELJANZ XR 313,592 wax base no.116 431 XELODA 96 wax base no.28 431 XELPROS 592 WELCHOL 191,192 XEMBIFY 592 WELLBUTRIN SR 66 XENAZINE 205 WELLBUTRIN XL 67 xenon 133 in 592 WERA 299 XEOMIN 489 WESTHROID 303 XEPI 592 wheat germ oil 541 XERAC AC 244 whey protein isolate 431 XERESE 142 white (food color) 431 XERMELO 592 white willow bark/salicin 431 XGEVA 324 WILATE 163 XHANCE 592 wild cherry flavor 431 XIAFLEX 431 WINRHO SDF 316 XIFAXAN 46 witch hazel extract 431 XIGDUO XR 151,592 WIXELA INHUB 486,487 XIIDRA 445 WOMAN'S LAXATIVE 272 XIMINO 592 WOMEN'S COMPLEX 431 XOFIGO 104 WOMEN'S DAILY 541 XOFLUZA 592 WOMEN'S DAILY FORMULA 541 XOLAIR 487,592,593 WOMEN'S GENTLE LAXATIVE 272 XOLEGEL 84 WOMEN'S LAXATIVE 272 XOPENEX 462 WOMEN'S MULTIVITAMIN 541 XOPENEX CONCENTRATE 462 WOMEN'S ONE DAILY 541 XOPENEX HFA 462 WOMENS DAILY GUMMIES 541 XOSPATA 593 WP THYROID 303 XPOVIO 593 WYMZYA FE 299 XRYLIX 244 XTAMPZA ER 33 X XTANDI 93 XADAGO 591 XULANE 299 XALATAN 447 XULTOPHY 100-3.6 154 XALKORI 112 XURIDEN 431 XANAX 145 xylitol 431 XANAX XR 145 XYLOCAINE 37 xanthan gum 431 XYLOCAINE DENTAL-EPINEPHRINE 37 XARELTO 157,592 XYLOCAINE IV 37 XATMEP 592 XYLOCAINE WITH EPINEPHRINE 37 XCLAIR 431 XYLOCAINE-MPF 37 XCOPRI 592 XYLOCAINE-MPF WITH EPINEPHRINE 38 xylometazoline hcl 431 ZEGERID 274 XYNTHA 163 ZEJULA 593 XYNTHA SOLOFUSE 163 ZELAPAR 119 XYREM 493 ZELBORAF 112 XYZAL 458 ZEMAIRA 487 XYZMUNE 593 ZEMBRACE SYMTOUCH 88 ZEMPLAR 324 Y ZENATANE 244 y-port adapter-extension set (enteral) 431 ZENPEP 247 YASMIN 28 299 ZENZEDI 196 YAZ 299 ZEPATIER 135 yeast extract 432 ZEPHREX-D 432 YELETS 541 ZEPOSIA 593 yellow (food color) 432 ZEPZELCA 593 YERVOY 114 ZERIT 138 YF-VAX 320 ZERVIATE 593 yohimbine hcl 279,432 ZESTORETIC 184 YONSA 593 ZESTRIL 168 YOSPRALA 164 ZETIA 192 YUPELRI 593 ZETONNA 450 YUVAFEM 299 ZEVALIN 115 ZIAC 184 Z ZIAGEN 138 Z-TUSS AC 487 ZIANA 244 ZADITOR 442 zidovudine 138 zafirlukast 458 ZIEXTENZO 593 zaleplon 491 ZILACAINE PATCH 244 ZALTRAP 104 zileuton 458 ZALVIT 593 ZILXI 594 ZANAFLEX 489 zinc acetate dihydrate 432 ZANOSAR 92 zinc amino acid chelate 506 ZANTAC 263 zinc chloride 432,506 ZARAH 299 zinc citrate 432 ZARONTIN 58 zinc gluconate 432,506 ZARXIO 159 zinc methionine sulfate 432 ZAVESCA 247 zinc oxide 244,432 ZCORT 593 ZINC OXIDE DIAPER CREAM 244 ZEASORB 85 zinc picolinate 432 ZEASORB AF 85 zinc sulfate 432,506,594 zeaxanthin 432 zinc sulfate heptahydrate 432 ZEBUTAL 205 zinc undecylenate 432 ZINC-220 507 ZOMIG ZMT 88 ZINECARD 104 ZONALON 244 ZINGO 38 ZONEGRAN 58 ZIONODIL 244 zonisamide 58,432 ZIONODIL-100 244 ZONTIVITY 164 ZIOPTAN 447 ZOO FRIENDS 541 ziprasidone hcl 127 ZOO FRIENDS ORIGINAL 541 ziprasidone mesylate 127 ZORBTIVE 284 ZIPSOR 9 ZORTRESS 313,594 ZIRABEV 594 ZORVOLEX 9 ZIRGAN 131 ZOSTAVAX 320 ZITHRANOL 244 ZOSTRIX HP 244 ZITHROMAX 53 ZOSTRIX HP FOOT 244 ZITHROMAX TRI-PAK 53 ZOSYN 52 ZOCOR 189 ZOVIA 1-35E 299 ZODRYL AC 50 487 ZOVIRAX 142 ZODRYL AC 60 487 ZTLIDO 594 ZODRYL AC 80 487 ZUBSOLV 40,594 ZODRYL DAC 50 487 ZUMANDIMINE 299 ZODRYL DAC 60 487 ZUPLENZ 77 ZODRYL DAC 80 487 ZURAMPIC 85 ZODRYL DEC 50 487 ZYBAN 41 ZODRYL DEC 60 487 ZYCLARA 244 ZODRYL DEC 80 487 ZYDELIG 113 ZOFRAN 77 ZYFLO 459 ZOHYDRO ER 11 ZYFLO CR 459 ZOLADEX 307 ZYKADIA 113,594 zoledronic acid 324 ZYLET 441 zoledronic acid in mannitol and 0.9 % sodium ZYLOPRIM 86 chloride 324 ZYMAXID 441 zoledronic acid in mannitol and water for ZYNCOF 487 injection 324 ZYPITAMAG 594 ZOLINZA 105 ZYPREXA 127,128 zolmitriptan 88,432 ZYPREXA RELPREVV 128 ZOLOFT 71 ZYPREXA ZYDIS 128,129 ZOLPAK 594 ZYTIGA 93 zolpidem tartrate 491 ZYVOX 46 ZOLPIMIST 491 ZOMACTON 284 ZOMETA 324 ZOMIG 88