Centene Employee

PREFERRED DRUG LIST

The Centene Employee Formulary includes a list of drugs covered by your prescription benefit. The formulary is updated often and may change. To get the most up-to-date information, you may view the latest formulary on our website at envolverx.com or call us at 1-844-262-6337.

What is the Centene Employee Formulary? The Centene Employee Formulary is a list of covered drugs used to treat common diseases or health problems. The formulary is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on:  Safety;  Effectiveness;  Side effects; and  Value (If two drugs are equally effective, the less costly drug will be preferred)

How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not know your copayment or coinsurance for each tier, please refer to your plan documents.

Abbreviation Description 1 Value generic drugs

2 Preferred generic drugs

3 Value brand drugs 4 Preferred brand drugs 5 Non-preferred brand drugs

6 Prevention Drug $0 (ACA regulated)

ii Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the formulary:

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations.

PA Prior Authorization These drugs require prior authorization for coverage, effectiveness, or safety reasons. This means that your doctor must request approval from the plan before the drug will be covered.

PV Preventive Drugs Preventive benefit drugs covered at no cost to members under the Affordable Care Act. A deductible does not apply. To get a brand drug that has a generic available, your doctor must request prior authorization to show medical necessity. You will be responsible for the difference in cost between the brand and the generic drug.

QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug. RX/OTC Prescription & Certain drugs are available both in a prescription form and in an Over- the-Counter OTC form. Only prescription drugs are covered by your plan with (OTC) the exception of some insulins, insulin supplies and some covered preventive drugs.

ST Step Therapy You must first try and fail another specific drug(s) before these drugs will be covered.

Can I go to any pharmacy? You must use pharmacies that are in the network. These pharmacies have a contract with Envolve Pharmacy Solutions. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at https://pharmacy.envolvehealth.com or call us at the telephone number on your member ID card.

If you fill your prescription at an out-of-network pharmacy, the pharmacy will not be able to bill us online so you will have to pay the full cost of your drug.

Some injectable and high cost drugs may be considered “specialty drugs”. Specialty drugs are limited to a 30 day supply and in most cases must be must be obtained from one of the plan’s Specialty Pharmacies.

iii Can I use a mail order pharmacy? You can use the HomescriptsTM Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those that you take daily and are needed for a long term condition.

To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90- day supply of each drug. For more information about Homescripts Mail Order Pharmacy go to www.homescripts.envolvehealth.com.

How can I save money on my prescription drugs? You can save time and money with these simple steps:  Ask your doctor about generic drugs that may work for you.  Fill prescriptions at network pharmacies.  Be sure your doctor prescribes drugs on the formulary.  Fill your maintenance drugs through our mail order pharmacy.

4 Nondiscrimination Notice

Envolve Pharmacy Solutions, Inc. on behalf of itself and its affiliates does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Email: [email protected]

Mail: Civil Rights Coordinator Envolve Pharmacy Solutions 1850 W. Rio Salado Parkway, Suite 211

Tempe, AZ 85281 Phone: 800-460-8988 or (800) 413-7721 Fax: 888-246-1422 TTY: 866-492-9674

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, or TTY 711.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, (TDD 1-800-537-7697 Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

5 Language Assistance Notices

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call 1-844-262-6337, or TTY 711. We have free services to help you communicate with us. Such as, letters in other languages or large print. ENGLISH Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number on your ID card or TTY 711. Brindamos servicios gratuitos para ayudarle a comunicarse con nosotros. Ofrecemos cartas en otros SPANISH idiomas o en letra grande. Puede pedir un intérprete. Para obtener ayuda, llame al número telefónico gratuito de su tarjeta de identificación o TTY 711. Nous avons des services gratuits pour nous aider à communiquer avec vous, comme des lettres écrites FRENCH dans d’autres langues ou imprimées en gros caractères. Vous pouvez également solliciter un interprète. Pour toute demande d’assistance, veuillez appeler le numéro gratuit figurant sur votre carte d’identification ou bien TTY 711 Wir bieten kostenlose Services an, um Ihnen dabei zu helfen, mit uns Verbindung aufzunehmen, GERMAN beispielsweise durch Briefe in anderen Sprachen oder Großdruck. Sie können auch einen Dolmetscher anfordern. Wenn Sie Hilfe benötigen, rufen Sie bitte die gebührenfreie Nummer auf Ihrem Ausweis oder TTY 711 an. Offriamo servizi gratuiti per aiutarla a comunicare con noi, come lettere in altre lingue o a caratteri più ITALIAN grandi, oppure il servizio di interpretariato. Per chiedere aiuto, chiami il numero verde sulla sua tessera ID o TTY 711. Temos serviços gratuitos para ajudar a se comunicar conosco – tais como, cartas em outros idiomas ou PORTUGUESE impressão em letras grandes. Ou você pode obter a ajuda de um intérprete. Para pedir ajuda, por favor ligue para o número de telefone gratuito em seu cartão de identidade ou TTY 711. Nou gen sèvis ki gratis pou sa ede w kominike avè n. Tankou lèt nan lòt lang oubyen eki ak lèt laj. FR CREOLE Oubyen, ou kapab mande pou yon entèprèt. Pou w mande pou n sa ede w, sonnen nimewo telefòn gratis la ki sou kat idantifikasyon ou an oubyen TTY ka sonnen 711. 我们有有费有务有有帮有您与有们有有，例如提供其他语有有有有有有号有有有有有有有。或者您有有 CHINESE 有有有有有有译员。有有帮有，请有电您 ID 卡上的免费电话号码有有 TTY 711。言語サービスは無料でご提供いたします。通訳を侜頼できます。 JAPANESE また文書の代読および、ご希望の言語による文書の郵送が可能です。支援が必要な場合は、ID カードの裏側に記載されている[電話番号を記入]までお電話ください。 귀하께서 저희와 소통하시는 데 도움이 되는 무료 서비스를 제공해드립니다다. 른 언어로 또는 대형 활자본으로 서신을 KOREAN 제공하는 것이 그러한 예입니다통.역사를 요청하실 수도 있습니다도.움이 필요하시면 귀하의ID 카드에 안내된 수신자 부담 전화 번호로 또는TTY의 경우711번으로 연락해 주십시오. Oferujemy bezpłatne usługi ułatwiające komunikowanie się z nami, na przykład pisma w innym języku POLISH lub duża czcionka. Można również poprosić o pomoc tłumacza. Aby poprosić o pomoc, proszę zadzwonić pod bezpłatny numer znajdujący się na karcie identyfikacyjnej lub numer TTY 711. Мы предоставляем бесплатные услуги, которые помогут вам поддерживать с нами связь. Такие как, например, отправка писем на различных языках или писем, выполненных RUSSIAN крупным шрифтом. Вы также можете обратиться за помощью переводчика. Чтобы получить соответствующую помощь, позвоните нам, пожалуйста, по бесплатному номеру телефона, указанному в вашем членском удостоверении, или наберите номер 771 на телекоммуникационном аппарате (телетайпе) для слабослышащих. Mayroon kaming mga libreng serbisyo upang tulungan kang makipagkomunika sa amin. Halimbawa, mga TAGALOG letra sa mga ibang wika o large print. O kaya’y maaari kang humingi ng interpreter. Upang humingi ng tulong, mangyaring tawagan ang toll-free na numero na nakasulat sa iyong ID card o tawagan ang TTY 711. Chúng tôi có các dịch vụ miễn phí để giúp quý vị liên lạc với chúng tôi. Như, thư từ bằng các ngôn ngữ VIETNAMESE khác hoặc chữ in khổ lớn. Hoặc, quý vị có thể yêu cầu một thông dịch viên. Để yêu cầu giúp đỡ, xin gọi số điện thoại miễn phí có ghi trên thẻ ID của quý vị hoặc TTY 711. ﻣﺪﺧ ﺎ ﺎﻨﯾﺪﻟ ت ﻓﻲ ﺗﺪﻋﺎﺴﻤﻟ ﻚ ﯿﻧﺎﺠﻣ ﺔ ا ﻮﺘﻟ ا ﯿﺒﺳ ﻞ ﻠﻋ ﻰ .ﺎﻨﻌﻣ ﻞﺻ ا ﺎﺜﻤﻟ ل، ر ﻐﻠﺑ ﺎ ﻞﺋﺎﺳ ت أ ﺮﺧ ى أو ﺣﺄﺑ ﺮ ف ﯿﺒﻛ ﺮ ة . ،أو ﻨﻜﻤﯾ ﻚ أن ARABIC ﺟﺮﺘﻣ ﻢ ﻠﻄﺗ ﺐ ﺷﻔﻮدري ﻮﺧ ا ﮏﻤﮐﻄﻠﺐﻟ .ا ﺖﺳﺎﻋﺪﺴ ﻤﻟ،ة ، ﺎﻣﺪﺧر ﺟﺎ ﻣﺎ ًء ﺎﺑأن ﺎﻔﻄﻟ ﻗﻢﺮ ﻟﺑﺎ ت ﻞرا ﻧﺎﮕﯾﺼﺘﺗ ا ﻲ ﻧﺎرا ﺑﻤﺠﻟﺮا ای ﺮﺑﻤﻮﺟﻮﻟد ﻤﺷ ﺎﻔﻚ ﯾ ﺑﺮﮫ ﺗﻌ ﻤﮐﺔ ﻗﺎﻄﮏﺑ ﻰايﻠ ﻗﺮﺑﻋ أوﺮ ﺑﻮ ا ا ﻂري ﺧ ار ﺎﺒﺗﺳﻄﺔط ﻣﺎ ﺎﺑ ، ﺑﮫ ﻣﺎﻧ ﮫ ﻨﻧﺎﻣ ﺪ ز ﺎﺑ ن ھﺎی د ﮕﯾ ﺮ و ﺎﭼ ﺑﺎ ﻣﺎﻧ ﮫ ﺎﯾ پ ﺰﺑ رگ ا ﺖﺳ در د ﺮﺘﺳ س راد ﯾﻢ و ﯾﺎ ا ﺗﻮ ﯽﻣ ﮑﻨﯾ ﻤﺷﮫTT Yﺎ. ا ﺎﺿﺎﻘﺗ711 ﯿﻧ ﺪ ی ﺟﺮﺘﻣ .ﺪﯿﻨﮐﻢ PERSIAN ﺮﺑ ای ﺷﻤﺎره ﺗﻠﻔﻦراﯾﮕﺎن ﺑﺮ روي ﮐﺎرتﺧﻮ ﺷﻨﺎﺳﺎﯾﯽ د وﺎﻤﺗ TTY 711 ﯾﺎ سﺑﮕﯿﺮﯾﺪ. 6 Disclaimer:

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New- to-market products and new variations of products already in the marketplace may not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by an independent Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Please contact Envolve Pharmacy Solutions Customer Service at 1-844- 262-6337 to check coverage and copay information for a specific medicine.

The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.

Member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, please contact an Envolve Pharmacy Solutions Customer Service representative at 1-844-262-6337.

vii Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- CAFCIT SOLN (Use 5 OBESITY/ANOREXIANTS - Drugs to Treat Caffeine Citrate) ADHD, Sleep and Eating Disorders caffeine citrate soln 2 Amphetamines CAFFEINE/SODIUM 4 ADDERALL TABS (Use BENZOATE SOLN Amphetamine- 5 Dextroamphetamine) DOPRAM SOLN 4 ADDERALL XR CP24 (Use Amphetamine- 5 Attention-Deficit/Hyperactivity Disorder (ADHD) Dextroamphetamine) atomoxetine hcl caps 2 PA ADZENYS ER SUER 5 clonidine hcl (adhd) tb12 2 PA ADZENYS XR-ODT TBED 5 guanfacine hcl (adhd) tb24 2 PA amphetamine- 2 dextroamphetamine cp24 INTUNIV TB24 (Use 5 PA Guanfacine HCl (ADHD)) amphetamine- 2 dextroamphetamine tabs KAPVAY TB12 (Use 5 PA Clonidine HCl (ADHD)) DESOXYN TABS (Use 5 Methamphetamine HCl) STRATTERA CAPS (Use 5 PA Atomoxetine HCl) DEXEDRINE CP24 (Use Dextroamphetamine 5 Stimulants - Misc. Sulfate) APTENSIO XR CP24 5 dextroamphetamine sulfate 2 cp24 armodafinil tabs 200 mg 2 dextroamphetamine sulfate 2 soln armodafinil tabs 50 mg, 2 QL(1 ea daily) 150 mg, 250 mg dextroamphetamine sulfate 2 tabs CONCERTA TBCR (Use 5 Methylphenidate HCl) DYANAVEL XR SUER 5 COTEMPLA XR-ODT 5 TBED EVEKEO TABS 5 DAYTRANA PTCH 5 methamphetamine hcl tabs 2 dexmethylphenidate hcl 2 MYDAYIS CP24 5 cp24 dexmethylphenidate hcl 2 PROCENTRA SOLN (Use tabs Dextroamphetamine 5 FOCALIN TABS (Use 5 Sulfate) Dexmethylphenidate HCl) VYVANSE CAPS 4 FOCALIN XR CP24 (Use 5 Dexmethylphenidate HCl) VYVANSE CHEW 4 METADATE CD CPCR 5 (Use Methylphenidate HCl) ZENZEDI TABS 4 METHYLIN CHEW (Use 5 Methylphenidate HCl) Analeptics

Updated August 1, 2018

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYLIN SOLN (Use 5 Alternative Medicine - A's Methylphenidate HCl) CYTO RALA POWD 5 RX/OTC methylphenidate hcl chew 2 NEOKE RA LIPOIC POWD 5 RX/OTC methylphenidate hcl cp24 2 Alternative Medicine - C's methylphenidate hcl cpcr 2 CITRUS BERGAMOT 5 POWD METHYLPHENIDATE HCL 4 ER TBCR Alternative Medicine - E's methylphenidate hcl soln 2 ISCAR MALI INJ 5 methylphenidate hcl tabs 2 Alternative Medicine - R's RED YEAST RICE POWD 5 methylphenidate hcl tbcr 2 500 MG/0.5GM METHYLPHENIDATE RESERVAPAK KIT SYRP 5 HYDROCHLORIDE ER 5 (LA) CP24 RESERVAPAK PLUS KIT 5 METHYLPHENIDATE SYRP HYDROCHLORIDE ER 4 Alternative Medicine Combinations TB24 CO-BALAMIN CAPS 5 modafinil tabs 100 mg 2 QL(1 ea daily) CO-VERATROL CAPS 5 modafinil tabs 200 mg 2 QL(2 ea daily) AMEBICIDES NUVIGIL TABS 200 MG 5 (Use Armodafinil) Amebicides NUVIGIL TABS 50 MG, QL(1 ea daily) 150 MG, 250 MG (Use 5 SOLOSEC PACK 5 Armodafinil) AMINOGLYCOSIDES - Drugs to Treat Bacterial PROVIGIL TABS 100 MG 5 QL(1 ea daily) Infections (Use Modafinil) Aminoglycosides PROVIGIL TABS 200 MG 5 QL(2 ea daily) (Use Modafinil) amikacin sulfate soln 2 QUILLICHEW ER CHER 5 BETHKIS NEBU 4 PA; SP QUILLIVANT XR SUSR 4 gentamicin in saline soln 2 RITALIN LA CP24 10 MG, 20 MG, 30 MG, 40 MG 5 gentamicin sulfate soln 2 (Use Methylphenidate HCl) GENTAMICIN RITALIN LA CP24 60 MG 5 SULFATE/0.9% SODIUM CHLORIDE SOLN 0.9%- 5 RITALIN TABS (Use 5 0.9MG/ML, 0.9%- Methylphenidate HCl) 1.4MG/ML ALTERNATIVE MEDICINES

Updated August 1, 2018

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTAMICIN HUMIRA PEN-CD/UC/HS 4 PA; SP SULFATE/0.9% SODIUM STARTER PNKT CHLORIDE SOLN 0.9%- 4 HUMIRA PEN-PS/UV 4 PA; SP 1.6MG/ML, 0.9%-1MG/ML, STARTER PNKT 0.9%-2MG/ML HUMIRA PSKT 4 PA; SP ISOTONIC GENTAMICIN 4 SOLN SIMPONI ARIA SOLN 4 PA; SP KITABIS PAK NEBU 5 PA; SP SIMPONI SOAJ 4 PA; SP neomycin sulfate tabs 2 SIMPONI SOSY 4 PA; SP paromomycin sulfate caps 2 Antirheumatic - Enzyme Inhibitors STREPTOMYCIN 4 SULFATE SOLR XELJANZ TABS 4 PA; SP TOBI NEBU (Use 5 PA; SP PA; SP Tobramycin) XELJANZ XR TB24 4 TOBI PODHALER CAPS 5 PA; SP Antirheumatic Antimetabolites PA; SP tobramycin nebu 2 PA; SP OTREXUP SOAJ 5 PA; SP RASUVO SOAJ 10 PA; SP TOBRAMYCIN NEBU 5 MG/0.2ML, 15 MG/0.3ML, TOBRAMYCIN SULFATE 25 MG/0.5ML, 30 SOLN 10 MG/ML, 40 4 MG/0.6ML, 7.5 MG/ML MG/0.15ML, 12.5 4 MG/0.25ML, 17.5 tobramycin sulfate soln 40 MG/0.35ML, 22.5 mg/ml, 80 mg/2ml, 1.2 2 MG/0.45ML, 27.5 gm/30ml MG/0.55ML tobramycin sulfate solr 1.2 2 RASUVO SOAJ 20 5 PA; SP gm MG/0.4ML ZEMDRI SOLN 5 RHEUMATREX TABS 5 ANALGESICS - ANTI-INFLAMMATORY - Drugs Gold Compounds to Treat Pain, Swelling, Muscle and Joint Conditions RIDAURA CAPS 5 Analgesics - Anti-inflammatory Combinations Interleukin-1 Blockers EQUAPAX/IBUPROFEN/M 5 PA; SP INREX THPK ARCALYST SOLR 5 PRASTERA KIT 5 Interleukin-1 Receptor Antagonist (IL-1Ra) PA; SP Anti-TNF-alpha - Monoclonal Antibodies KINERET SOSY 5 HUMIRA PEDIATRIC PA; SP Interleukin-1beta Blockers CROHNS DISEASE 4 STARTER PACK PSKT 5 PA; QL(30 ILARIS SOLN day(s) limit) PA; SP HUMIRA PEN PNKT 4 Interleukin-6 Receptor Inhibitors

Updated August 1, 2018

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTEMRA SOLN 5 PA; SP diclofenac sodium tb24 or 2 100 mg PA; SP ACTEMRA SOSY 5 diclofenac sodium tbec or 2 25 mg, 50 mg, 75 mg KEVZARA SOSY 4 diclofenac sodium- 2 capsaicin thpk Nonsteroidal Anti-inflammatory Agents (NSAIDs) diclofenac w/ misoprostol 2 ACTIVE INJECTION KIT 5 tbec KET-L KIT DUEXIS TABS 5 ACTIVE INJECTION KIT 5 KETMARC-L KIT DYLOJECT SOLN 5 ANAPROX DS TABS (Use 5 Naproxen Sodium) EC-NAPROSYN TBEC 5 QL(2 ea daily) ARTHROTEC 50 TBEC (Use Naproxen) (Use Diclofenac w/ 5 etodolac caps 2 Misoprostol) ARTHROTEC 75 TBEC etodolac tabs 2 (Use Diclofenac w/ 5 Misoprostol) etodolac tb24 2 CALDOLOR SOLN 5 FELDENE CAPS (Use 5 Piroxicam) CAPXIB KIT KIT 5 FENOPROFEN CALCIUM 5 CAPS 200 MG CELEBREX CAPS (Use 5 QL(2 ea daily) Celecoxib) FENOPROFEN CALCIUM 4 CAPS 400 MG celecoxib caps 2 QL(2 ea daily) fenoprofen calcium tabs 2 600 mg CHILDRENS ADVIL SUSP 5 RX/OTC (Use Ibuprofen) FENORTHO CAPS 200 5 MG CHILDRENS MOTRIN 5 RX/OTC SUSP (Use Ibuprofen) FENORTHO CAPS 400 4 MG DAYPRO TABS (Use 5 Oxaprozin) FLANAX PAIN RELIEF KIT 5 KIT DERMA SILKRX 5 ANODYNEXA PAK THPK FLEXIZOL COMBIPAK 5 DERMA SILKRX THPK DICLOPAK THPK (Use 5 Diclofenac Sodium- flurbiprofen tabs 2 Capsaicin) IBUPROFEN COMFORT 5 DERMACINRX PAC KIT ANALGESIC COMBOPAK 5 KIT ibuprofen lysine soln 2 DERMACINRX RX/OTC INFLAMMATRAL PAK 5 ibuprofen susp 100 mg/5ml 2 THPK ibuprofen tabs 400 mg, 600 2 diclofenac potassium tabs 2 mg, 800 mg

Updated August 1, 2018

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IC 400 KIT 5 meloxicam tabs 2 QL(1 ea daily)

IC 800 KIT 5 MOBIC TABS (Use 5 QL(1 ea daily) Meloxicam) INDOCIN SUPP 5 nabumetone tabs 2

INDOCIN SUSP 5 NALFON CAPS 4 indomethacin caps 2 NAPRELAN TB24 375 MG, 500 MG (Use Naproxen 5 indomethacin cpcr 2 Sodium) NAPRELAN TB24 750 MG 5 indomethacin sodium solr 2 NAPROSYN SUSP (Use 5 INFLAMMATION 5 Naproxen) REDUCTION PACK THPK NAPROSYN TABS (Use 5 KETOPROFEN CAPS 25 5 Naproxen) MG NAPROXEN COMFORT 5 KETOPROFEN CAPS 50 4 PAC KIT MG, 75 MG naproxen sodium tabs 275 2 ketoprofen caps 50 mg, 75 2 mg, 550 mg mg naproxen sodium tb24 375 2 KETOPROFEN ER CP24 4 mg, 500 mg naproxen susp 125 mg/5ml 2 KETOROCAINE-L KIT 5 naproxen tabs 250 mg, 375 2 KETOROCAINE-LM KIT 5 mg, 500 mg naproxen tbec 375 mg, 500 QL(2 ea daily) ketorolac tromethamine 2 2 soln ij 15 mg/ml, 30 mg/ml mg ketorolac tromethamine NEOPROFEN SOLN (Use 5 soln im 30 mg/ml, 60 2 Ibuprofen Lysine) mg/2ml oxaprozin tabs 2 ketorolac tromethamine 2 QL(20 ea per tabs or 10 mg 30 days retail) piroxicam caps 2 LIDOXIB KIT KIT 5 PONSTEL CAPS (Use 5 Mefenamic Acid) LODINE TABS (Use 5 Etodolac) PREVIDOLRX 5 ANALGESIC PAK THPK MECLOFENAMATE 5 SODIUM CAPS 100 MG READYSHARP ANESTHETICS 5 MECLOFENAMATE 4 +KETOROLAC KIT SODIUM CAPS 50 MG READYSHARP 5 mefenamic acid caps 2 KETOROLAC KIT

MELOXICAM COMFORT 5 SPRIX SOLN 5 PAC KIT

Updated August 1, 2018

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulindac tabs 2 ENBREL SOSY 4 PA; SP

TIVORBEX CAPS 5 ENBREL SURECLICK 4 PA; SP SOAJ TOLMETIN SODIUM 4 ANALGESICS - NonNarcotic - Drugs to Treat CAPS 400 MG Pain, Muscle and Joint Conditions tolmetin sodium caps 400 2 mg Analgesic Combinations TOLMETIN SODIUM TABS 4 ALLZITAL TABS 5 200 MG, 600 MG butalbital-acetaminophen 2 TORONOVA II SUIK KIT 5 tabs butalbital-acetaminophen- TORONOVA SUIK KIT 5 caffeine caps 300mg- 2 50mg-40mg VIMOVO TBEC 5 butalbital-acetaminophen- QL(6 ea daily) caffeine caps 325mg- 2 VIVLODEX CAPS 5 50mg-40mg ZIPSOR CAPS 5 butalbital-acetaminophen- QL(6 ea daily) caffeine tabs 325mg-50mg- 2 40mg ZORVOLEX CAPS 5 butalbital-aspirin-caffeine 2 QL(6 ea daily) Phosphodiesterase 4 (PDE4) Inhibitors caps PA; SP BUTALBITAL/ACETAMINO 5 OTEZLA TABS 4 PHEN CAPS PA; SP OTEZLA TBPK 4 BUTALBITAL/ASPIRIN/CA 5 FFEINE TABS Pyrimidine Synthesis Inhibitors DURAXIN CAPS 4 ARAVA TABS (Use 5 QL(1 ea daily) Leflunomide) ESGIC TABS (Use QL(6 ea daily) QL(1 ea daily) Butalbital-Acetaminophen- 5 leflunomide tabs 2 Caffeine) FIORICET CAPS (Use Selective Costimulation Modulators Butalbital-Acetaminophen- 5 ORENCIA CLICKJECT 5 PA; SP Caffeine) SOAJ FIORINAL CAPS (Use 5 QL(6 ea daily) ORENCIA SOLR IV 250 5 PA; SP Butalbital-Aspirin-Caffeine) MG LEVACET TABS 5 ORENCIA SOSY SC 125 5 PA; SP MG/ML TENCON TABS 4 ORENCIA SOSY SC 50 5 PA MG/0.4ML, 87.5 MG/0.7ML VANATOL LQ SOLN 4 Soluble Tumor Necrosis Factor Receptor Agents VANATOL S SOLN 4 ENBREL MINI SOCT 4 PA; SP Analgesics Other ENBREL SOLR 4 PA; SP clonidine hcl (analgesia) 2 soln Updated August 1, 2018

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DURACLON SOLN (Use 5 CODEINE SULFATE TABS QL(6 ea daily) Clonidine HCl (Analgesia)) 30 MG, 60 MG (Use 5 Codeine Sulfate) OFIRMEV SOLN 5 CONZIP CP24 4 QL(1 ea daily) Analgesics-Peptide Channel Blockers DEMEROL SOLN IJ 25 PRIALT SOLN 5 PA; SP MG/ML, 50 MG/ML, 100 5 MG/ML (Use Meperidine Salicylates HCl) AL; At least 45 DEMEROL SOLN IJ 75 ASCRIPTIN TABS 6 yrs old - Up to MG/ML, 100 MG/2ML, 25 5 79 yrs old MG/0.5ML, 75 MG/1.5ML AL; Up to 79 aspirin chew or 81 mg 6 DEMEROL TABS OR 100 5 QL(6 ea daily) yrs old MG (Use Meperidine HCl) AL; At least 45 DILAUDID LIQD OR 1 QL(15.767 ml aspirin tabs or 325 mg 6 yrs old - Up to MG/ML (Use 5 daily) 79 yrs old Hydromorphone HCl) AL; At least 45 DILAUDID SOLN IJ 1 aspirin tbec or 324 mg, 325 6 yrs old - Up to mg MG/ML, 2 MG/ML, 4 5 79 yrs old MG/ML (Use AL; Up to 79 Hydromorphone HCl) aspirin tbec or 81 mg 6 yrs old DILAUDID TABS OR 2 QL(8 ea daily) MG, 4 MG, 8 MG (Use 5 choline & mag salicylate 2 liqd Hydromorphone HCl) diflunisal tabs 2 DILAUDID-HP SOLN (Use 5 Hydromorphone HCl) DISALCID TABS (Use 5 DOLOPHINE TABS 10 MG 5 QL(10 ea daily) Salsalate) (Use Methadone HCl) ECOTRIN REGULAR AL; At least 45 DOLOPHINE TABS 5 MG 5 QL(4 ea daily) STRENGTH TBEC (Use 5 yrs old - Up to (Use Methadone HCl) Aspirin) 79 yrs old DURAGESIC PT72 (Use 5 QL(0.334 ea salsalate tabs 2 Fentanyl) daily) EMBEDA CPCR 5 ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions EXALGO T24A 12 MG, 32 QL(2 ea daily) Opioid Agonists MG (Use Hydromorphone 5 HCl) QL(4 ea daily) ABSTRAL SUBL 5 EXALGO T24A 8 MG, 16 QL(1 ea daily) MG (Use Hydromorphone 5 ACTIQ LPOP (Use 5 PA; QL(4 ea Fentanyl Citrate) daily) HCl) fentanyl citrate lpop bu 200 PA; QL(4 ea codeine sulfate tabs 15 mg 2 QL(2 ea daily) mcg, 400 mcg, 600 mcg, 2 daily) 800 mcg, 1200 mcg, 1600 CODEINE SULFATE TABS QL(2 ea daily) mcg 15 MG (Use Codeine 5 Sulfate) FENTANYL CITRATE 4 SOCT IJ 100 MCG/2ML codeine sulfate tabs 30 mg, 2 QL(6 ea daily) 60 mg

Updated August 1, 2018

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FENTANYL CITRATE HYDROMORPHONE HCL 5 SOLN IJ 100 MCG/2ML, 5 SUPP RE 3 MG 250 MCG/5ML (Use hydromorphone hcl t24a or 2 QL(2 ea daily) Fentanyl Citrate) 12 mg, 32 mg fentanyl citrate soln ij 100 hydromorphone hcl t24a or 2 QL(1 ea daily) mcg/2ml, 250 mcg/5ml, 2 8mg, 8 mg, 16 mg 1000 mcg/20ml, 2500 mcg/50ml hydromorphone hcl tabs or 2 QL(8 ea daily) 2 mg, 4 mg, 8 mg FENTANYL CITRATE 4 SOLN IJ 500 MCG/10ML HYDROMORPHONE HCL/SODIUMCHLORIDE 5 FENTANYL CITRATE SOSY SOLN IV 5000 5 MCG/100ML HYDROMORPHONE HYDROCHLORIDE SOLN 4 FENTANYL CITRATE 5 1 MG/ML, 110 MG/55ML SOSY IJ 100 MCG/2ML HYDROMORPHONE FENTANYL 5 HYDROCHLORIDE SOLN 5 CITRATE/NACL SOSY 2 MG/ML, 10 MG/ML (Use FENTANYL Hydromorphone HCl) CITRATE/SODIUM 5 HYDROMORPHONE CHLORIDE SOLN EP HYDROCHLORIDE SOLN 5 0.9%-1MG/250ML 4 MG/ML FENTANYL HYDROMORPHONE CITRATE/SODIUM HYDROCHLORIDE/ 5 CHLORIDE SOLN IV 0.9%- SODIUM CHLORIDE 2.5MG/250ML, 0.9%- 5 SOLN 250MCG/50ML, 0.9%- 1MG/100ML, 0.9%- HYDROMORPHONE 2MG/100ML, 0.9%- HYDROCHLORIDE/SODIU 5 5MG/250ML M CHLORIDE SOLN FENTANYL HYDROMORPHONE CITRATE/SODIUM HYDROCHLORIDE/SODIU 5 M CHLORIDE SOSY CHLORIDE SOSY IV 5 0.9%-500MCG/50ML, HYDROMORPHONE/SODI 5 0.9%-15MCG/3ML, 0.9%- UM CHLORIDE SOLN 10MCG/ML HYSINGLA ER T24A 4 fentanyl pt72 12 mcg/hr, 25 QL(0.334 ea mcg/hr, 50 mcg/hr, 75 2 daily) INFUMORPH 200 SOLN 5 mcg/hr, 100 mcg/hr fentanyl pt72 37.5 mcg/hr, 2 INFUMORPH 500 SOLN 5 62.5 mcg/hr, 87.5 mcg/hr FENTORA TABS 4 QL(4 ea daily) IONSYS PTCH 5 KADIAN CP24 10 MG, 20 QL(2 ea daily) hydromorphone hcl liqd or 2 QL(15.767 ml 1 mg/ml daily) MG, 30 MG, 50 MG, 60 5 MG, 80 MG, 100 MG (Use hydromorphone hcl soln ij 1 Morphine Sulfate) mg/ml, 2 mg/ml, 4 mg/ml, 2 10 mg/ml, 50 mg/5ml, 500 KADIAN CP24 40 MG, 200 5 mg/50ml MG

Updated August 1, 2018

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAZANDA SOLN 100 5 MORPHABOND ER T12A 5 QL(2 ea daily) MCG/ACT, 400 MCG/ACT morphine sulfate cp24 or QL(2 ea daily) LAZANDA SOLN 300 5 PA MCG/ACT 10 mg, 20 mg, 30 mg, 50 2 mg, 60 mg, 80 mg, 100 mg LEVORPHANOL 4 TARTRATE TABS MORPHINE SULFATE 5 DEVI IM 10 MG/0.7ML MEPERIDINE HCL SOLN 4 IJ 10 MG/ML MORPHINE SULFATE ER 4 QL(1 ea daily) meperidine hcl soln ij 25 CP24 mg/ml, 50 mg/ml, 100 2 MORPHINE SULFATE mg/ml SOLN IJ 2 MG/ML, 4 5 MG/ML, 5 MG/ML MEPERIDINE HCL SOLN 4 QL(500 ml per OR 50 MG/5ML fill retail) MORPHINE SULFATE SOLN IV 2 MG/ML, 150 5 meperidine hcl tabs or 50 2 QL(6 ea daily) mg, 100 mg MG/30ML MEPERIDINE morphine sulfate soln or 10 2 QL(100 ml HYDROCHLORIDE/SODIU 5 mg/5ml daily) M CHLORIDE SOLN morphine sulfate soln or 20 2 QL(50 ml daily) mg/5ml methadone hcl conc or 10 2 QL(10 ml daily) mg/ml morphine sulfate soln or 20 2 QL(10 ml daily) mg/ml, 100 mg/5ml methadone hcl soln ij 10 2 mg/ml MORPHINE SULFATE 5 METHADONE HCL SOLN SUPP RE 30 MG IJ 10 MG/ML (Use 5 MORPHINE SULFATE QL(24 ea per Methadone HCl) SUPP RE 5 MG, 10 MG, 4 fill retail) 20 MG methadone hcl soln or 10 2 QL(50 ml daily) mg/5ml MORPHINE SULFATE 4 QL(6 ea daily) METHADONE HCL SOLN QL(50 ml daily) TABS OR 15 MG, 30 MG OR 10 MG/5ML (Use 5 morphine sulfate tbcr or 15 Methadone HCl) mg, 30 mg, 60 mg, 100 mg, 2 200 mg methadone hcl soln or 5 2 QL(100 ml mg/5ml daily) MORPHINE METHADONE HCL SOLN QL(100 ml SULFATE/SODIUM 4 OR 5 MG/5ML (Use 5 daily) CHLORIDE SOLN 0.9%- Methadone HCl) 1000MG/100ML MORPHINE methadone hcl tabs or 10 2 QL(10 ea daily) mg SULFATE/SODIUM 5 CHLORIDE SOLN 0.9%- methadone hcl tabs or 5 2 QL(4 ea daily) 50MG/50ML mg MORPHINE methadone hcl tbso or 40 2 QL(2 ea daily) SULFATE/SODIUM mg CHLORIDE SOSY 0.9%- 5 METHADOSE CONC (Use 5 QL(10 ml daily) 50MG/50ML, 0.9%- Methadone HCl) 0.5MG/ML, 0.9%-2MG/ML, METHADOSE SUGAR- QL(10 ml daily) 0.9%-4MG/ML FREE CONC (Use 5 MS CONTIN TBCR (Use 5 Methadone HCl) Morphine Sulfate)

Updated August 1, 2018

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUCYNTA ER TB12 4 QL(2 ea daily) OXYMORPHONE QL(2 ea daily) HYDROCHLORIDE ER NUCYNTA TABS 4 QL(6 ea daily) TB12 5 MG, 10 MG, 15 4 MG, 20 MG, 30 MG, 7.5 OPANA ER (CRUSH QL(2 ea daily) MG RESISTANT) T12A 10 MG, 4 20 MG, 30 MG remifentanil hcl solr 2 REMIFENTANIL OPANA ER (CRUSH 4 QL(4 ea daily) RESISTANT) T12A 40 MG HYDROCHLORIDE/SODIU 5 OPANA ER (CRUSH QL(2 ea daily) M CHLORIDE SOSY RESISTANT) T12A 5 MG, 5 ROXICODONE TABS (Use 5 QL(6 ea daily) 15 MG, 7.5 MG Oxycodone HCl) OPANA SOLN IJ 1 MG/ML 5 ROXYBOND TABA 5 SUBLIMAZE SOLN (Use OPANA TABS OR 10 MG 5 QL(12 ea daily) 5 (Use Oxymorphone HCl) Fentanyl Citrate) QL(4 ea daily) OPANA TABS OR 5 MG 5 QL(6 ea daily) SUBSYS LIQD 100 MCG 4 (Use Oxymorphone HCl) SUBSYS LIQD 200 MCG, QL(8 ea daily) OXAYDO TABA 5 400 MCG, 600 MCG, 800 4 QL(6 ea daily) MCG, 1200 MCG, 1600 oxycodone hcl caps 5 mg 2 MCG SUFENTANIL CITRATE oxycodone hcl conc 100 2 QL(6 ml daily) mg/5ml SOLN 50 MCG/ML (Use 5 Sufentanil Citrate) OXYCODONE HCL ER 4 QL(2 ea daily) T12A sufentanil citrate soln 50 mcg/ml, 100 mcg/2ml, 250 2 oxycodone hcl soln 5 2 QL(30 ml daily) mg/5ml mcg/5ml oxycodone hcl tabs 5 mg, QL(6 ea daily) SYNAPRYN FUSEPAQ 5 10 mg, 15 mg, 20 mg, 30 2 SUSR mg TRAMADOL HCL ER CP24 4 QL(1 ea daily) 100 MG, 200 MG, 300 MG OXYCONTIN T12A 4 QL(2 ea daily) TRAMADOL HCL ER CP24 5 150 MG oxymorphone hcl tabs 10 2 QL(12 ea daily) mg tramadol hcl tabs 50 mg 2 QL(8 ea daily) oxymorphone hcl tabs 5 2 QL(6 ea daily) mg tramadol hcl tb24 100 mg, 2 QL(1 ea daily) 200 mg, 300 mg oxymorphone hcl tb12 40 2 QL(4 ea daily) mg ULTIVA SOLR (Use 5 oxymorphone hcl tb12 5 QL(2 ea daily) Remifentanil HCl) mg, 10 mg, 15 mg, 20 mg, 2 ULTRAM ER TB24 (Use 5 QL(1 ea daily) 30 mg, 7.5 mg Tramadol HCl) OXYMORPHONE QL(4 ea daily) ULTRAM TABS (Use 5 QL(8 ea daily) HYDROCHLORIDE ER 4 Tramadol HCl) TB12 40 MG XTAMPZA ER C12A 5

ZOHYDRO ER C12A 5

Updated August 1, 2018

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Opioid Combinations FENTANYL CITRATE/ROPIVACAINE 5 acetaminophen w/ codeine 2 QL(75 ml daily) soln 120mg/5ml-12mg/5ml HYDROCHLORIDE SOLN FENTANYL acetaminophen w/ codeine 2 QL(13 ea daily) CITRATE/ROPIVACAINE 5 tabs 300mg-15mg HYDROCHLORIDE/SODIU acetaminophen w/ codeine 2 QL(12 ea daily) M CHLORIDE SOLN tabs 300mg-30mg FENTANYL acetaminophen w/ codeine QL(6 ea daily) 2 CITRATE/ROPIVACAINE 5 tabs 300mg-60mg HYDROCHLORIDE/SODIU M CHLORIDE SOSY acetaminophen-caff- 2 dihydrocod tabs FIORICET/CODEINE ACETAMINOPHEN/CAFFE CAPS (Use Butalbital- 5 INE/DIHYDROCODEINE 4 Acetaminophen-Caffeine w/ CAPS Codeine) FIORINAL/CODEINE #3 QL(6 ea daily) ASPIRIN-CAFFEINE- 4 DIHYDROCODEINE CAPS CAPS (Use Butalbital- 5 butalbital-acetaminophen- Aspirin-Caffeine w/Cod) caffeine w/ codeine caps 2 hydrocodone- QL(180 ml 300mg-50mg-40mg-30mg acetaminophen soln daily) butalbital-acetaminophen- QL(6 ea daily) 2.5mg/5ml-108mg/5ml, 2 caffeine w/ codeine caps 2 5mg/10ml-217mg/10ml, 325mg-50mg-40mg-30mg 10mg/15ml-325mg/15ml, 7.5mg/15ml-325mg/15ml butalbital-aspirin-caffeine 2 QL(6 ea daily) w/cod caps hydrocodone- acetaminophen tabs 2 CAPITAL/CODEINE SUSP 5 2.5mg-325mg FENTANYL hydrocodone- QL(13 ea daily) acetaminophen tabs 5mg- CITRATE/BUPIVACAINE 5 2 HCL/SODIUM CHLORIDE 300mg, 10mg-300mg, SOLN 7.5mg-300mg FENTANYL hydrocodone- QL(12 ea daily) CITRATE/BUPIVACAINE 5 acetaminophen tabs 5mg- 2 HYDROCHLORIDE SOLN 325mg, 10mg-325mg, 7.5mg-325mg FENTANYL hydrocodone-ibuprofen QL(5 ea daily) CITRATE/BUPIVACAINE 5 2 HYDROCHLORIDE/SODIU tabs M CHLORIDE SOLN HYDROMORPHONE FENTANYL HYDROCHLORIDE/BUPIV CITRATE/BUPIVICAINE ACAINE 5 HYDROCHLORIDE/SODIU HYDROCHLORIDE/SODIU M CHLORIDE SOLN M SOLN HYDROMORPHONE 0.063%-0.9%- 5 1.25MG/250ML, 0.125%- HYDROCHLORIDE/ROPIV 5 0.9%-750MCG/250ML, ACAINE 0.063%-0.9%- HYDROCHLORIDE SOLN 0.5MG/100ML, 0.063%- IBUDONE TABS (Use 5 QL(5 ea daily) 0.9%-0.5MG/250ML Hydrocodone-Ibuprofen)

Updated August 1, 2018

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LORTAB ELIX 5 BUNAVAIL FILM 4 PA

MEPERIDINE BUPRENEX SOLN (Use 5 HCL/PROMETHAZINE 5 Buprenorphine HCl) HCL CAPS buprenorphine hcl soln ij 2 NORCO TABS (Use QL(12 ea daily) 0.3 mg/ml Hydrocodone- 5 buprenorphine hcl subl sl 2 2 PA; QL(3 ea Acetaminophen) mg, 8 mg daily) oxycodone w/ QL(12 ea daily) 2 buprenorphine hcl- 2 PA; QL(3 ea acetaminophen tabs naloxone hcl dihydrate film daily) QL(12 ea daily) oxycodone-aspirin tabs 2 buprenorphine hcl- 2 PA; QL(3 ea naloxone hcl dihydrate subl daily) OXYCODONE/ACETAMIN QL(60 ml daily) 4 BUPRENORPHINE PTWK 4 PA OPHEN SOLN 15 MCG/HR, 7.5 MCG/HR OXYCODONE/IBUPROFE 4 QL(4 ea daily) BUPRENORPHINE PTWK PA; QL(0.143 N TABS 5 MCG/HR, 10 MCG/HR, 4 ea daily) PERCOCET TABS (Use QL(12 ea daily) 20 MCG/HR Oxycodone w/ 5 BUTORPHANOL Acetaminophen) TARTRATE SOLN IJ 1 4 PRIMLEV TABS 5 MG/ML butorphanol tartrate soln ij 2 REPREXAIN TABS (Use 5 QL(5 ea daily) 2 mg/ml Hydrocodone-Ibuprofen) butorphanol tartrate soln na 2 QL(0.4167 ml SYNALGOS-DC CAPS 4 10 mg/ml daily) BUTRANS PTWK 15 PA tramadol-acetaminophen 2 QL(8 ea daily) 4 tabs MCG/HR, 7.5 MCG/HR BUTRANS PTWK 5 PA; QL(0.143 TREZIX CAPS 4 MCG/HR, 10 MCG/HR, 20 4 ea daily) MCG/HR TYLENOL/CODEINE #3 QL(12 ea daily) TABS (Use Acetaminophen 5 nalbuphine hcl soln 2 QL(8 ml daily) w/ Codeine) TYLENOL/CODEINE #4 QL(6 ea daily) pentazocine w/ naloxone 2 QL(12 ea daily) TABS (Use Acetaminophen 5 tabs w/ Codeine) PROBUPHINE IMPLANT 5 KIT IMPL ULTRACET TABS (Use 5 QL(8 ea daily) Tramadol-Acetaminophen) SUBLOCADE SOSY 5 XARTEMIS XR TBCR 5 SUBOXONE FILM 4MG- 4 PA XODOL TABS (Use QL(13 ea daily) 1MG, 12MG-3MG Hydrocodone- 5 SUBOXONE FILM 8MG- 4 PA; QL(3 ea Acetaminophen) 2MG, 2MG-0.5MG daily) 4 QL(180 ml TALWIN SOLN 5 ZAMICET SOLN daily) ZUBSOLV SUBL 0.7MG- PA Opioid Partial Agonists 0.18MG, 5.7MG-1.4MG, 4 BELBUCA FILM 5 1.4MG-0.36MG

Updated August 1, 2018

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZUBSOLV SUBL 8.6MG- TESTIM GEL (Use 5 PA; QL(10 gm 2.1MG, 11.4MG-2.9MG, 5 Testosterone) daily) 2.9MG-0.71MG TESTONE CIK KIT 5 ANDROGENS-ANABOLIC - Drugs to Regulate Hormones TESTOPEL PLLT 5 Androgens PA; QL(0.334 testosterone cypionate soln 2 ANDRODERM PT24 4 QL(1 ea daily) ml daily) testosterone enanthate 2 PA ANDROGEL GEL 25 QL(5 gm daily) soln MG/2.5GM (Use 5 Testosterone) 2 PA; QL(5 gm testosterone gel 1 % daily) ANDROGEL GEL 40.5 MG/2.5GM, 20.25 5 TESTOSTERONE GEL 1 4 PA; QL(10 gm MG/1.25GM %, 50 MG/5GM daily) ANDROGEL GEL 50 PA; QL(10 gm testosterone gel 1 %, 50 2 PA; QL(10 gm MG/5GM (Use 5 daily) mg/5gm daily) Testosterone) TESTOSTERONE GEL 10 5 PA; QL(4 gm MG/ACT daily) ANDROGEL PUMP GEL 5 testosterone gel 25 2 QL(5 gm daily) mg/2.5gm ANDROID CAPS (Use 5 Methyltestosterone) TESTOSTERONE GEL 25 4 QL(5 gm daily) MG/2.5GM ANDROXY TABS 5 TESTOSTERONE PUMP 4 PA; QL(5 gm AVEED SOLN 5 GEL daily) PA; QL(6 ml testosterone soln 30 mg/act 2 AXIRON SOLN (Use 5 PA; QL(6 ml daily) Testosterone) daily) TESTRED CAPS (Use 5 danazol caps 2 Methyltestosterone) 4 PA; QL(10 gm DEPO-TESTOSTERONE PA; QL(0.334 VOGELXO GEL daily) SOLN (Use Testosterone 5 ml daily) Cypionate) 4 PA; QL(5 gm VOGELXO PUMP GEL daily) FIRST-TESTOSTERONE MC COMPOUNDING KIT 5 ANORECTAL AGENTS - Rectal Drugs to Treat CREA Pain, Swelling and Itching FIRST-TESTOSTERONE 5 Intrarectal Steroids OINT CORTENEMA ENEM (Use QL(420 ml per FORTESTA GEL 5 PA; QL(4 gm Hydrocortisone 5 fill retail) daily) (Intrarectal)) METHITEST TABS 5 CORTIFOAM FOAM 4 METHYLTESTOSTERONE 4 hydrocortisone (intrarectal) 2 QL(420 ml per CAPS enem fill retail) NATESTO GEL 5 UCERIS FOAM RE 2 5 MG/ACT STRIANT MISC 5 Rectal Combinations

Updated August 1, 2018

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANALPRAM ADVANCED 5 BILTRICIDE TABS (Use 5 KIT Praziquantel) ANALPRAM-HC CREA QL(2 gm daily) EMVERM CHEW 4 QL(6 ea per fill 1%-1% (Use 5 retail) Hydrocortisone Acetate w/ Pramoxine) ivermectin tabs 2 ANALPRAM-HC LOTN 5 praziquantel tabs 2 1%-2.5% STROMECTOL TABS (Use hydrocortisone acetate w/ 2 QL(2 gm daily) 5 pramoxine crea 1%-1% Ivermectin) LIDOCAINE HCL- ANTI-INFECTIVE AGENTS - MISC. - Drugs to HYDROCORTISONE 5 Treat Bacterial Infections ACETATE WITH ALOE GEL Anti-infective Agents - Misc. bacitracin solr im 50000 lidocaine-hydrocortisone 2 2 acetate (rectal) crea unit lidocaine-hydrocortisone 2 DALVANCE SOLR 5 acetate (rectal) kit FIRST-METRONIDAZOLE 5 PROCORT CREA 5 100 SUSR FIRST-METRONIDAZOLE 5 PROCTOFOAM HC FOAM 4 50 SUSR Rectal Steroids FIRST-VANCOMYCIN 25 5 SOLN ANUSOL-HC CREA (Use 5 Hydrocortisone (Rectal)) FIRST-VANCOMYCIN 50 5 SOLN hydrocortisone (rectal) crea 2 FLAGYL CAPS (Use 5 PROCTOCORT CREA 1 % Metronidazole) (Use Hydrocortisone 5 FLAGYL TABS (Use 5 (Rectal)) Metronidazole) Vasodilating Agents IMPAVIDO CAPS 5

RECTIV OINT 5 METRO IV SOLN 5 ANTACIDS METRONIDAZOLE BENZOATE/SYRSPEND 5 Antacids - Bicarbonate SF PH4 SUSR SODIUM BICARBONATE 5 RX/OTC metronidazole caps 2 POWD OR ANTHELMINTICS - Drugs to Treat Worm metronidazole in nacl soln 2 Infections Anthelmintics metronidazole tabs 2 ALBENZA TABS 4 NEBUPENT SOLR 5

BENZNIDAZOLE TABS 5 ORBACTIV SOLR 5

Updated August 1, 2018

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTAM 300 SOLR 5 Anti-infective Misc. - Combinations BACTRIM DS TABS (Use PRIMSOL SOLN 5 Sulfamethoxazole- 5 Trimethoprim) TINDAMAX TABS (Use 5 Tinidazole) BACTRIM TABS (Use Sulfamethoxazole- 5 tinidazole tabs 2 Trimethoprim) sulfamethoxazole- 2 trimethoprim tabs 2 trimethoprim soln sulfamethoxazole- 2 TRIMPEX SOLN 5 trimethoprim susp sulfamethoxazole- VANCOCIN HCL CAPS 5 2 (Use Vancomycin HCl) trimethoprim tabs VANCOMYCIN HCL + 5 Antiprotozoal Agents SYRSPENDSF PH4 SUSP ALINIA SUSR 5 vancomycin hcl caps or 2 125 mg, 250 mg ALINIA TABS 5 VANCOMYCIN HCL IN 5 DEXTROSE SOLN atovaquone susp 2 VANCOMYCIN HCL SOLN 5 IV 0.9%-1GM/200ML MEPRON SUSP (Use 5 Atovaquone) vancomycin hcl solr iv 10 2 gm, 5000 mg Carbapenems VANCOMYCIN HCL SOLR 5 DORIBAX SOLR 5 IV 100 GM vancomycin hcl solr iv 1000 2 QL(14 ea per DORIPENEM SOLR 5 mg fill retail) vancomycin hcl solr iv 500 2 QL(0.4667 ea ertapenem sodium solr 2 mg daily) VANCOMYCIN imipenem-cilastatin solr 2 HCL/SODIUM CHLORIDE 5 SOLN INVANZ SOLR IJ (Use 5 Ertapenem Sodium) VANCOMYCIN HYDROCHLORIDE/DEXT 5 INVANZ SOLR IV 5 ROSE SOLN VANCOMYCIN meropenem solr 2 HYDROCHLORIDE/SODIU 5 MEROPENEM/SODIUM 5 M CHLORIDE SOLN CHLORIDE SOLR VANCOMYCIN SOLN 5 MERREM SOLR (Use 5 Meropenem) VIBATIV SOLR 5 PRIMAXIN IV SOLR (Use 5 Imipenem-Cilastatin) XIFAXAN TABS 200 MG 5 Chloramphenicols 4 PA; QL(2 ea XIFAXAN TABS 550 MG daily)

Updated August 1, 2018

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHLORAMPHENICOL clindamycin phosphate in 2 SODIUM SUCCINATE 4 d5w soln SOLR clindamycin phosphate soln Cyclic Lipopeptides ij 150 mg/ml, 300 mg/2ml, 2 600 mg/4ml, 900 mg/6ml, CUBICIN RF SOLR (Use 5 Daptomycin) 9000 mg/60ml clindamycin phosphate soln CUBICIN SOLR (Use 5 2 ) iv 150 mg/ml, 300 mg/2ml, Daptomycin 600 mg/4ml, 900 mg/6ml daptomycin solr 2 LINCOCIN SOLN (Use 5 Lincomycin HCl) Glycylcyclines lincomycin hcl soln 2 TIGECYCLINE SOLR 5 Oxazolidinones tigecycline solr 2 linezolid soln iv 600 2 mg/300ml TYGACIL SOLR (Use 5 Tigecycline) LINEZOLID SOLN IV 4 600MG/300ML-0.9% Ketolides linezolid susr or 100 2 KETEK TABS 5 mg/5ml Leprostatics linezolid tabs or 600 mg 2 dapsone tabs 2 SIVEXTRO SOLR IV 5

Lincosamides SIVEXTRO TABS OR 4 CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Use 5 ZYVOX SOLN IV 200 5 Clindamycin HCl) MG/100ML CLEOCIN IN D5W SOLN ZYVOX SOLN IV 600 5 (Use Clindamycin 5 MG/300ML (Use Linezolid) ) Phosphate in D5W ZYVOX SUSR OR 100 5 CLEOCIN PEDIATRIC MG/5ML (Use Linezolid) GRANULES SOLR (Use 5 ZYVOX TABS OR 600 MG 5 Clindamycin Palmitate (Use Linezolid) Hydrochloride) Polymyxins CLEOCIN PHOSPHATE SOLN (Use Clindamycin 5 polymyxin b sulfate solr 2 Phosphate in D5W) CLEOCIN PHOSPHATE Streptogramins SOLN (Use Clindamycin 5 SYNERCID SOLR 5 Phosphate) ANTIANGINAL AGENTS - Drugs to Treat Chest CLIN SINGLE USE KIT KIT 5 Pain clindamycin hcl caps 2 Antianginals-Other RANEXA TB12 1000 MG 4 QL(2 ea daily) clindamycin palmitate 2 hydrochloride solr

Updated August 1, 2018

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RANEXA TB12 500 MG 4 QL(3 ea daily) NITROLINGUAL PUMPSPRAY SOLN (Use 5 Nitrates Nitroglycerin) DILATRATE SR CPCR 5 NITROMIST AERS 5 NITROSTAT SUBL (Use 5 GONITRO PACK 5 Nitroglycerin) ISORDIL TITRADOSE 5 ANTIANXIETY AGENTS - Drugs to Treat Anxiety TABS 40 MG ISORDIL TITRADOSE Antianxiety Agents - Misc. TABS 5 MG (Use 5 QL(3 ea daily) Isosorbide Dinitrate) buspirone hcl tabs 2 ISOSORBIDE DINITRATE 4 droperidol soln 2 ER TBCR HYDROXYZINE HCL 4 isosorbide dinitrate tabs 2 SOLN IM 25 MG/ML isosorbide mononitrate 2 QL(2 ea daily) hydroxyzine hcl soln im 50 2 tabs 10 mg, 20 mg mg/ml isosorbide mononitrate 2 QL(1 ea daily) hydroxyzine hcl syrp or 10 2 tb24 30 mg, 60 mg, 120 mg mg/5ml NITRO-BID OINT 5 hydroxyzine hcl tabs or 10 2 mg, 25 mg, 50 mg NITRO-DUR PT24 0.1 HYDROXYZINE 4 MG/HR, 0.2 MG/HR, 0.4 5 PAMOATE CAPS 100 MG MG/HR, 0.6 MG/HR (Use hydroxyzine pamoate caps 2 Nitroglycerin) 25 mg, 50 mg NITRO-DUR PT24 0.3 5 MG/HR, 0.8 MG/HR meprobamate tabs 2 nitroglycerin cpcr or 9 mg, 2 VISTARIL CAPS (Use 5 2.5 mg, 6.5 mg Hydroxyzine Pamoate) nitroglycerin in d5w soln 2 Benzodiazepines ALPRAZOLAM INTENSOL NITROGLYCERIN IN 4 5 DEXTROSE 5% SOLN CONC alprazolam tabs 0.25 mg, QL(4 ea daily) NITROGLYCERIN 5 2 LINGUAL AERS 0.5 mg, 1 mg, 2 mg nitroglycerin pt24 td 0.1 alprazolam tb24 0.5 mg, 1 2 mg/hr, 0.2 mg/hr, 0.4 2 mg, 2 mg, 3 mg mg/hr, 0.6 mg/hr alprazolam tbdp 0.25 mg, 2 0.5 mg, 1 mg, 2 mg NITROGLYCERIN SOLN 5 IV 5 MG/ML ATIVAN SOLN IJ 2 MG/ML, 4 MG/ML (Use 5 nitroglycerin soln tl 0.4 2 mg/spray Lorazepam) ATIVAN TABS OR 0.5 MG, QL(4 ea daily) nitroglycerin subl sl 0.3 mg, 2 0.4 mg, 0.6 mg 1 MG, 2 MG (Use 5 Lorazepam)

Updated August 1, 2018

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits chlordiazepoxide hcl caps 2 QL(4 ea daily) disopyramide phosphate 2 caps clorazepate dipotassium QL(4 ea daily) 2 NORPACE CAPS (Use 4 tabs Disopyramide Phosphate) diazepam conc or 5 mg/ml 2 NORPACE CR CP12 5 DIAZEPAM SOAJ IM 10 5 MG/2ML procainamide hcl soln 2 DIAZEPAM SOLN IJ 5 4 QUINIDINE GLUCONATE 5 MG/ML SOLN IJ 80 MG/ML DIAZEPAM SOLN OR 5 4 quinidine gluconate tbcr or 2 MG/5ML 324 mg diazepam tabs or 2 mg, 5 2 QL(4 ea daily) QUINIDINE SULFATE 4 mg, 10 mg TABS lorazepam conc or 2 mg/ml 2 QL(5 ml daily) Antiarrhythmics Type I-B lidocaine hcl (cardiac) soln 2 lorazepam soln ij 2 mg/ml, 2 4 mg/ml, 20 mg/10ml LIDOCAINE HCL SOLN IV 4 lorazepam tabs or 0.5 mg, 2 QL(4 ea daily) 10 MG/ML 1 mg, 2 mg lidocaine in d5w soln 2 LORAZEPAM/DEXTROSE 5 SOLN mexiletine hcl caps 2 LORAZEPAM/SODIUM 5 CHLORIDE SOLN XYLOCAINE SOLN (Use 5 Lidocaine HCl (Cardiac)) oxazepam caps 10 mg, 15 2 QL(4 ea daily) mg, 30 mg Antiarrhythmics Type I-C QL(4 ea daily) OXAZEPAM CAPS 30 MG 4 flecainide acetate tabs 2 TRANXENE T TABS (Use 5 QL(4 ea daily) Clorazepate Dipotassium) propafenone hcl cp12 2 VALIUM TABS (Use 5 QL(4 ea daily) Diazepam) propafenone hcl tabs 2 RYTHMOL SR CP12 (Use XANAX TABS (Use 5 QL(4 ea daily) 5 Alprazolam) Propafenone HCl) RYTHMOL TABS (Use XANAX XR TB24 (Use 5 5 Alprazolam) Propafenone HCl) ANTIARRHYTHMICS - Drugs to treat abnormal Antiarrhythmics Type III heart rhythms amiodarone hcl soln 2 Antiarrhythmics - Misc. amiodarone hcl tabs 2 ADENOCARD SOLN (Use 5 Adenosine) AMIODARONE adenosine soln 3 mg/ml, 6 2 HYDROCHLORIDE/DEXT 5 mg/2ml, 12 mg/4ml ROSE SOLN ADENOSINE SOSY 60 5 CORVERT SOLN (Use 5 MG/20ML, 90 MG/30ML Ibutilide Fumarate) Antiarrhythmics Type I-A Updated August 1, 2018

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dofetilide caps 2 SP Leukotriene Modulators ACCOLATE TABS (Use 5 QL(2 ea daily) ibutilide fumarate soln 2 Zafirlukast) QL(1 ea daily) MULTAQ TABS 4 montelukast sodium chew 1 QL(1 ea daily) NEXTERONE SOLN 5 montelukast sodium pack 1 QL(1 ea daily) TIKOSYN CAPS (Use 5 SP montelukast sodium tabs 1 Dofetilide) SINGULAIR CHEW (Use 5 QL(1 ea daily) ANTIASTHMATIC AND BRONCHODILATOR Montelukast Sodium) AGENTS - Drugs to Treat Lung Conditions SINGULAIR PACK (Use 5 QL(1 ea daily) Anti-Inflammatory Agents Montelukast Sodium) cromolyn sodium nebu 2 QL(8 ml daily) SINGULAIR TABS (Use 5 QL(1 ea daily) Montelukast Sodium) Antiasthmatic - Monoclonal Antibodies zafirlukast tabs 2 QL(2 ea daily) CINQAIR SOLN 5 zileuton tb12 2 FASENRA SOSY 5 PA; SP ZYFLO CR TB12 (Use 5 Zileuton) NUCALA SOLR 5 PA; SP ZYFLO TABS 5 XOLAIR SOLR 5 PA; SP Selective Phosphodiesterase 4 (PDE4) Inhibitors Asthma and Bronchodilator Agent Combinations DALIRESP TABS 3 QL(1 ea daily) dyphylline-guaifenesin liqd 2 Steroid Inhalants Bronchodilators - Anticholinergics AEROSPAN AERS 5 ATROVENT HFA AERS 3 ALVESCO AERS 3 INCRUSE ELLIPTA AEPB 5 ARMONAIR RESPICLICK 5 113 AEPB 1 QL(12.5 ml ipratropium bromide soln daily) ARMONAIR RESPICLICK 5 232 AEPB LONHALA MAGNAIR 5 QL(2 ml daily) REFILL KIT SOLN ARMONAIR RESPICLICK 5 55 AEPB LONHALA MAGNAIR 5 QL(2 ml daily) STARTER KIT SOLN ARNUITY ELLIPTA AEPB 4 SEEBRI NEOHALER 5 CAPS ASMANEX HFA AERO 4 SPIRIVA HANDIHALER 3 QL(1 ea daily) CAPS ASMANEX TWISTHALER 120 METERED DOSES 3 SPIRIVA RESPIMAT 4 AEPB AERS ASMANEX TWISTHALER TUDORZA PRESSAIR 3 14 METERED DOSES 3 AEPB AEPB Updated August 1, 2018

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASMANEX TWISTHALER ANORO ELLIPTA AEPB 4 30 METERED DOSES 3 AEPB ARCAPTA NEOHALER 5 QL(1 ea daily) ASMANEX TWISTHALER CAPS 60 METERED DOSES 3 BEVESPI AEROSPHERE 4 AEPB AERO ASMANEX TWISTHALER BREO ELLIPTA AEPB 3 7 METERED DOSES 3 25MCG/INH-100MCG/INH AEPB BREO ELLIPTA AEPB 5 budesonide (inhalation) 1 QL(4 ml daily) 25MCG/INH-200MCG/INH susp BROVANA NEBU 3 FLOVENT DISKUS AEPB 3 QL(2 ea daily) COMBIVENT RESPIMAT 3 FLOVENT HFA AERO 3 AERS DULERA AERO 3 PULMICORT FLEXHALER 3 AEPB fluticasone-salmeterol aepb 2 PULMICORT SUSP (Use 5 QL(4 ml daily) Budesonide (Inhalation)) ipratropium-albuterol soln 1 QL(18 ml daily) QVAR AERS 3 isoproterenol hcl soln 2 QVAR REDIHALER AERB 3 ISUPREL SOLN (Use 5 Sympathomimetics Isoproterenol HCl) levalbuterol hcl nebu 0.31 QL(9.6 ml ADVAIR DISKUS AEPB 3 mg/3ml, 0.63 mg/3ml, 1.25 1 daily) mg/3ml ADVAIR HFA AERO 3 levalbuterol hcl nebu 1.25 2 QL(2 ea daily) mg/0.5ml AIRDUO RESPICLICK 5 113/14 AEPB LEVALBUTEROL 3 TARTRATE HFA AERO AIRDUO RESPICLICK 5 232/14 AEPB METAPROTERENOL QL(30 ml daily) SULFATE SYRP 10 4 AIRDUO RESPICLICK 5 55/14 AEPB MG/5ML METAPROTERENOL ALBUTEROL SULFATE 3 ER TB12 SULFATE TABS 10 MG, 4 20 MG albuterol sulfate nebu in 1 QL(2 ml daily) 0.5 % PERFOROMIST NEBU 4 QL(4 ml daily) albuterol sulfate nebu in QL(12.5 ml 0.63 mg/3ml, 0.083 %, 1.25 1 daily) PROAIR HFA AERS 3 mg/3ml PROAIR RESPICLICK 5 albuterol sulfate syrp or 2 1 AEPB mg/5ml PROVENTIL HFA AERS 3 albuterol sulfate tabs or 2 1 mg, 4 mg SEREVENT DISKUS 3 QL(2 ea daily) albuterol sulfate tb12 or 4 1 AEPB mg, 8 mg

Updated August 1, 2018

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STIOLTO RESPIMAT 5 Coumarin Anticoagulants AERS COUMADIN TABS (Use 4 STRIVERDI RESPIMAT 4 Warfarin Sodium) AERS warfarin sodium tabs 2 SYMBICORT AERO 3 Direct Factor Xa Inhibitors terbutaline sulfate soln 1 BEVYXXA CAPS 5 terbutaline sulfate tabs 1 ELIQUIS STARTER PACK 4 TABS TRELEGY ELLIPTA AEPB 4 ELIQUIS TABS 4 UTIBRON NEOHALER 5 CAPS SAVAYSA TABS 5 VENTOLIN HFA AERS 3 XARELTO STARTER 4 PACK TBPK VOSPIRE ER TB12 (Use 5 Albuterol Sulfate) XARELTO TABS 10 MG 4 QL(1 ea daily) XOPENEX QL(2 ea daily) CONCENTRATE NEBU 5 XARELTO TABS 15 MG, 4 (Use Levalbuterol HCl) 20 MG XOPENEX HFA AERO 3 Heparins And Heparinoid-Like Agents ARIXTRA SOLN (Use 5 PA; SP XOPENEX NEBU (Use 5 QL(9.6 ml Fondaparinux Sodium) Levalbuterol HCl) daily) enoxaparin sodium soln 2 PA; SP Xanthines PA; SP aminophylline soln 2 fondaparinux sodium soln 2 PA; SP ELIXOPHYLLIN ELIX 5 FRAGMIN SOLN 5 heparin (porcine) in sodium 2 THEO-24 CP24 5 chloride soln theophylline soln 2 HEPARIN LOCK FLUSH 4 SOLN theophylline tb12 2 heparin sod (porcine) in 2 d5w soln theophylline tb24 2 heparin sodium (porcine) lock flush & nacl lock flush 2 THEOPHYLLINE/D5W 5 kit SOLN heparin sodium (porcine) 2 ANTICOAGULANTS - Blood Thinners lock flush soln heparin sodium (porcine) 2 Anticoagulants - Misc. soln DEFITELIO SOLN 5 HEPARIN SODIUM SOSY 5

SODIUM CITRATE SOSY 5 HEPARIN SODIUM/D5W 4 SOLN

Updated August 1, 2018

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEPARIN TRICITRASOL CONC 5 SODIUM/DEXTROSE 4 SOLN Thrombin Inhibitors HEPARIN SODIUM/NACL 5 ARGATROBAN SOLN 0.45% SOLN 125MG/125ML-0.9%, 5 HEPARIN 250MG/250ML-0.9% SODIUM/SODIUM ARGATROBAN SOLN 250 4 CHLORIDE 0.9% SOLN 5 MG/2.5ML (Use Heparin (Porcine) in Sodium Chloride) argatroban soln 250 2 mg/2.5ml HEPARIN ARGATROBAN SOLN 250 SODIUM/SODIUM 4 CHLORIDE SOLN MG/2.5ML (Use 5 2000UNIT/500ML-0.9% Argatroban) HEPARIN ARGATROBAN SOLN 50 5 SODIUM/SODIUM MG/50ML CHLORIDE SOLN IPRIVASK SOLR 5 4000UNIT/L-0.9%, 5 30000UNIT/L-0.9%, PRADAXA CAPS 150 MG 4 QL(2 ea daily) 500UNIT/250ML-0.45%, 25000UNIT/250ML-0.45% PRADAXA CAPS 75 MG, 5 HEPARIN 110 MG SODIUM/SODIUM ANTICONVULSANTS - Drugs to Treat Seizures CHLORIDE SOSY 5 20UNIT/20ML-0.9%, AMPA Glutamate Receptor Antagonists 50UNIT/50ML-0.9%, 50UNIT/50ML-0.45% FYCOMPA SUSP 4 LOVENOX SOLN (Use 5 PA; SP Enoxaparin Sodium) FYCOMPA TABS 4 SASH KIT FOR FLUSHING Anticonvulsants - Benzodiazepines VASCULAR ACCESS 4 DEVICES KIT clonazepam tabs 2 QL(4 ea daily) In Vitro Anticoagulants clonazepam tbdp 2 QL(4 ea daily) ACD FORMULA A SOLN 5 DIASTAT ACUDIAL GEL 5 QL(1 ea per fill ACD FORMULA B SOLN 5 10 MG retail) DIASTAT ACUDIAL GEL 4 QL(1 ea per fill ACD-A NOCLOT-50 SOLN 5 20 MG retail) 5 QL(1 ea per fill ANTICOAGULANT DIASTAT PEDIATRIC GEL retail) CITRATE DEXTROSE 5 SOLUTION A SOLN DIAZEPAM GEL RE 10 5 QL(1 ea per fill MG, 2.5 MG retail) ANTICOAGULANT DIAZEPAM GEL RE 20 QL(1 ea per fill CITRATE PHOSPHATE 5 4 DEXTROSE SOLUTION MG retail) SOLN DIAZEPAM RECTAL GEL 5 QL(1 ea per fill GEL 10 MG, 2.5 MG retail) ANTICOAGULANT 5 SODIUM CITRATE SOLN

Updated August 1, 2018

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIAZEPAM RECTAL GEL 4 QL(1 ea per fill gabapentin soln 250 2 QL(60 ml daily) GEL 20 MG retail) mg/5ml, 300 mg/6ml KLONOPIN TABS (Use 5 QL(4 ea daily) gabapentin tabs 600 mg, 2 QL(4 ea daily) Clonazepam) 800 mg ONFI SUSP 5 KEPPRA SOLN IV 500 MG/5ML (Use 5 ONFI TABS 5 Levetiracetam) KEPPRA SOLN OR 100 QL(30 ml daily) Anticonvulsants - Misc. MG/ML (Use 5 Levetiracetam) APTIOM TABS 5 KEPPRA TABS OR 1000 5 QL(3 ea daily) MG (Use Levetiracetam) BANZEL SUSP 5 SP KEPPRA TABS OR 250 QL(4 ea daily) BANZEL TABS 5 SP MG, 500 MG, 750 MG (Use 5 Levetiracetam) BRIVIACT SOLN 5 KEPPRA XR TB24 (Use 5 QL(4 ea daily) Levetiracetam) BRIVIACT TABS 5 LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use 5 carbamazepine chew 100 2 Lamotrigine) mg LAMICTAL ODT KIT 4 carbamazepine cp12 100 2 mg LAMICTAL ODT TBDP 25 carbamazepine cp12 200 2 QL(6 ea daily) MG, 50 MG, 100 MG, 200 5 mg MG (Use Lamotrigine) carbamazepine cp12 300 2 QL(4 ea daily) LAMICTAL STARTER/NOT mg TAKING 5 CARBAMAZEPINE KIT carbamazepine susp 100 2 mg/5ml (Use Lamotrigine) LAMICTAL carbamazepine tabs 200 2 mg STARTER/TAKING CARBAMAZEPINE/NOT 5 carbamazepine tb12 100 2 mg TAKING VALPROATE KIT (Use Lamotrigine) carbamazepine tb12 200 2 QL(6 ea daily) mg LAMICTAL STARTER/TAKING 5 carbamazepine tb12 400 2 QL(4 ea daily) VALPROATE KIT (Use mg Lamotrigine) CARBATROL CP12 100 4 LAMICTAL TABS (Use 5 MG (Use Carbamazepine) Lamotrigine) CARBATROL CP12 200 4 QL(6 ea daily) MG (Use Carbamazepine) LAMICTAL XR KIT 5 CARBATROL CP12 300 4 QL(4 ea daily) LAMICTAL XR TB24 200 QL(2 ea daily) MG (Use Carbamazepine) MG, 250 MG, 300 MG (Use 5 Lamotrigine) FANATREX FUSEPAQ 5 SUSP LAMICTAL XR TB24 25 MG, 50 MG, 100 MG (Use 5 gabapentin caps 100 mg, 2 QL(4 ea daily) 300 mg, 400 mg Lamotrigine) Updated August 1, 2018

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lamotrigine chew 5 mg, 25 2 NEURONTIN TABS 600 QL(4 ea daily) mg MG, 800 MG (Use 5 Gabapentin) lamotrigine kit 25 mg, 2 oxcarbazepine susp 60 2 QL(40 ml daily) mg/ml, 300 mg/5ml lamotrigine tabs 25 mg, 2 100 mg, 150 mg, 200 mg oxcarbazepine tabs 150 2 QL(4 ea daily) mg, 300 mg, 600 mg lamotrigine tb24 200 mg, 2 QL(2 ea daily) 250 mg, 300 mg OXTELLAR XR TB24 150 4 QL(3 ea daily) MG, 300 MG lamotrigine tb24 25 mg, 50 2 mg, 100 mg OXTELLAR XR TB24 600 4 QL(4 ea daily) MG lamotrigine tbdp 25 mg, 50 2 mg, 100 mg, 200 mg POTIGA TABS 5 levetiracetam in sodium 2 chloride soln primidone tabs 2 levetiracetam soln iv 500 2 mg/5ml QUDEXY XR CS24 5 LEVETIRACETAM SOLN IV 500MG/100ML- SPRITAM TB3D 5 820MG/100ML, 1000MG/100ML- TEGRETOL SUSP (Use 4 750MG/100ML, 5 Carbamazepine) 1500MG/100ML- TEGRETOL TABS (Use 4 540MG/100ML (Use Carbamazepine) Levetiracetam in Sodium TEGRETOL-XR TB12 100 4 Chloride) MG (Use Carbamazepine) levetiracetam soln or 100 QL(30 ml daily) 2 TEGRETOL-XR TB12 200 4 QL(6 ea daily) mg/ml, 500 mg/5ml MG (Use Carbamazepine) levetiracetam tabs or 1000 QL(3 ea daily) 2 TEGRETOL-XR TB12 400 4 QL(4 ea daily) mg MG (Use Carbamazepine) levetiracetam tabs or 250 2 QL(4 ea daily) TOPAMAX SPRINKLE QL(6 ea daily) mg, 500 mg, 750 mg CPSP 15 MG (Use 5 Topiramate) levetiracetam tb24 or 500 2 QL(4 ea daily) mg, 750 mg TOPAMAX SPRINKLE QL(8 ea daily) CPSP 25 MG (Use 5 LYRICA CAPS 225 MG, 4 PA; QL(2 ea 300 MG daily) Topiramate) LYRICA CAPS 25 MG, 50 PA; QL(3 ea TOPAMAX TABS 100 MG 5 QL(3 ea daily) MG, 75 MG, 100 MG, 150 4 daily) (Use Topiramate) MG, 200 MG TOPAMAX TABS 200 MG 5 QL(8 ea daily) LYRICA SOLN 20 MG/ML 4 PA (Use Topiramate) TOPAMAX TABS 25 MG, 5 QL(4 ea daily) MYSOLINE TABS (Use 5 50 MG (Use Topiramate) Primidone) QL(6 ea daily) NEURONTIN CAPS 100 QL(4 ea daily) topiramate cpsp 15 mg 2 MG, 300 MG, 400 MG (Use 5 QL(8 ea daily) Gabapentin) topiramate cpsp 25 mg 2 NEURONTIN SOLN 250 5 QL(60 ml daily) TOPIRAMATE ER CS24 5 MG/5ML (Use Gabapentin)

Updated August 1, 2018

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits topiramate tabs 100 mg 2 QL(3 ea daily) vigabatrin pack 2 PA; SP topiramate tabs 200 mg 2 QL(8 ea daily) Hydantoins CEREBYX SOLN (Use 5 topiramate tabs 25 mg, 50 2 QL(4 ea daily) Fosphenytoin Sodium) mg DILANTIN CAPS 100 MG TRILEPTAL SUSP 300 QL(40 ml daily) (Use Phenytoin Sodium 4 MG/5ML (Use 5 Extended) Oxcarbazepine) TRILEPTAL TABS 150 QL(4 ea daily) DILANTIN CAPS 30 MG 5 MG, 300 MG, 600 MG (Use 5 ) DILANTIN INFATABS 4 Oxcarbazepine CHEW (Use Phenytoin) TROKENDI XR CP24 4 DILANTIN-125 SUSP (Use 4 Phenytoin) VIMPAT SOLN IV 200 5 MG/20ML fosphenytoin sodium soln 2 VIMPAT SOLN OR 10 4 QL(40 ml daily) MG/ML PEGANONE TABS 5 VIMPAT TABS OR 50 MG, 4 QL(2 ea daily) PHENYTEK CAPS (Use 100 MG, 150 MG, 200 MG Phenytoin Sodium 4 ZONEGRAN CAPS (Use 5 QL(6 ea daily) Extended) Zonisamide) phenytoin chew 2 zonisamide caps 2 QL(6 ea daily) phenytoin sodium extended 2 Carbamates caps felbamate susp 600 2 QL(120 ml phenytoin sodium soln 2 mg/5ml daily) felbamate tabs 400 mg 2 QL(9 ea daily) phenytoin susp 2 Succinimides felbamate tabs 600 mg 2 QL(6 ea daily) CELONTIN CAPS 5 FELBATOL SUSP 600 5 QL(120 ml MG/5ML (Use Felbamate) daily) ethosuximide caps 250 mg 2 QL(6 ea daily) FELBATOL TABS 400 MG 5 QL(9 ea daily) (Use Felbamate) ethosuximide soln 250 2 QL(30 ml daily) mg/5ml FELBATOL TABS 600 MG 5 QL(6 ea daily) (Use Felbamate) ZARONTIN CAPS 250 MG 4 QL(6 ea daily) (Use Ethosuximide) GABA Modulators ZARONTIN SOLN 250 QL(30 ml daily) GABITRIL TABS (Use 5 MG/5ML (Use 4 Tiagabine HCl) Ethosuximide) SABRIL PACK (Use 5 PA; SP Vigabatrin) Valproic Acid PA; SP DEPACON SOLN (Use 4 SABRIL TABS 5 Valproate Sodium) DEPAKENE CAPS 250 MG 4 tiagabine hcl tabs 2 (Use Valproic Acid)

Updated August 1, 2018

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPAKENE SOLN 250 WELLBUTRIN SR TB12 5 MG/5ML (Use Valproate 5 (Use Bupropion HCl) Sodium) WELLBUTRIN XL TB24 5 DEPAKOTE ER TB24 (Use 5 (Use Bupropion HCl) Divalproex Sodium) Monoamine Oxidase Inhibitors (MAOIs) DEPAKOTE SPRINKLES CSDR (Use Divalproex 5 EMSAM PT24 5 Sodium) MARPLAN TABS 5 DEPAKOTE TBEC (Use 5 Divalproex Sodium) NARDIL TABS (Use 5 divalproex sodium csdr 2 Phenelzine Sulfate) PARNATE TABS (Use 5 divalproex sodium tb24 2 Tranylcypromine Sulfate) 2 divalproex sodium tbec 2 phenelzine sulfate tabs tranylcypromine sulfate 2 valproate sodium soln 2 tabs valproic acid caps 2 Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS (Use 5 ST ANTIDEPRESSANTS - Drugs to Treat Citalopram Hydrobromide) Depression citalopram hydrobromide 2 Alpha-2 Receptor Antagonists (Tetracyclics) soln 10 mg/5ml citalopram hydrobromide 2 ST mirtazapine tabs 2 tabs 10 mg, 20 mg, 40 mg escitalopram oxalate soln 5 2 mirtazapine tbdp 2 mg/5ml REMERON SOLTAB TBDP 5 escitalopram oxalate tabs 5 2 ST (Use Mirtazapine) mg, 10 mg, 20 mg REMERON TABS (Use 5 fluoxetine hcl caps 10 mg, 2 ST Mirtazapine) 20 mg, 40 mg Antidepressant Combinations fluoxetine hcl cpdr 90 mg 2 PRAMLYTE THPK 5 fluoxetine hcl soln 20 2 mg/5ml Antidepressants - Misc. fluoxetine hcl tabs 10 mg, 2 ST APLENZIN TB24 5 20 mg, 60 mg FLUOXETINE 4 ST bupropion hcl tabs 2 HYDROCHLORIDE TABS FLUOXETINE ST bupropion hcl tb12 2 HYDROCHLORIDE TABS 5 (Use Fluoxetine HCl) bupropion hcl tb24 2 fluvoxamine maleate cp24 2 ST FORFIVO XL TB24 5 fluvoxamine maleate tabs 2 ST maprotiline hcl tabs 2

Updated August 1, 2018

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEXAPRO SOLN 5 DESVENLAFAXINE ER 5 ST MG/5ML (Use 5 TB24 50 MG, 100 MG Escitalopram Oxalate) DESVENLAFAXINE ER 5 LEXAPRO TABS 5 MG, 10 ST TB24 50 MG, 100 MG MG, 20 MG (Use 5 desvenlafaxine succinate 2 ST Escitalopram Oxalate) tb24 ST paroxetine hcl tabs 2 duloxetine hcl cpep 20 mg, 2 ST 30 mg, 60 mg ST paroxetine hcl tb24 2 duloxetine hcl cpep 40 mg 2 PAXIL CR TB24 (Use ST 5 EFFEXOR XR CP24 (Use 5 ST Paroxetine HCl) Venlafaxine HCl) PAXIL SUSP 10 MG/5ML 5 FETZIMA CP24 5 PAXIL TABS 10 MG, 20 ST FETZIMA TITRATION 5 MG, 30 MG, 40 MG (Use 5 PACK C4PK Paroxetine HCl) KHEDEZLA TB24 5 ST PEXEVA TABS 5 PRISTIQ TB24 (Use 5 ST PROZAC CAPS (Use 5 ST Desvenlafaxine Succinate) Fluoxetine HCl) venlafaxine hcl cp24 2 ST PROZAC WEEKLY CPDR 5 (Use Fluoxetine HCl) VENLAFAXINE HCL ER 4 ST sertraline hcl conc 20 2 TB24 225 MG mg/ml VENLAFAXINE HCL ER ST sertraline hcl tabs 25 mg, 2 ST TB24 75 MG, 150 MG, 37.5 5 50 mg, 100 mg MG (Use Venlafaxine HCl) ZOLOFT CONC 20 MG/ML 5 ST (Use Sertraline HCl) venlafaxine hcl tabs 2 ZOLOFT TABS 25 MG, 50 ST venlafaxine hcl tb24 2 ST MG, 100 MG (Use 5 Sertraline HCl) Tricyclic Agents Serotonin Modulators amitriptyline hcl tabs 2 nefazodone hcl tabs 2 amoxapine tabs 2 trazodone hcl tabs 2 ANAFRANIL CAPS (Use 5 Clomipramine HCl) TRINTELLIX TABS 4 clomipramine hcl caps 2 VIIBRYD STARTER PACK 4 KIT desipramine hcl tabs 2 VIIBRYD TABS 4 doxepin hcl caps 2 Serotonin-Norepinephrine Reuptake Inhibitors doxepin hcl conc 2 CYMBALTA CPEP (Use 5 ST Duloxetine HCl)

Updated August 1, 2018

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELAVIL TABS (Use 5 alogliptin-pioglitazone tabs 2 Amitriptyline HCl) DUETACT TABS (Use QL(1 ea daily) imipramine hcl tabs 2 Pioglitazone HCl- 5 Glimepiride) imipramine pamoate caps 2 glipizide-metformin hcl tabs QL(2 ea daily) 2.5mg-250mg, 2.5mg- 2 NORPRAMIN TABS (Use 5 Desipramine HCl) 500mg nortriptyline hcl caps 2 glipizide-metformin hcl tabs 2 QL(4 ea daily) 5mg-500mg nortriptyline hcl soln 2 GLUCOVANCE TABS QL(2 ea daily) 2.5MG-500MG (Use 5 PAMELOR CAPS (Use 5 Glyburide-Metformin) Nortriptyline HCl) GLUCOVANCE TABS QL(4 ea daily) protriptyline hcl tabs 2 5MG-500MG (Use 5 Glyburide-Metformin) SURMONTIL CAPS (Use 5 glyburide-metformin tabs QL(2 ea daily) Trimipramine Maleate) 2.5mg-500mg, 1.25mg- 1 250mg TOFRANIL TABS (Use 5 Imipramine HCl) glyburide-metformin tabs 1 QL(4 ea daily) trimipramine maleate caps 2 5mg-500mg GLYXAMBI TABS 5 ANTIDIABETICS - Drugs to Regulate Blood Sugar INVOKAMET TABS 5 Alpha-Glucosidase Inhibitors INVOKAMET XR TB24 5 acarbose tabs 2 QL(3 ea daily) JANUMET TABS 3 QL(2 ea daily) GLYSET TABS (Use 5 QL(3 ea daily) Miglitol) JANUMET XR TB24 3 QL(2 ea daily) miglitol tabs 2 QL(3 ea daily) 50MG-1000MG JANUMET XR TB24 QL(1 ea daily) PRECOSE TABS (Use 5 QL(3 ea daily) 50MG-500MG, 100MG- 3 Acarbose) 1000MG Antidiabetic - Amylin Analogs JENTADUETO TABS 3 QL(2 ea daily) QL(0.36 ml SYMLINPEN 120 SOPN 4 daily) JENTADUETO XR TB24 4 SYMLINPEN 60 SOPN 3 QL(0.2 ml daily) KAZANO TABS 3 Antidiabetic Combinations KOMBIGLYZE XR TB24 3 ACTOPLUS MET TABS QL(2 ea daily) (Use Pioglitazone HCl- 5 OSENI TABS 5 Metformin HCl) pioglitazone hcl-glimepiride 2 QL(1 ea daily) ACTOPLUS MET XR TB24 5 tabs alogliptin-metformin hcl 1 pioglitazone hcl-metformin 1 QL(2 ea daily) tabs hcl tabs

Updated August 1, 2018

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QTERN TABS 4 metformin hcl tb24 1000 1 QL(2 ea daily) mg repaglinide-metformin hcl 2 QL(2 ea daily) QL(4 ea daily) tabs metformin hcl tb24 500 mg 1 SEGLUROMET TABS 5 metformin hcl tb24 750 mg 1 QL(3 ea daily)

SOLIQUA 100/33 SOPN 5 RIOMET SOLN 5

STEGLUJAN TABS 5 QL(1 ea daily) Diabetic Other GLUCAGEN HYPOKIT 4 QL(1 ea per fill SYNJARDY TABS 3 SOLR retail) GLUCAGON 4 QL(1 ea per fill SYNJARDY XR TB24 3 EMERGENCY KIT KIT retail) XIGDUO XR TB24 4 KORLYM TABS 5

XULTOPHY 100/3.6 SOPN 5 PROGLYCEM SUSP 5 Biguanides Dipeptidyl Peptidase-4 (DPP-4) Inhibitors FORTAMET TB24 1000 5 QL(2 ea daily) alogliptin benzoate tabs 2 MG (Use Metformin HCl) QL(1 ea daily) FORTAMET TB24 500 MG 5 QL(4 ea daily) JANUVIA TABS 3 (Use Metformin HCl) GLUCOPHAGE TABS QL(2 ea daily) NESINA TABS 5 1000 MG (Use Metformin 5 HCl) ONGLYZA TABS 3 GLUCOPHAGE TABS 500 5 QL(5 ea daily) QL(1 ea daily) MG (Use Metformin HCl) TRADJENTA TABS 3 GLUCOPHAGE TABS 850 5 QL(3 ea daily) Dopamine Receptor Agonists - Antidiabetic MG (Use Metformin HCl) GLUCOPHAGE XR TB24 QL(4 ea daily) CYCLOSET TABS 3 500 MG (Use Metformin 5 HCl) Incretin Mimetic Agents (GLP-1 Receptor GLUCOPHAGE XR TB24 QL(3 ea daily) BYDUREON BCISE AUIJ 3 750 MG (Use Metformin 5 HCl) BYDUREON PEN PEN 3 GLUMETZA TB24 1000 5 QL(2 ea daily) MG (Use Metformin HCl) BYDUREON SRER 5 GLUMETZA TB24 500 MG 5 QL(4 ea daily) (Use Metformin HCl) BYETTA SOPN 5 metformin hcl tabs 1000 1 QL(2 ea daily) mg OZEMPIC SOPN 5 metformin hcl tabs 500 mg 1 QL(5 ea daily) TANZEUM PEN 5 metformin hcl tabs 850 mg 1 QL(3 ea daily) TRULICITY SOPN 4

Updated August 1, 2018

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3 QL(0.3 ml HUMULIN N KWIKPEN 3 VICTOZA SOPN daily) SUPN Insulin Sensitizing Agents 3 QL(1.67 ml HUMULIN N SUSP daily) ACTOS TABS (Use 5 QL(1 ea daily) Pioglitazone HCl) 3 QL(1.67 ml HUMULIN R SOLN daily) AVANDIA TABS 5 HUMULIN R U-500 3 QL(13.34 ml (CONCENTRATED) SOLN daily) pioglitazone hcl tabs 1 QL(1 ea daily) HUMULIN R U-500 4 Insulin KWIKPEN SOPN QL(1 ml daily) ADMELOG SOLN 3 LANTUS SOLN 3 LANTUS SOLOSTAR QL(1 ml daily) ADMELOG SOLOSTAR 5 3 SOPN SOPN LEVEMIR FLEXTOUCH 3 QL(1 ml daily) AFREZZA POWD 5 SOPN QL(1 ml daily) APIDRA SOLN 3 LEVEMIR SOLN 3 NOVOLIN 70/30 RELION QL(1.67 ml APIDRA SOLOSTAR 3 4 SOPN SUSP daily) QL(1.67 ml BASAGLAR KWIKPEN 3 QL(1 ml daily) NOVOLIN 70/30 SUSP 4 SOPN daily) NOVOLIN N RELION QL(1.67 ml FIASP FLEXTOUCH 3 QL(1 ml daily) 3 SOPN SUSP daily) QL(1.67 ml 3 QL(1.67 ml NOVOLIN N SUSP 3 FIASP SOLN daily) daily) NOVOLIN R RELION QL(1.67 ml HUMALOG JUNIOR 5 3 KWIKPEN SOPN SOLN daily) QL(1.67 ml HUMALOG KWIKPEN 5 NOVOLIN R SOLN 3 SOPN daily) NOVOLOG FLEXPEN QL(1 ml daily) HUMALOG MIX 50/50 3 3 KWIKPEN SUPN SOPN NOVOLOG MIX 70/30 QL(1 ml daily) HUMALOG MIX 50/50 3 SUSP PREFILLED FLEXPEN 3 SUPN HUMALOG MIX 75/25 3 KWIKPEN SUPN NOVOLOG MIX 70/30 3 QL(1.67 ml SUSP daily) HUMALOG MIX 75/25 3 SUSP NOVOLOG PENFILL 4 QL(1 ml daily) SOCT HUMALOG SOCT 5 3 QL(1.67 ml NOVOLOG SOLN daily) HUMALOG SOLN 3 TOUJEO MAX SOLOSTAR 4 SOPN HUMULIN 70/30 KWIKPEN 3 SUPN TOUJEO SOLOSTAR 4 SOPN 4 QL(1.67 ml HUMULIN 70/30 SUSP daily)

Updated August 1, 2018

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRESIBA FLEXTOUCH 4 tolbutamide tabs 2 SOPN Meglitinide Analogues ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea nateglinide tabs 1 QL(3 ea daily) Antidiarrheal - Chloride Channel Antagonists PRANDIN TABS 0.5 MG, 1 5 QL(4 ea daily) MG (Use Repaglinide) FULYZAQ TBEC 5 PRANDIN TABS 2 MG 5 QL(8 ea daily) MYTESI TBEC 5 (Use Repaglinide) repaglinide tabs 0.5 mg, 1 2 QL(4 ea daily) Antidiarrheal/Probiotic Agents - Misc. mg ACIDOPHILUS CAPS 5 RX/OTC repaglinide tabs 2 mg 2 QL(8 ea daily) ACIDOPHILUS HIGH- 5 RX/OTC STARLIX TABS (Use 5 QL(3 ea daily) POTENCY CAPS Nateglinide) ACIDOPHILUS PEARLS 5 RX/OTC Sodium-Glucose Co-Transporter 2 (SGLT2) CAPS ACIDOPHILUS 5 RX/OTC FARXIGA TABS 3 PROBIOTIC BLEND CAPS INVOKANA TABS 3 ACIDOPHILUS SUPER 5 RX/OTC PROBIOTIC CAPS JARDIANCE TABS 4 ACIDOPHILUS/GOAT 5 RX/OTC MILK CAPS STEGLATRO TABS 5 QL(1 ea daily) ADVANCED PROBIOTIC 5 RX/OTC 10 CAPS Sulfonylureas ADVANCED PROBIOTIC 5 RX/OTC AMARYL TABS (Use 5 QL(2 ea daily) CAPS Glimepiride) ALIGN CAPS 5 RX/OTC chlorpropamide tabs 2 ALIGN EXTRA 5 RX/OTC glimepiride tabs 1 QL(2 ea daily) STRENGTH CAPS ALOE 10000 & 5 RX/OTC glipizide tabs 1 PROBIOTICS CAPS BIOHM PROBIOTIC 5 RX/OTC glipizide tb24 1 SUPPLEMENT CAPS BIOHM PROBIOTIC RX/OTC GLUCOTROL TABS (Use 5 Glipizide) SUPPLEMENT/VITAMIN C 5 CAPS GLUCOTROL XL TB24 5 (Use Glipizide) CHILDRENS PROBIOTIC 5 RX/OTC PEARLS CAPS glyburide micronized tabs 2 CULTURELLE RX/OTC ADVANCED IMMUNE 5 glyburide tabs 1 DEFENSE CAPS CULTURELLE PRO-WELL RX/OTC GLYNASE TABS (Use 5 5 Glyburide Micronized) CAPS CVS ADULT 50+ 5 RX/OTC TOLAZAMIDE TABS 4 PROBIOTIC CAPS

Updated August 1, 2018

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS ADULT PROBIOTIC 5 RX/OTC LACTO-PECTIN CAPS 5 RX/OTC CAPS RX/OTC CVS DIGESTIVE 5 RX/OTC MEGA PROBIOTIC CAPS 5 PROBIOTIC CAPS RX/OTC META BIOTIC/BIO- 5 RX/OTC CVS PROBIOTIC CAPS 5 ACTIVE 12 CAPS CVS PROBIOTIC RX/OTC NATRUL PROBIOTIC 5 RX/OTC MAXIMUM STRENGTH 5 CAPS CAPS PEARLS IC CAPS 5 RX/OTC CVS PROBIOTIC PEARLS 5 RX/OTC EXTRA STRENGTH CAPS PHILLIPS COLON 5 RX/OTC HEALTH CAPS CVS SENIOR PROBIOTIC 5 RX/OTC CAPS PREORBOTIC CAPS 5 RX/OTC DAILY PROBIOTIC CAPS 5 RX/OTC PRO NUTRIENTS 5 RX/OTC PROBIOTIC PACK DIFF-STAT CAPS 5 RX/OTC PRO-BIOTIC BLEND 5 RX/OTC CAPS DIFF-STAT PACK 5 RX/OTC PRO-FLORA IMMUNE 5 RX/OTC DIGESTIVE ADVANTAGE 5 RX/OTC CAPS CAPS PROBIOMAX DAILY DF 5 RX/OTC DIGESTIVE ADVANTAGE RX/OTC CAPS LACTOSE DEFENSE 5 PROBIOMAX PLUS DF 5 RX/OTC FORMULA CAPS PACK EQ PROBIOTIC RX/OTC PROBIOTIC & RX/OTC DIGESTIVE SYSTEM 5 ACIDOPHILUS FORMULA 5 SUPPORT CAPS EXTRA STRENGTH CAPS EQL DAILY PROBIOTIC RX/OTC 5 PROBIOTIC + 5 RX/OTC CAPS COLOSTRUM PACK EQL PROBIOTIC COLON RX/OTC 5 PROBIOTIC + OMEGA-3 5 RX/OTC SUPPORT CAPS CAPS FLORA VANCE CAPS 5 RX/OTC PROBIOTIC RX/OTC ACIDOPHILUS BEADS 5 FLORAJEN BIFIDOBLEND 5 RX/OTC CAPS CAPS PROBIOTIC 5 RX/OTC FLORAJEN3 CAPS 5 RX/OTC ACIDOPHILUS CAPS PROBIOTIC ADVANCED 5 RX/OTC FLORAJEN4KIDS CAPS 5 RX/OTC ULTRAPOTENCY CAPS PROBIOTIC CAPS 5 RX/OTC FORTIFY DAILY 5 RX/OTC PROBIOTIC CAPS PROBIOTIC COLON 5 RX/OTC GNP ACIDOPHILUS HIGH 5 RX/OTC SUPPORT CAPS POTENCY CAPS PROBIOTIC RX/OTC GNP PROBIOTIC COLON 5 RX/OTC COMPLEX/ACIDOPHILUS 5 SUPPORT CAPS CAPS RX/OTC HM ACIDOPHILUS CAPS 5 PROBIOTIC DAILY CAPS 5 RX/OTC

Updated August 1, 2018

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROBIOTIC MATURE 5 RX/OTC VISBIOME PROBIOTIC 5 RX/OTC ADULT CAPS HIGH POTENCY PACK PROBIOTIC PEARLS 5 RX/OTC VSL#3 CAPS 5 RX/OTC ADVANTAGE CAPS RX/OTC PROBIOTIC PEARLS 5 RX/OTC VSL#3 DS PACK 5 CAPS Antidiarrheal/Probiotic Combinations probiotic product chew 2 RESTORA RX CAPS 5 PROBIOTIC-10 CAPS 5 RX/OTC RESTORA SPRINKLES 5 PROBIOTIC-10 ULTIMATE 5 RX/OTC PACK CAPS Antiperistaltic Agents PRODIGEN CAPS 5 RX/OTC diphenoxylate w/ atropine 2 tabs RA PROBIOTIC COLON 5 RX/OTC CARE CAPS DIPHENOXYLATE/ATROP 4 INE LIQD RA PROBIOTIC 5 RX/OTC COMPLEX CAPS IMODIUM A-D CAPS 2 MG 5 RX/OTC (Use Loperamide HCl) RA PROBIOTIC RX/OTC DIGESTIVE SUPPORT 5 LOMOTIL TABS (Use 5 CAPS Diphenoxylate w/ Atropine) RX/OTC RA PROBIOTIC MAXIMUM 5 RX/OTC loperamide hcl caps 2 mg 2 STRENGTH CAPS RE:IIMMUNE PACK 5 RX/OTC MOTOFEN TABS 5

RESTORA CAPS 5 RX/OTC opium tincture tinc 2

RISAQUAD CAPS 5 RX/OTC PAREGORIC TINC 4

RISAQUAD-2 CAPS 5 RX/OTC ANTIDOTES AND SPECIFIC ANTAGONISTS Antidote Combinations And Kits SM ACIDOPHILUS 5 RX/OTC PEARLS CAPS DUODOTE SOAJ 5 SUPER PROBIOTIC CAPS 5 RX/OTC NITHIODOTE KIT 5 SUPER PROBIOTIC RX/OTC DIGESTIVE SUPPORT 5 Antidotes - Chelating Agents CAPS CHEMET CAPS 5 TRUBIOTICS CAPS 5 RX/OTC EXJADE TBSO 5 PA; SP TRUNATURE DIGESTIVE 5 RX/OTC PROBIOTIC CAPS FERRIPROX SOLN 5 ULTRAFLORA IMMUNE 5 RX/OTC HEALTH CAPS FERRIPROX TABS 5 VISBIOME PROBIOTIC 5 RX/OTC HIGH POTENCY CAPS JADENU SPRINKLE PACK 5 PA; SP

Updated August 1, 2018

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JADENU TABS 5 PA; SP SODIUM NITRITE SOLN 5

PENTETATE CALCIUM 5 SODIUM THIOSULFATE 4 TRISODIUM SOLN SOLN PENTETATE ZINC 5 VISTOGARD PACK 4 TRISODIUM SOLN Antidotes and Specific Antagonists Benzodiazepine Antagonists ACETADOTE SOLN (Use 5 flumazenil soln 2 Acetylcysteine (Antidote)) Opioid Antagonists acetylcysteine (antidote) 2 soln EVZIO SOAJ 0.4 5 MG/0.4ML ANTIZOL SOLN (Use 5 Fomepizole) NALOXONE HCL SOCT 4 0.4 MG/ML BAL IN OIL SOLN 5 naloxone hcl soln 0.4 2 BRIDION SOLN 5 mg/ml, 4 mg/10ml NALOXONE HCL SOSY 2 4 CALCIUM DISODIUM 5 MG/2ML VERSENATE SOLN naltrexone hcl tabs 2 CETYLEV TBEF 5 NALTREXONE IMPL 5 CYANOKIT SOLR 5 NARCAN LIQD 4 deferoxamine mesylate solr 2 PA; SP VIVITROL SUSR 5 PA; SP DESFERAL SOLR (Use 5 PA; SP Deferoxamine Mesylate) ANTIEMETICS - Drugs to Treat Nausea and DIGIFAB SOLR 5 Vomiting 5-HT3 Receptor Antagonists fomepizole soln 2 ALOXI SOLN (Use 5 Palonosetron HCl) METHYLENE BLUE SOLN 4 ANZEMET TABS 5 PHYSOSTIGMINE 5 SALICYLATE SOLN GRANISETRON HCL 4 SOLN IV 0.1 MG/ML PRALIDOXIME CHLORIDE 5 SOAJ granisetron hcl soln iv 0.1 2 mg/ml, 1 mg/ml, 4 mg/4ml PRAXBIND SOLN 5 Limit 10 per granisetron hcl tabs or 1 PROTOPAM CHLORIDE 5 2 month;QL(0.33 SOLR mg 4 ea daily) PROVAYBLUE SOLN 5 ondansetron hcl soln ij 4 2 mg/2ml, 40 mg/20ml RADIOGARDASE CAPS 5 ondansetron hcl soln or 4 2 QL(50 ml per mg/5ml fill retail) SM IPECAC SYRUP SYRP 5 ondansetron hcl tabs or 24 2 QL(0.143 ea mg daily)

Updated August 1, 2018

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ondansetron hcl tabs or 4 2 QL(2 ea daily) AKYNZEO SOLR 5 mg, 8 mg ONDANSETRON BONJESTA TBCR 5 QL(2 ea daily) HYDROCHLORIDE/SODIU 5 M CHLORIDE SOLN CESAMET CAPS 5 ondansetron tbdp 2 QL(2 ea daily) COCA COLA SYRUP 5 SYRP palonosetron hcl soln 2 DICLEGIS TBEC 4 PALONOSETRON HYDROCHLORIDE SOLN 5 dronabinol caps 2 0.25 MG/5ML MARINOL CAPS (Use 4 QL(0.0667 ea 5 SANCUSO PTCH daily) Dronabinol) SUSTOL PRSY 5 SYNDROS SOLN 5 Substance P/Neurokinin 1 (NK1) Receptor ZOFRAN ODT TBDP (Use 5 QL(2 ea daily) Ondansetron) aprepitant caps 2 ZOFRAN SOLN 4 MG/5ML 5 QL(50 ml per (Use Ondansetron HCl) fill retail) EMEND CAPS OR 40 MG, ZOFRAN TABS 4 MG, 8 QL(2 ea daily) 80 MG, 125 MG (Use 5 MG (Use Ondansetron 5 Aprepitant) HCl) EMEND SOLR IV 150 MG 5 ZUPLENZ FILM 5 EMEND SUSR OR 125 MG 5 Antiemetics - Anticholinergic EMEND TRIPACK CAPS 5 DIMENHYDRINATE SOLN 5 (Use Aprepitant) IJ 50 MG/ML VARUBI TABS 4 meclizine hcl tabs 25 mg, 2 RX/OTC 12.5 mg ANTIFUNGALS - Drugs to Treat Fungal Infections scopolamine pt72 2 Antifungal - Glucan Synthesis Inhibitors TIGAN CAPS OR 300 MG (Use Trimethobenzamide 5 CANCIDAS SOLR (Use 5 HCl) Caspofungin Acetate) caspofungin acetate solr 50 TIGAN SOLN IM 100 5 2 MG/ML mg, 70 mg CASPOFUNGIN ACETATE 5 TRANSDERM-SCOP PT72 5 SOLR 50 MG, 70 MG TRANSDERM-SCOP PT72 5 ERAXIS SOLR 5 (Use Scopolamine) trimethobenzamide hcl 2 MYCAMINE SOLR 5 caps Antifungals Antiemetics - Miscellaneous ABELCET SUSP 5 AKYNZEO CAPS 5

Updated August 1, 2018

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMBISOME SUSR 5 FLUCONAZOLE IN NACL 5 SOLN 100MG/50ML-0.9% AMPHOTERICIN B SOLR 4 fluconazole in nacl soln 200mg/100ml-0.9%, 2 ANCOBON CAPS (Use 5 400mg/200ml-0.9% Flucytosine) fluconazole susr 10 mg/ml, 2 QL(70 ml per BIO-STATIN CAPS 5 40 mg/ml fill retail) fluconazole tabs 100 mg 2 QL(1 ea daily) flucytosine caps 2 QL(2 ea per fill fluconazole tabs 150 mg 2 GRIS-PEG TABS (Use 5 retail) Griseofulvin Ultramicrosize) fluconazole tabs 200 mg 2 QL(2 ea daily) griseofulvin microsize susp 2 QL(7 ea per fill fluconazole tabs 50 mg 2 griseofulvin microsize tabs 2 retail) PA; QL(1 ea itraconazole caps 2 griseofulvin ultramicrosize 2 daily) tabs ketoconazole tabs 2 QL(2 ea daily) LAMISIL PACK 125 MG, 5 187.5 MG NOXAFIL SOLN 5 LAMISIL TABS 250 MG 5 QL(1 ea daily) (Use Terbinafine HCl) NOXAFIL SUSP 5 nystatin powd 2 NOXAFIL TBEC 5 nystatin tabs 2 QL(6 ea daily) ONMEL TABS 5 terbinafine hcl tabs 2 QL(1 ea daily) SPORANOX CAPS 100 5 PA; QL(1 ea Imidazole-Related Antifungals MG (Use Itraconazole) daily) SPORANOX PULSEPAK 5 PA; QL(1 ea CRESEMBA CAPS 5 CAPS (Use Itraconazole) daily) CRESEMBA SOLR 5 SPORANOX SOLN 10 5 MG/ML DIFLUCAN SUSR 10 QL(70 ml per VFEND IV SOLR (Use 5 MG/ML, 40 MG/ML (Use 5 fill retail) Voriconazole) Fluconazole) VFEND SUSR (Use 5 DIFLUCAN TABS 100 MG 5 QL(1 ea daily) Voriconazole) (Use Fluconazole) VFEND TABS (Use 5 DIFLUCAN TABS 150 MG 5 QL(2 ea per fill Voriconazole) (Use Fluconazole) retail) voriconazole solr 2 DIFLUCAN TABS 200 MG 5 QL(2 ea daily) (Use Fluconazole) voriconazole susr 2 DIFLUCAN TABS 50 MG 5 QL(7 ea per fill (Use Fluconazole) retail) voriconazole tabs 2 fluconazole in dextrose 2 soln ANTIHISTAMINES - Drugs to Treat Allergies

Updated August 1, 2018

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antihistamines - Alkylamines cetirizine hcl chew 5 mg, 10 2 QL(1 ea daily) mg BROMPHENIRAMINE 5 SOLN QL(240 ml per cetirizine hcl soln 1 mg/ml, 2 fill retail); BROMPHENIRAMINE 4 5 mg/5ml RX/OTC TANNATE CHEW QL(240 ml per RESPA-BR TB12 5 cetirizine hcl syrp 1 mg/ml, 2 fill retail); 5 mg/5ml RX/OTC Antihistamines - Ethanolamines cetirizine hcl tabs 10 mg 2 QL(1 ea daily) ALER-DRYL TABS 5 cetirizine hcl tabs 5 mg 2 carbinoxamine maleate 2 soln CLARINEX SYRP 0.5 5 carbinoxamine maleate 2 MG/ML tabs CLARINEX TABS 5 MG 5 QL(1 ea daily) clemastine fumarate tabs 2 (Use Desloratadine) 2.68 mg DESLORATADINE ODT 4 QL(1 ea daily) CLEMASTINE FUMARATE 4 TBDP TABS 2.68 MG desloratadine tabs 2 QL(1 ea daily) DICOPANOL FUSEPAQ 5 SUSR fexofenadine hcl susp 2 DICOPANOL RAPIDPAQ 5 SUSR fexofenadine hcl tabs 2 diphenhydramine hcl caps 2 QL(4 ea daily); or 50 mg RX/OTC levocetirizine QL(10 ml dihydrochloride soln 2.5 2 daily); RX/OTC QL(240 ml per mg/5ml diphenhydramine hcl elix or 2 fill retail); 12.5 mg/5ml RX/OTC levocetirizine 2 QL(1 ea daily); dihydrochloride tabs 5 mg RX/OTC diphenhydramine hcl soln ij 2 50 mg/ml XYZAL ALLERGY 24HR QL(10 ml CHILDRENS SOLN (Use 5 daily); RX/OTC diphenhydramine hcl syrp 2 Levocetirizine or 12.5 mg/5ml Dihydrochloride) KARBINAL ER SUER 5 XYZAL ALLERGY 24HR QL(1 ea daily); TABS (Use Levocetirizine 5 RX/OTC SILPHEN COUGH SYRP 5 Dihydrochloride) XYZAL SOLN 2.5 MG/5ML QL(10 ml Antihistamines - Non-Sedating (Use Levocetirizine 5 daily); RX/OTC ALLEGRA ALLERGY Dihydrochloride) CHILDRENS SUSP 30 5 XYZAL TABS 5 MG (Use QL(1 ea daily); MG/5ML (Use Levocetirizine 5 RX/OTC Fexofenadine HCl) Dihydrochloride) ALLEGRA ALLERGY 5 ZYRTEC ALLERGY TABS 5 QL(1 ea daily) CHILDRENS TBDP 30 MG (Use Cetirizine HCl) ALLEGRA ALLERGY ZYRTEC CHILDRENS QL(240 ml per TABS (Use Fexofenadine 5 ALLERGY SOLN (Use 5 fill retail); HCl) Cetirizine HCl) RX/OTC

Updated August 1, 2018

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antihistamines - Phenothiazines cholestyramine light powd 2 QL(6 gm daily) 4 gm/dose PHENERGAN SOLN (Use 5 Promethazine HCl) cholestyramine pack 4 gm 2 QL(6 ea daily) promethazine hcl soln ij 25 2 mg/ml, 50 mg/ml cholestyramine powd 4 2 QL(6 gm daily) gm/dose promethazine hcl soln or 2 QL(240 ml per 6.25 mg/5ml fill retail) colesevelam hcl pack 3.75 2 QL(1 ea daily) gm promethazine hcl supp re 2 QL(12 ea per 25 mg, 50 mg, 12.5 mg fill retail) colesevelam hcl tabs 625 2 QL(7 ea daily) mg promethazine hcl syrp or 2 QL(240 ml per 6.25 mg/5ml fill retail) COLESTID FLAVORED QL(6 gm daily) GRAN 5 GM (Use 5 promethazine hcl tabs or 2 Colestipol HCl) 25 mg, 50 mg, 12.5 mg COLESTID FLAVORED QL(6 ea daily) Antihistamines - Piperidines PACK 5 GM/7.5GM (Use 5 Colestipol HCl) cyproheptadine hcl syrp 2 COLESTID GRAN 5 GM 5 QL(6 gm daily) cyproheptadine hcl tabs 2 (Use Colestipol HCl) COLESTID PACK 5 GM 5 QL(6 ea daily) ANTIHYPERLIPIDEMICS - Drugs to Treat High (Use Colestipol HCl) Cholesterol COLESTID TABS 1 GM 5 QL(16 ea daily) Antihyperlipidemics - Combinations (Use Colestipol HCl) QL(6 gm daily) 2 ST; QL(1 ea colestipol hcl gran 5 gm 2 ezetimibe-simvastatin tabs daily) colestipol hcl pack 5 gm 2 QL(6 ea daily) OMEGA-3/D-3 WELLNESS 5 PACK KIT colestipol hcl tabs 1 gm 2 QL(16 ea daily) SURE RESULT O3D3 5 SYSTEM KIT QUESTRAN LIGHT POWD 5 QL(6 gm daily) VYTORIN TABS (Use 5 ST; QL(1 ea (Use Cholestyramine Light) Ezetimibe-Simvastatin) daily) QUESTRAN PACK 4 GM 5 QL(6 ea daily) Antihyperlipidemics - Misc. (Use Cholestyramine) KYNAMRO SOSY 5 PA; SP QUESTRAN POWD 4 QL(6 gm daily) GM/DOSE (Use 5 LOVAZA CAPS (Use QL(4 ea daily) Cholestyramine) Omega-3-acid Ethyl 5 WELCHOL PACK 3.75 GM 5 QL(1 ea daily) Esters) (Use Colesevelam HCl) omega-3-acid ethyl esters QL(4 ea daily) 2 WELCHOL TABS 625 MG 5 QL(7 ea daily) caps (Use Colesevelam HCl) VASCEPA CAPS 0.5 GM 5 Fibric Acid Derivatives

VASCEPA CAPS 1 GM 4 ANTARA CAPS 5 QL(1 ea daily) Bile Acid Sequestrants choline fenofibrate cpdr 2 cholestyramine light pack 4 QL(6 ea daily) 2 FENOFIBRATE CAPS 50 5 QL(1 ea daily) gm MG, 150 MG

Updated August 1, 2018

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fenofibrate micronized caps 2 QL(1 ea daily) $0 copay for CRESTOR TABS 5 MG, 10 Generic only, fenofibrate tabs 120 mg 2 MG (Use Rosuvastatin 5 age 40 to Calcium) 76;QL(1 ea fenofibrate tabs 40 mg, 48 QL(1 ea daily) daily); PV mg, 54 mg, 145 mg, 160 2 EQUAPAX/ATORVASTATI 5 mg N CALCIUM/COQ10 THPK QL(1 ea daily) FENOFIBRIC ACID TABS 5 FLOLIPID SUSP 5

FENOGLIDE TABS 120 5 $0 copay for MG (Use Fenofibrate) Generic only, fluvastatin sodium caps 20 2 age 40 to FENOGLIDE TABS 40 MG 5 QL(1 ea daily) mg, 40 mg (Use Fenofibrate) 76;QL(1 ea QL(1 ea daily) daily); PV FIBRICOR TABS 5 ST; $0 copay QL(2 ea daily) for Generic gemfibrozil tabs 2 fluvastatin sodium tb24 80 2 only, age 40 to mg QL(1 ea daily) 76;QL(1 ea LIPOFEN CAPS 5 daily); PV ST; $0 copay LOFIBRA CAPS (Use 5 QL(1 ea daily) Fenofibrate Micronized) LESCOL XL TB24 ( for Generic Use 5 only, age 40 to LOFIBRA TABS (Use 5 QL(1 ea daily) Fluvastatin Sodium) Fenofibrate) 76;QL(1 ea daily); PV LOPID TABS (Use 5 QL(2 ea daily) Gemfibrozil) ST; $0 copay LIPITOR TABS 10 MG, 20 for Generic TRICOR TABS (Use 5 QL(1 ea daily) MG (Use Atorvastatin 5 only, age 40 to Fenofibrate) Calcium) 76;QL(1 ea TRIGLIDE TABS 4 QL(1 ea daily) daily); PV LIPITOR TABS 40 MG, 80 ST; QL(1 ea TRILIPIX CPDR (Use 5 QL(1 ea daily) MG (Use Atorvastatin 5 daily) Choline Fenofibrate) Calcium) HMG CoA Reductase Inhibitors LIVALO TABS 5 ST ST ALTOPREV TB24 5 ST; $0 copay ST; $0 copay for Generic lovastatin tabs 10 mg, 20 2 only, age 40 to for Generic mg atorvastatin calcium tabs 2 only, age 40 to 76;QL(1 ea 10 mg, 20 mg 76;QL(1 ea daily); PV daily); PV ST; $0 copay for Generic atorvastatin calcium tabs 2 ST; QL(1 ea 40 mg, 80 mg daily) lovastatin tabs 40 mg 2 only, age 40 to 76;QL(2 ea CRESTOR TABS 20 MG, QL(1 ea daily) daily); PV 40 MG (Use Rosuvastatin 5 Calcium) ST; $0 copay for Generic MEVACOR TABS (Use 5 ) only, age 40 to Lovastatin 76;QL(2 ea daily); PV

Updated August 1, 2018

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; $0 copay NIACOR TABS 4 for Generic PRAVACHOL TABS (Use 5 Pravastatin Sodium) only, age 40 to NIASPAN TBCR 500 MG QL(1 ea daily) 76;QL(1 ea (Use Niacin 5 daily); PV (Antihyperlipidemic)) ST; $0 copay NIASPAN TBCR 750 MG, QL(2 ea daily) for Generic 1000 MG (Use Niacin 5 pravastatin sodium tabs 2 only, age 40 to (Antihyperlipidemic)) 76;QL(1 ea daily); PV Proprotein Convertase Subtilisin/Kexin Type 9 PRALUENT SOPN 4 PA; SP rosuvastatin calcium tabs 2 QL(1 ea daily) 20 mg, 40 mg PA; SP $0 copay for PRALUENT SOSY 4 Generic only, rosuvastatin calcium tabs 5 REPATHA PUSHTRONEX 4 SP 2 age 40 to SYSTEM SOCT mg, 10 mg 76;QL(1 ea daily); PV REPATHA SOSY 4 PA; SP ST; $0 copay for Generic REPATHA SURECLICK 4 PA; SP simvastatin tabs 5 mg, 10 2 only, age 40 to SOAJ mg, 20 mg, 40 mg 76;QL(1 ea ANTIHYPERTENSIVES - Drugs to Treat High daily); PV Blood Pressure 2 ST; QL(1 ea ACE Inhibitors simvastatin tabs 80 mg daily) ACCUPRIL TABS (Use 5 QL(2 ea daily) ST; $0 copay Quinapril HCl) ZOCOR TABS 5 MG, 10 for Generic MG, 20 MG, 40 MG (Use 5 only, age 40 to ACEON TABS (Use 5 QL(2 ea daily) Simvastatin) 76;QL(1 ea Perindopril Erbumine) daily); PV ALTACE CAPS (Use 5 QL(2 ea daily) Ramipril) ZOCOR TABS 80 MG (Use 5 ST; QL(1 ea Simvastatin) daily) benazepril hcl tabs 10 mg, 2 QL(2 ea daily) 20 mg, 40 mg ZYPITAMAG TABS 5 QL(1 ea daily) benazepril hcl tabs 5 mg 2 QL(1 ea daily) Intestinal Cholesterol Absorption Inhibitors captopril tabs 2 QL(3 ea daily) ezetimibe tabs 2 QL(1 ea daily) enalapril maleate tabs 2 QL(2 ea daily) ZETIA TABS (Use 5 QL(1 ea daily) Ezetimibe) enalaprilat inj 2 Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS 5 EPANED SOLN 5 Nicotinic Acid Derivatives EPANED SOLR 5 niacin (antihyperlipidemic) QL(1 ea daily) 2 fosinopril sodium tabs 10 2 QL(1 ea daily) tbcr 500 mg mg, 20 mg niacin (antihyperlipidemic) QL(2 ea daily) 2 fosinopril sodium tabs 40 2 QL(2 ea daily) tbcr 750 mg, 1000 mg mg

Updated August 1, 2018

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lisinopril tabs 2.5 mg 2 QL(1 ea daily) AVAPRO TABS (Use 5 QL(1 ea daily) Irbesartan) lisinopril tabs 5 mg, 10 mg, 2 QL(2 ea daily) BENICAR TABS 20 MG, 40 QL(1 ea daily) 20 mg, 30 mg, 40 mg MG (Use Olmesartan 5 Medoxomil) LOTENSIN TABS (Use 5 QL(2 ea daily) Benazepril HCl) BENICAR TABS 5 MG QL(2 ea daily) (Use Olmesartan 5 MAVIK TABS (Use 5 QL(1 ea daily) Trandolapril) Medoxomil) moexipril hcl tabs 2 QL(2 ea daily) candesartan cilexetil tabs 2 QL(1 ea daily) 32 mg QL(2 ea daily) perindopril erbumine tabs 2 candesartan cilexetil tabs 4 2 QL(2 ea daily) mg, 8 mg, 16 mg PRINIVIL TABS (Use QL(2 ea daily) 5 COZAAR TABS 100 MG 5 QL(1 ea daily) Lisinopril) (Use Losartan Potassium) QBRELIS SOLN 5 COZAAR TABS 25 MG, 50 QL(2 ea daily) MG (Use Losartan 5 quinapril hcl tabs 2 QL(2 ea daily) Potassium) DIOVAN TABS 40 MG, 320 5 QL(1 ea daily) ramipril caps 2 QL(2 ea daily) MG (Use Valsartan) DIOVAN TABS 80 MG, 160 QL(2 ea daily) trandolapril tabs 1 mg, 2 2 QL(1 ea daily) 5 mg MG (Use Valsartan) trandolapril tabs 4 mg 2 QL(2 ea daily) EDARBI TABS 5 eprosartan mesylate tabs 2 QL(1 ea daily) VASOTEC TABS (Use 5 QL(2 ea daily) Enalapril Maleate) irbesartan tabs 2 QL(1 ea daily) ZESTRIL TABS 2.5 MG 5 QL(1 ea daily) (Use Lisinopril) losartan potassium tabs 2 QL(1 ea daily) ZESTRIL TABS 5 MG, 10 QL(2 ea daily) 100 mg MG, 20 MG, 30 MG, 40 MG 5 losartan potassium tabs 25 2 QL(2 ea daily) (Use Lisinopril) mg, 50 mg Agents for Pheochromocytoma MICARDIS TABS (Use 5 QL(1 ea daily) DEMSER CAPS 5 Telmisartan) olmesartan medoxomil tabs 2 QL(1 ea daily) DIBENZYLINE CAPS (Use 5 20 mg, 40 mg Phenoxybenzamine HCl) olmesartan medoxomil tabs 2 QL(2 ea daily) phenoxybenzamine hcl 2 5 mg caps telmisartan tabs 2 QL(1 ea daily) phentolamine mesylate solr 2 valsartan tabs 40 mg, 320 2 QL(1 ea daily) Angiotensin II Receptor Antagonists mg valsartan tabs 80 mg, 160 QL(2 ea daily) ATACAND TABS 32 MG 5 QL(1 ea daily) 2 (Use Candesartan Cilexetil) mg ATACAND TABS 4 MG, 8 QL(2 ea daily) Antiadrenergic Antihypertensives MG, 16 MG (Use 5 CARDURA TABS (Use 5 Candesartan Cilexetil) Doxazosin Mesylate)

Updated August 1, 2018

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CATAPRES TABS (Use 5 ATACAND HCT TABS QL(1 ea daily) Clonidine HCl) (Use Candesartan Cilexetil- 5 Hydrochlorothiazide) CATAPRES-TTS-1 PTWK 5 QL(0.143 ea (Use Clonidine HCl) daily) atenolol & chlorthalidone 2 QL(1 ea daily) tabs CATAPRES-TTS-2 PTWK 5 QL(0.143 ea (Use Clonidine HCl) daily) AVALIDE TABS (Use QL(1 ea daily) Irbesartan- 5 CATAPRES-TTS-3 PTWK 5 QL(0.143 ea (Use Clonidine HCl) daily) Hydrochlorothiazide) clonidine hcl ptwk td 0.1 QL(0.143 ea AZOR TABS (Use QL(1 ea daily) mg/24hr, 0.2 mg/24hr, 0.3 2 daily) Amlodipine Besylate- 5 mg/24hr Olmesartan Medoxomil) benazepril & QL(1 ea daily) clonidine hcl tabs or 0.1 2 2 mg, 0.2 mg, 0.3 mg hydrochlorothiazide tabs BENICAR HCT TABS (Use QL(1 ea daily) doxazosin mesylate tabs 2 Olmesartan Medoxomil- 5 Hydrochlorothiazide) guanfacine hcl tabs 2 bisoprolol & QL(2 ea daily) hydrochlorothiazide tabs 2 methyldopa tabs 2 10mg-6.25mg METHYLDOPATE HCL 4 bisoprolol & QL(1 ea daily) SOLN hydrochlorothiazide tabs 2 5mg-6.25mg, 2.5mg- MINIPRESS CAPS (Use 5 Prazosin HCl) 6.25mg prazosin hcl caps 2 BYVALSON TABS 5 candesartan cilexetil- QL(1 ea daily) TENEX TABS (Use 5 2 Guanfacine HCl) hydrochlorothiazide tabs CAPTOPRIL/HYDROCHL QL(3 ea daily) terazosin hcl caps 2 OROTHIAZIDE TABS 4 25MG-15MG, 50MG-15MG Antihypertensive Combinations CAPTOPRIL/HYDROCHL QL(2 ea daily) ACCURETIC TABS 20MG- QL(2 ea daily) OROTHIAZIDE TABS 4 12.5MG (Use Quinapril- 5 25MG-25MG, 50MG-25MG Hydrochlorothiazide) QL(2 ea daily) ACCURETIC TABS 20MG- QL(1 ea daily) CLORPRES TABS 4 25MG, 10MG-12.5MG 5 (Use Quinapril- CORZIDE TABS (Use QL(1 ea daily) Hydrochlorothiazide) Nadolol & 5 Bendroflumethiazide) amlodipine besylate- 2 QL(1 ea daily) benazepril hcl caps DIOVAN HCT TABS (Use QL(1 ea daily) Valsartan- 5 amlodipine besylate- 2 QL(1 ea daily) Hydrochlorothiazide) olmesartan medoxomil tabs DUTOPROL TB24 5 amlodipine besylate- 2 QL(1 ea daily) valsartan tabs EDARBYCLOR TABS 5 amlodipine-valsartan- 2 QL(1 ea daily) hydrochlorothiazide tabs enalapril maleate & 2 QL(2 ea daily) hydrochlorothiazide tabs

Updated August 1, 2018

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXFORGE HCT TABS QL(1 ea daily) METOPROLOL 5 (Use Amlodipine-Valsartan- SUCCINATE 5 Hydrochlorothiazide) ER/HYDROCHLOROTHIA EXFORGE TABS (Use QL(1 ea daily) ZIDE TB24 Amlodipine Besylate- 5 METOPROLOL/HYDROCH 4 QL(2 ea daily) Valsartan) LOROTHIAZIDE TABS fosinopril sodium & QL(1 ea daily) MICARDIS HCT TABS QL(2 ea daily) 2 hydrochlorothiazide tabs 80MG-12.5MG (Use 5 10mg-12.5mg Telmisartan- fosinopril sodium & QL(4 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs 2 MICARDIS HCT TABS QL(1 ea daily) 20mg-12.5mg 80MG-25MG, 40MG- 5 HYZAAR TABS (Use QL(1 ea daily) 12.5MG (Use Telmisartan- Losartan Potassium & 5 Hydrochlorothiazide) Hydrochlorothiazide) moexipril- QL(1 ea daily) hydrochlorothiazide tabs irbesartan- 2 QL(1 ea daily) 2 hydrochlorothiazide tabs 15mg-12.5mg, 7.5mg- 12.5mg lisinopril & QL(1 ea daily) hydrochlorothiazide tabs 2 moexipril- QL(2 ea daily) 10mg-12.5mg hydrochlorothiazide tabs 2 15mg-25mg lisinopril & QL(4 ea daily) hydrochlorothiazide tabs 2 nadolol & 2 QL(1 ea daily) 20mg-12.5mg bendroflumethiazide tabs lisinopril & QL(2 ea daily) olmesartan medoxomil- QL(1 ea daily) hydrochlorothiazide tabs 2 amlodipine- 2 20mg-25mg hydrochlorothiazide tabs LOPRESSOR HCT TABS QL(2 ea daily) olmesartan medoxomil- 2 QL(1 ea daily) (Use Metoprolol & 5 hydrochlorothiazide tabs Hydrochlorothiazide) PRESTALIA TABS 5 losartan potassium & 2 QL(1 ea daily) hydrochlorothiazide tabs propranolol & 2 QL(2 ea daily) LOTENSIN HCT TABS QL(1 ea daily) hydrochlorothiazide tabs (Use Benazepril & 5 quinapril- QL(2 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs 2 LOTREL CAPS (Use QL(1 ea daily) 20mg-12.5mg Amlodipine Besylate- 5 quinapril- QL(1 ea daily) Benazepril HCl) hydrochlorothiazide tabs 2 methyldopa & QL(3 ea daily) 20mg-25mg, 10mg-12.5mg hydrochlorothiazide tabs 2 TARKA TBCR (Use QL(1 ea daily) 250mg-15mg Trandolapril-Verapamil 5 methyldopa & QL(2 ea daily) HCl) hydrochlorothiazide tabs 2 TEKTURNA HCT TABS QL(2 ea daily) 250mg-25mg 150MG-25MG, 150MG- 4 12.5MG metoprolol & 2 QL(2 ea daily) hydrochlorothiazide tabs TEKTURNA HCT TABS QL(1 ea daily) 300MG-25MG, 300MG- 4 12.5MG

Updated August 1, 2018

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits telmisartan-amlodipine tabs 2 QL(1 ea daily) Antihypertensives - Misc. PA; SP telmisartan- QL(2 ea daily) VECAMYL TABS 5 hydrochlorothiazide tabs 2 80mg-12.5mg Direct Renin Inhibitors telmisartan- QL(1 ea daily) TEKTURNA TABS 150 MG 4 QL(2 ea daily) hydrochlorothiazide tabs 2 80mg-25mg, 40mg-12.5mg TEKTURNA TABS 300 MG 4 QL(1 ea daily) TENORETIC 100 TABS QL(1 ea daily) (Use Atenolol & 5 Selective Aldosterone Receptor Antagonists Chlorthalidone) eplerenone tabs 2 QL(2 ea daily) TENORETIC 50 TABS QL(1 ea daily) (Use Atenolol & 5 INSPRA TABS (Use 5 QL(2 ea daily) Chlorthalidone) Eplerenone) trandolapril-verapamil hcl 2 QL(1 ea daily) Vasodilators tbcr CORLOPAM SOLN 4 TRANDOLAPRIL/VERAPA 5 QL(1 ea daily) MIL HCL ER TBCR hydralazine hcl soln 2 TRIBENZOR TABS (Use QL(1 ea daily) Olmesartan Medoxomil- 5 hydralazine hcl tabs 2 Amlodipine- Hydrochlorothiazide) minoxidil tabs 2 TWYNSTA TABS (Use 5 QL(1 ea daily) Telmisartan-Amlodipine) NIPRIDE RTU SOLN 5 valsartan- 2 QL(1 ea daily) hydrochlorothiazide tabs NITROPRESS SOLN (Use 5 Nitroprusside Sodium) VASERETIC TABS (Use QL(2 ea daily) Enalapril Maleate & 5 nitroprusside sodium soln 2 Hydrochlorothiazide) ZESTORETIC TABS QL(1 ea daily) ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) 10MG-12.5MG (Use 5 Lisinopril & Antimalarial Combinations Hydrochlorothiazide) atovaquone-proguanil hcl 2 ZESTORETIC TABS QL(4 ea daily) tabs 20MG-12.5MG (Use 5 QL(24 ea per Lisinopril & COARTEM TABS 5 Hydrochlorothiazide) fill retail) ZESTORETIC TABS QL(2 ea daily) MALARONE TABS (Use 5 Atovaquone-Proguanil HCl) 20MG-25MG (Use 5 Lisinopril & Antimalarials Hydrochlorothiazide) CHLOROQUINE QL(2 ea daily) ZIAC TABS 10MG-6.25MG QL(2 ea daily) PHOSPHATE TABS 250 4 (Use Bisoprolol & 5 MG Hydrochlorothiazide) chloroquine phosphate tabs 2 QL(0.1429 ea ZIAC TABS 5MG-6.25MG, QL(1 ea daily) 500 mg daily) 2.5MG-6.25MG (Use 5 Bisoprolol & DARAPRIM TABS 5 Hydrochlorothiazide) Updated August 1, 2018

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydroxychloroquine sulfate 2 pyridostigmine bromide 2 tabs tabs mefloquine hcl tabs 2 pyridostigmine bromide tbcr 2

MEFLOQUINE HCL TABS 4 REGONOL SOLN 5 PLAQUENIL TABS (Use ANTIMYCOBACTERIAL AGENTS - Drugs to Hydroxychloroquine 5 Treat Tuberculosis (Bacterial Infections) Sulfate) Anti TB Combinations PRIMAQUINE 5 PHOSPHATE TABS RIFAMATE CAPS 5 QUALAQUIN CAPS (Use 5 QL(84 ea per Quinine Sulfate) fill retail) RIFATER TABS 5 2 QL(84 ea per quinine sulfate caps fill retail) Antimycobacterial Agents CAPASTAT SULFATE 5 ANTIMYASTHENIC/CHOLINERGIC AGENTS SOLR Antimyasthenic/Cholinergic Agents CYCLOSERINE CAPS 4 BLOXIVERZ SOLN (Use 5 Neostigmine Methylsulfate) ethambutol hcl tabs 2 ENLON SOLN 5 ISONIAZID SOLN IJ 100 4 MG/ML GUANIDINE HCL TABS 5 ISONIAZID SYRP OR 50 4 MG/5ML MESTINON SYRP 60 5 MG/5ML isoniazid tabs or 100 mg, 2 300 mg MESTINON TABS 60 MG (Use Pyridostigmine 5 MYAMBUTOL TABS (Use 5 Bromide) Ethambutol HCl) MESTINON TIMESPAN MYCOBUTIN CAPS (Use 5 TBCR (Use Pyridostigmine 5 Rifabutin) Bromide) PASER PACK 5 NEOSTIGMINE METHYLSULFATE SOLN 4 PRIFTIN TABS 5 IJ 0.5 MG/ML, 1 MG/ML NEOSTIGMINE pyrazinamide tabs 2 METHYLSULFATE SOLN 4 IV 5 MG/10ML, 10 rifabutin caps 2 MG/10ML RIFADIN CAPS (Use 5 neostigmine methylsulfate Rifampin) soln iv 5 mg/10ml, 10 2 mg/10ml RIFADIN SOLR (Use 5 Rifampin) NEOSTIGMINE METHYLSULFATE SOSY 5 rifampin caps 2 IV 3 MG/3ML, 4 MG/4ML, 5 MG/5ML rifampin solr 2

Updated August 1, 2018

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIRTURO TABS 5 IFEX SOLR 3 GM 5

TRECATOR TABS 5 ifosfamide soln 1 gm/20ml, 2 3 gm/60ml ANTINEOPLASTICS AND ADJUNCTIVE ifosfamide solr 1 gm 2 THERAPIES - Drugs to Treat Cancer Alkylating Agents IFOSFAMIDE SOLR 3 GM 5 ALKERAN SOLR IV 50 MG 5 SP (Use Melphalan HCl) LEUKERAN TABS 5 ALKERAN TABS OR 2 MG 5 SP (Use Melphalan) melphalan hcl solr 2 BENDAMUSTINE 5 SP melphalan tabs 2 HYDROCHLORIDE SOLN BENDEKA SOLN 5 SP MUSTARGEN SOLR 5

BICNU SOLR 5 MYLERAN TABS 5 busulfan soln 2 oxaliplatin soln 2

BUSULFEX SOLN (Use 5 oxaliplatin solr 2 Busulfan) TEMODAR CAPS OR 5 PA; SP carboplatin soln 2 MG, 20 MG, 100 MG, 140 5 MG, 180 MG, 250 MG (Use CISPLATIN SOLN 200 4 Temozolomide) MG/200ML TEMODAR SOLR IV 100 5 SP cisplatin soln 50 mg/50ml, 2 MG 100 mg/100ml temozolomide caps 2 PA; SP cyclophosphamide caps or 2 25 mg, 50 mg CYCLOPHOSPHAMIDE TEPADINA SOLR 5 CAPS OR 25 MG, 50 MG 5 (Use Cyclophosphamide) thiotepa solr 2 cyclophosphamide solr ij 1 2 SP gm, 2 gm, 500 mg TREANDA SOLR 5 EVOMELA SOLR 5 YONDELIS SOLR 5

GLEOSTINE CAPS 10 MG, 4 ZANOSAR SOLR 5 40 MG, 100 MG GLEOSTINE CAPS 5 MG 5 Antimetabolites ALIMTA SOLR 5 GLIADEL WAFER WAFR 5 ARRANON SOLN 5 HEXALEN CAPS 5 azacitidine susr 2 SP IFEX SOLR 1 GM (Use 5 Ifosfamide) capecitabine tabs 2 PA; SP

Updated August 1, 2018

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cladribine soln 2 TABLOID TABS 5 SP clofarabine soln 2 TREXALL TABS 5

CLOLAR SOLN (Use 5 VIDAZA SUSR (Use 5 SP Clofarabine) Azacitidine) cytarabine soln 2 XATMEP SOLN 5

CYTARABINEAQUEOUS 4 XELODA TABS (Use 5 PA; SP SOLN Capecitabine) DACOGEN SOLR (Use 5 SP Antineoplastic - Angiogenesis Inhibitors Decitabine) AVASTIN SOLN 5 SP decitabine solr 2 SP CYRAMZA SOLN 5 DEPOCYT SUSP 5 ZALTRAP SOLN 5 SP FLOXURIDINE SOLR 4 Antineoplastic - Antibodies fludarabine phosphate soln 2 ADCETRIS SOLR 5 SP fludarabine phosphate solr 2 ARZERRA CONC 5 SP fluorouracil soln iv 1 gm/20ml, 5 gm/100ml, 2.5 2 BLINCYTO SOLR 5 gm/50ml, 500 mg/10ml FOLOTYN SOLN 5 CAMPATH SOLN 5 gemcitabine hcl soln 2 DARZALEX SOLN 5 gemcitabine hcl solr 2 EMPLICITI SOLR 5 ERBITUX SOLN 5 SP GEMZAR SOLR (Use 5 Gemcitabine HCl) GAZYVA SOLN 5 mercaptopurine tabs 2 SP methotrexate sodium soln ij HERCEPTIN SOLR 5 1 gm/40ml, 50 mg/2ml, 200 2 SP mg/8ml, 250 mg/10ml KADCYLA SOLR 5 METHOTREXATE SODIUM SOLN IJ 250 4 KEYTRUDA SOLN 5 MG/10ML LARTRUVO SOLN 5 methotrexate sodium solr ij 2 1 gm MYLOTARG SOLR 5 methotrexate sodium tabs 2 or 2.5 mg OPDIVO SOLN 5 PURIXAN SUSP 5 PERJETA SOLN 5 SP

Updated August 1, 2018

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PORTRAZZA SOLN 5 ELIGARD KIT 7.5 MG 4 SP

RITUXAN SOLN 5 SP EMCYT CAPS 5 SP

TECENTRIQ SOLN 5 5 PA; QL(4 ea ERLEADA TABS daily); SP UNITUXIN SOLN 5 exemestane tabs 2 SP SP VECTIBIX SOLN 5 FARESTON TABS 5 SP YERVOY SOLN 5 FASLODEX SOLN 5

ZEVALIN Y-90 KIT 5 FEMARA TABS (Use 5 Letrozole) Antineoplastic - BCL-2 Inhibitors FIRMAGON SOLR 5 SP VENCLEXTA STARTING 5 PACK TBPK flutamide caps 2 VENCLEXTA TABS 5 HYDROXYPROGESTERO NE CAPROATE SOLN 4 Antineoplastic - Cellular Immunotherapy 1.25 GM/5ML PROVENGE SUSP 5 letrozole tabs 2 Antineoplastic - Hedgehog Pathway Inhibitors leuprolide acetate kit 2 SP ERIVEDGE CAPS 5 PA; SP LUPRON DEPOT (1- 4 PA; SP ODOMZO CAPS 5 PA; SP MONTH) KIT LUPRON DEPOT (3- 5 SP Antineoplastic - Hormonal and Related Agents MONTH) KIT anastrozole tabs 2 LUPRON DEPOT (4- 5 SP MONTH) KIT ARIMIDEX TABS (Use 5 LUPRON DEPOT (6- 5 SP Anastrozole) MONTH) KIT AROMASIN TABS (Use 5 SP SP Exemestane) LYSODREN TABS 5 bicalutamide tabs 2 MEGACE ORAL SUSP 5 (Use Megestrol Acetate) CASODEX TABS (Use 5 Bicalutamide) megestrol acetate susp 2 DEPO-PROVERA SUSP 5 megestrol acetate tabs 2

ELIGARD KIT 22.5 MG 5 SP NILANDRON TABS (Use 5 Nilutamide) SP ELIGARD KIT 30 MG 4 nilutamide tabs 2 SP ELIGARD KIT 45 MG 4 SOLTAMOX SOLN 5 PV

Updated August 1, 2018

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 6 AL; At least 40 mitoxantrone hcl conc 2 SP tamoxifen citrate tabs yrs old SP TRELSTAR MIXJECT 5 SP VALSTAR SOLN 5 SUSR Antineoplastic Combinations TRELSTAR SUSR 5 SP KISQALI FEMARA 200 4 PA; SP VANTAS KIT 5 SP DOSE TBPK KISQALI FEMARA 400 4 PA; SP XTANDI CAPS 4 PA; SP DOSE TBPK KISQALI FEMARA 600 4 PA; SP ZOLADEX IMPL 5 SP DOSE TBPK

ZYTIGA TABS 4 PA; SP LONSURF TABS 5 Antineoplastic - Immunomodulators Antineoplastic Enzyme Inhibitors PA; SP POMALYST CAPS 5 PA; SP AFINITOR DISPERZ TBSO 4 PA; SP Antineoplastic Antibiotics AFINITOR TABS 4 BLEO 15K SOLR 5 ALECENSA CAPS 5 bleomycin sulfate solr 2 ALUNBRIG TABS 5 PA COSMEGEN SOLR (Use 5 PA Dactinomycin) ALUNBRIG TBPK 5 dactinomycin solr 2 BELEODAQ SOLR 5 daunorubicin hcl inj 2 BOSULIF TABS 4 PA; SP

DOXIL INJ (Use BRAFTOVI CAPS 5 Doxorubicin HCl 5 Liposomal) CABOMETYX TABS 4 PA; SP doxorubicin hcl liposomal 2 inj CALQUENCE CAPS 5 PA; SP doxorubicin hcl soln 2 2 mg/ml CAPRELSA TABS 5 DOXORUBICIN HCL 4 SOLR 10 MG, 50 MG COMETRIQ KIT 5 ELLENCE SOLN (Use 5 Epirubicin HCl) COTELLIC TABS 5 epirubicin hcl soln 2 FARYDAK CAPS 5 PA; SP

IDAMYCIN PFS SOLN 5 PA; SP (Use Idarubicin HCl) GILOTRIF TABS 5 idarubicin hcl soln 2 GLEEVEC TABS (Use 5 PA; SP Imatinib Mesylate) mitomycin solr 2 IBRANCE CAPS 4 PA; SP

Updated August 1, 2018

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ICLUSIG TABS 5 PA; SP NERLYNX TABS 5 PA

IDHIFA TABS 5 PA; SP NEXAVAR TABS 4 PA; SP imatinib mesylate tabs 2 PA; SP NINLARO CAPS 5

IMBRUVICA CAPS 140 5 ROMIDEPSIN SOLR 5 SP MG RUBRACA TABS 200 MG, 5 PA; QL(1 ea 5 IMBRUVICA CAPS 70 MG daily); SP 300 MG IMBRUVICA TABS 140 PA; QL(1 ea RUBRACA TABS 250 MG 5 PA MG, 280 MG, 420 MG, 560 5 daily); SP MG RYDAPT CAPS 4 PA INLYTA TABS 5 PA; SP SPRYCEL TABS 4 PA; SP IRESSA TABS 5 STIVARGA TABS 5 PA; SP ISTODAX (OVERFILL) 5 SP SOLR SUTENT CAPS 4 PA; SP ISTODAX SOLR 5 SP TAFINLAR CAPS 5 PA; SP JAKAFI TABS 5 PA; SP TAGRISSO TABS 5 KISQALI TABS 4 PA; SP TARCEVA TABS 4 PA; SP KYPROLIS SOLR 5 TASIGNA CAPS 5 PA; SP LENVIMA 10 MG DAILY 5 DOSE CPPK TIBSOVO TABS 5 LENVIMA 14 MG DAILY 5 SP DOSE CPPK TORISEL SOLN 5 LENVIMA 18 MG DAILY 5 PA; SP DOSE CPPK TYKERB TABS 5 SP LENVIMA 20 MG DAILY 5 VELCADE SOLR 5 DOSE CPPK PA; SP LENVIMA 24 MG DAILY 5 VERZENIO TABS 5 DOSE CPPK VOTRIENT TABS 4 PA; SP LENVIMA 8 MG DAILY 5 DOSE CPPK XALKORI CAPS 5 PA; SP LYNPARZA CAPS 50 MG 5 ZEJULA CAPS 5 PA LYNPARZA TABS 100 MG, 5 PA; SP 150 MG ZELBORAF TABS 5 PA; SP MEKINIST TABS 5 PA; SP ZOLINZA CAPS 5 PA; SP MEKTOVI TABS 5 ZYDELIG TABS 5

Updated August 1, 2018

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZYKADIA CAPS 5 PA; SP TARGRETIN CAPS OR 75 5 PA; SP MG (Use Bexarotene) Antineoplastic Enzymes THERACYS SUSR 5 ERWINAZE SOLR 5 TICE BCG SUSR 5 ONCASPAR SOLN 5 SP tretinoin (chemotherapy) 2 SP caps Antineoplastic Radiopharmaceuticals TRISENOX SOLN 5 METASTRON SOLN 5 UVADEX SOLN 5 QUADRAMET SOLN 5 Chemotherapy Adjuncts XOFIGO SOLN 5 ELITEK SOLR 5 Antineoplastics Misc. KEPIVANCE SOLR 5 ACTIMMUNE SOLN 5 SP Chemotherapy Rescue/Antidote Agents ALFERON N SOLN 5 SP dexrazoxane solr 2 bexarotene caps 2 PA; SP FUSILEV SOLR (Use 5 SP Levoleucovorin Calcium) DACARBAZINE SOLR 100 4 MG leucovorin calcium solr ij 50 mg, 100 mg, 200 mg, 350 2 dacarbazine solr 200 mg 2 mg HYDREA CAPS (Use 5 LEUCOVORIN CALCIUM 4 Hydroxyurea) SOLR IJ 500 MG hydroxyurea caps 2 LEUCOVORIN CALCIUM 4 TABS OR 10 MG, 15 MG SP INTRON A SOLN 5 leucovorin calcium tabs or 2 5 mg, 25 mg SP INTRON A SOLR 5 levoleucovorin calcium soln 2 SP INTRON A W/DILUENT 5 SP SP SOLR levoleucovorin calcium solr 2 SP MATULANE CAPS 5 LEVOLEUCOVORIN SOLN 5 SP 250 MG/25ML NIPENT SOLR 5 mesna soln 2 SP PHOTOFRIN SOLR 5 MESNEX SOLN IV 100 5 SP MG/ML (Use Mesna) PROLEUKIN SOLR 5 SP MESNEX TABS OR 400 5 PA; SP MG SYLATRON KIT 5 SP TOTECT SOLR 4 SYNRIBO SOLR 5 SP VORAXAZE SOLR 5

Updated August 1, 2018

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZINECARD SOLR (Use 5 paclitaxel conc 30 mg/5ml, Dexrazoxane) 300 mg/50ml, 100 2 mg/16.7ml Mitotic Inhibitors TAXOL CONC (Use 5 ABRAXANE SUSR 5 Paclitaxel) TAXOTERE CONC (Use 5 DOCEFREZ SOLR 5 Docetaxel) DOCETAXEL (NON- TENIPOSIDE SOLN 5 ALCOHOL FORMULA) 5 SOLN VINBLASTINE SULFATE 4 SOLN docetaxel conc 20 mg/ml, 2 80 mg/4ml vincristine sulfate soln 2 DOCETAXEL CONC 20 4 MG/ML, 80 MG/4ML vinorelbine tartrate soln 2 DOCETAXEL CONC 80 Oncolytic Viral Agents MG/2ML, 140 MG/7ML, 5 160 MG/8ML, 20 IMLYGIC SUSP 5 MG/0.5ML DOCETAXEL SOLN 20 Topoisomerase I Inhibitors MG/2ML, 80 MG/8ML, 160 5 CAMPTOSAR SOLN 300 5 MG/16ML MG/15ML docetaxel soln 20 mg/2ml, 2 CAMPTOSAR SOLN 40 80 mg/8ml, 160 mg/16ml MG/2ML, 100 MG/5ML 5 DOCETAXEL SOLN 20 (Use Irinotecan HCl) MG/2ML, 80 MG/8ML, 160 5 HYCAMTIN CAPS OR 0.25 5 PA; SP MG/16ML (Use Docetaxel) MG, 1 MG ETOPOPHOS SOLR 5 HYCAMTIN SOLR IV 4 MG 5 SP (Use Topotecan HCl) ETOPOSIDE CAPS OR 50 4 PA; SP MG irinotecan hcl soln 2 etoposide soln iv 1 2 gm/50ml, 500 mg/25ml IRINOTECAN SOLN 4 etoposide soln iv 100 2 SP mg/5ml ONIVYDE INJ 5 SP HALAVEN SOLN 5 topotecan hcl soln 4 2 SP mg/4ml SP IXEMPRA KIT SOLR 5 TOPOTECAN HCL SOLN 5 SP 4 MG/4ML JEVTANA SOLN 5 SP TOPOTECAN HCL SOLN SP 4 MG/4ML (Use Topotecan 5 MARQIBO SUSP 5 HCl) topotecan hcl solr 4 mg 2 SP NAVELBINE SOLN (Use 5 Vinorelbine Tartrate) ANTIPARKINSON AND RELATED THERAPY PACLITAXEL CONC 150 4 MG/25ML AGENTS - Drugs to Treat Parkinson's Disease Antiparkinson Adjuvants

Updated August 1, 2018

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbidopa tabs 2 GOCOVRI CP24 5

LODOSYN TABS (Use 5 MIRAPEX ER TB24 (Use Carbidopa) Pramipexole 5 Dihydrochloride) Antiparkinson Anticholinergics MIRAPEX TABS (Use benztropine mesylate soln 2 Pramipexole 5 Dihydrochloride) benztropine mesylate tabs 2 NEUPRO PT24 4 QL(1 ea daily) COGENTIN SOLN (Use 5 Benztropine Mesylate) OSMOLEX ER TB24 5 trihexyphenidyl hcl elix 0.4 2 QL(16.67 ml daily) PARLODEL CAPS (Use 5 mg/ml Bromocriptine Mesylate) trihexyphenidyl hcl tabs 2 2 PARLODEL TABS (Use 5 mg, 5 mg Bromocriptine Mesylate) Antiparkinson COMT Inhibitors pramipexole 2 COMTAN TABS (Use 5 dihydrochloride tabs Entacapone) pramipexole 2 entacapone tabs 2 dihydrochloride tb24 REQUIP TABS 0.25 MG, 3 QL(6 ea daily) TASMAR TABS (Use 5 MG, 4 MG (Use Ropinirole 5 Tolcapone) Hydrochloride) tolcapone tabs 2 REQUIP TABS 0.5 MG, 1 QL(3 ea daily) MG, 2 MG, 5 MG (Use 5 Antiparkinson Dopaminergics Ropinirole Hydrochloride) REQUIP XL TB24 2 MG, 4 QL(1 ea daily) amantadine hcl caps 2 MG, 6 MG (Use Ropinirole 5 Hydrochloride) amantadine hcl syrp 2 REQUIP XL TB24 8 MG, QL(2 ea daily) amantadine hcl tabs 2 12 MG (Use Ropinirole 5 Hydrochloride) APOKYN SOCT 5 ropinirole hydrochloride 2 QL(6 ea daily) tabs 0.25 mg, 3 mg, 4 mg bromocriptine mesylate 2 ropinirole hydrochloride QL(3 ea daily) caps tabs 0.5 mg, 1 mg, 2 mg, 5 2 bromocriptine mesylate 2 mg tabs ropinirole hydrochloride 2 QL(1 ea daily) carbidopa-levodopa tabs 2 tb24 2 mg, 4 mg, 6 mg ropinirole hydrochloride 2 QL(2 ea daily) carbidopa-levodopa tbcr 2 tb24 8 mg, 12 mg RYTARY CPCR 5 carbidopa-levodopa tbdp 2 SINEMET CR TBCR (Use 5 CARBIDOPA/LEVODOPA/ 5 Carbidopa-Levodopa) ENTACAPONE TABS SINEMET TABS (Use 5 DUOPA SUSP 5 Carbidopa-Levodopa)

Updated August 1, 2018

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 100 TABS 5 GEODON CAPS OR 20 MG, 40 MG, 60 MG, 80 MG 5 STALEVO 125 TABS 5 (Use Ziprasidone HCl) GEODON SOLR IM 20 MG 5 STALEVO 150 TABS 5 LATUDA TABS 4 STALEVO 200 TABS 5 NUPLAZID CAPS 5 STALEVO 50 TABS 5 NUPLAZID TABS 5 STALEVO 75 TABS 5 VRAYLAR CAPS 5 Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use 5 QL(1 ea daily) VRAYLAR CPPK 5 Rasagiline Mesylate) ziprasidone hcl caps 2 ELDEPRYL CAPS (Use 5 Selegiline HCl) Benzisoxazoles rasagiline mesylate tabs 2 QL(1 ea daily) FANAPT TABS 5 selegiline hcl caps 2 FANAPT TITRATION 5 PACK TABS selegiline hcl tabs 2 INVEGA SUSTENNA PA; QL(0.034 XADAGO TABS 5 SUSP 156 MG/ML, 78 5 ml daily); SP MG/0.5ML, 39 MG/0.25ML, 117 MG/0.75ML ZELAPAR TBDP 5 INVEGA SUSTENNA 5 PA; SP ANTIPSYCHOTICS/ANTIMANIC AGENTS - SUSP 234 MG/1.5ML Drugs to Treat Mood Disorders INVEGA TB24 (Use 5 Antimanic Agents Paliperidone) INVEGA TRINZA SUSP 5 PA; SP lithium carbonate caps 150 2 mg, 300 mg, 600 mg LITHIUM CARBONATE paliperidone tb24 2 CAPS 150 MG, 600 MG 4 RISPERDAL CONSTA 5 PA; SP (Use Lithium Carbonate) SUSR lithium carbonate tabs 300 2 RISPERDAL M-TAB TBDP 5 mg (Use Risperidone) lithium carbonate tbcr 300 2 RISPERDAL SOLN (Use 5 mg, 450 mg Risperidone) LITHIUM SOLN 5 RISPERDAL TABS (Use 5 Risperidone) LITHOBID TBCR (Use 4 Lithium Carbonate) RISPERIDONE ODT TBDP 4 Antipsychotics - Misc. risperidone soln 2 EQUETRO CP12 5 risperidone tabs 2

Updated August 1, 2018

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits risperidone tbdp 2 quetiapine fumarate tb24 PA 50 mg, 150 mg, 200 mg, 2 Butyrophenones 300 mg, 400 mg HALDOL DECANOATE SAPHRIS SUBL 5 100 SOLN (Use 5 Haloperidol Decanoate) SEROQUEL TABS (Use 5 ) HALDOL DECANOATE 50 Quetiapine Fumarate SOLN (Use Haloperidol 5 SEROQUEL XR TB24 (Use 5 PA Decanoate) Quetiapine Fumarate) HALDOL SOLN (Use 5 VERSACLOZ SUSP 5 Haloperidol Lactate) ZYPREXA RELPREVV 5 PA; SP haloperidol decanoate soln 2 SUSR ZYPREXA SOLR (Use 5 haloperidol lactate conc 2 Olanzapine) haloperidol lactate soln 2 ZYPREXA TABS (Use 5 Olanzapine) haloperidol tabs 2 ZYPREXA ZYDIS TBDP 5 (Use Olanzapine) Dibenzapines Dihydroindolones ADASUVE AEPB 5 MOLINDONE 4 HYDROCHLORIDE TABS CLOZAPINE ODT TBDP 4 Phenothiazines clozapine tabs 2 CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50 5 MG/2ML clozapine tbdp 2 chlorpromazine hcl tabs or CLOZARIL TABS (Use 5 10 mg, 25 mg, 50 mg, 100 2 Clozapine) mg, 200 mg FAZACLO TBDP 150 MG, 4 fluphenazine decanoate 2 200 MG soln FAZACLO TBDP 25 MG, FLUPHENAZINE HCL 4 100 MG, 12.5 MG (Use 5 CONC OR 5 MG/ML Clozapine) FLUPHENAZINE HCL 4 loxapine succinate caps 2 ELIX OR 2.5 MG/5ML FLUPHENAZINE HCL 4 olanzapine solr 2 SOLN IJ 2.5 MG/ML fluphenazine hcl tabs or 1 2 olanzapine tabs 2 mg, 5 mg, 10 mg, 2.5 mg olanzapine tbdp 2 perphenazine tabs 2 quetiapine fumarate tabs prochlorperazine edisylate 2 25 mg, 50 mg, 100 mg, 200 2 soln mg, 300 mg, 400 mg prochlorperazine maleate 2 tabs

Updated August 1, 2018

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prochlorperazine supp 2 HYDROGEN PEROXIDE 4 SOLN XX 30 % thioridazine hcl tabs 2 TRIPLE DYE LIQD 4 trifluoperazine hcl tabs 2 Chlorine Antiseptics RX/OTC Quinolinone Derivatives ANASEPT LIQD 5 SP ABILIFY MAINTENA PRSY 4 BENZALKONIUM 5 CHLORIDE SOLN SP ABILIFY MAINTENA SRER 4 BENZALKONIUM 5 RX/OTC CHLORIDE SOLN 50 % ABILIFY TABS (Use 5 PA Aripiprazole) CHLORHEXIDINE GLUCONATE SOLN XX 20 5 aripiprazole soln 1 mg/ml 2 PA % aripiprazole tabs 2 mg, 5 PA Iodine Antiseptics mg, 10 mg, 15 mg, 20 mg, 2 GNP IODIDES TINCTURE 5 RX/OTC 30 mg TINC aripiprazole tbdp 10 mg 2 PA GNP IODINE TINCTURE 5 RX/OTC TINC aripiprazole tbdp 15 mg 2 HM IODIDES TINCTURE 5 RX/OTC TINC ARISTADA INITIO PRSY 5 HM IODINE TINCTURE 5 RX/OTC TINC ARISTADA PRSY 4 PA; SP IODIDES TINCTURE TINC 5 RX/OTC REXULTI TABS 5 IODINE TINCTURE MILD 5 RX/OTC TINC Thioxanthenes IODINE TINCTURE TINC 5 RX/OTC thiothixene caps 2 LUGOLS STRONG 5 ANTISEPTICS & DISINFECTANTS IODINE SOLN QC IODIDES TINCTURE 5 RX/OTC Antiseptic Combinations TINC BUCALSEP LIQD 5 QC IODINE TINCTURE 5 RX/OTC TINC BUCALSEP SOLN 5 RA FIRST AID IODINE 5 RX/OTC TINC Antiseptics & Disinfectants SM IODIDES TINCTURE 5 RX/OTC FORMA-RAY SOLN 4 TINC SM IODINE TINCTURE 5 RX/OTC formaldehyde soln 10%, 10 2 QL(90 ml per TINC % fill retail) ANTIVIRALS - Drugs to Treat Viral Infections FORMALDEHYDE SOLN 5 RX/OTC 37 % Antiretrovirals GLUTARALDEHYDE 5 SOLN abacavir sulfate soln 20 2 mg/ml Updated August 1, 2018

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits abacavir sulfate tabs 300 2 QL(2 ea daily) EPIVIR TABS 300 MG 5 QL(1 ea daily) mg (Use Lamivudine) abacavir sulfate-lamivudine 2 QL(1 ea daily) EPZICOM TABS (Use QL(1 ea daily) tabs Abacavir Sulfate- 5 Lamivudine) abacavir sulfate- 2 QL(2 ea daily) lamivudine-zidovudine tabs EVOTAZ TABS 4 APTIVUS CAPS 5 fosamprenavir calcium tabs 2 APTIVUS SOLN 5 FUZEON SOLR 5 atazanavir sulfate caps 150 2 SL(2 ea daily) mg, 200 mg GENVOYA TABS 5 atazanavir sulfate caps 300 2 QL(1 ea daily) mg INTELENCE TABS 100 5 QL(4 ea daily) MG ATRIPLA TABS 4 QL(1 ea daily) INTELENCE TABS 200 5 QL(2 ea daily) MG BIKTARVY TABS 5 QL(1 ea daily) INTELENCE TABS 25 MG 5 QL(8 ea daily) CIMDUO TABS 5 INVIRASE CAPS 5 COMBIVIR TABS (Use 5 QL(2 ea daily) Lamivudine-Zidovudine) INVIRASE TABS 5 COMPLERA TABS 4 QL(1 ea daily) ISENTRESS CHEW 25 4 MG, 100 MG CRIXIVAN CAPS 5 ISENTRESS HD TABS 4 QL(2 ea daily) DESCOVY TABS 4 QL(1 ea daily) ISENTRESS PACK 100 4 MG didanosine cpdr 200 mg 2 QL(2 ea daily) ISENTRESS TABS 400 4 QL(2 ea daily) MG didanosine cpdr 250 mg, 2 QL(1 ea daily) 400 mg JULUCA TABS 5 EDURANT TABS 5 QL(1 ea daily) KALETRA SOLN QL(12.5 ml efavirenz caps 200 mg 2 QL(2 ea daily) 400MG/5ML-100MG/5ML 5 daily) (Use Lopinavir-Ritonavir) QL(3 ea daily) efavirenz caps 50 mg 2 KALETRA TABS 100MG- 5 QL(4 ea daily) 25MG, 200MG-50MG QL(1 ea daily) efavirenz tabs 600 mg 2 lamivudine soln 10 mg/ml 2 QL(30 ml daily) QL(1 ea daily) EMTRIVA CAPS 200 MG 5 lamivudine tabs 150 mg 2 QL(2 ea daily) EMTRIVA SOLN 10 5 QL(24 ml daily) QL(1 ea daily) MG/ML lamivudine tabs 300 mg 2 EPIVIR SOLN 10 MG/ML 5 QL(30 ml daily) QL(2 ea daily) (Use Lamivudine) lamivudine-zidovudine tabs 2 EPIVIR TABS 150 MG 5 QL(2 ea daily) LEXIVA SUSP 50 MG/ML 5 (Use Lamivudine)

Updated August 1, 2018

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEXIVA TABS 700 MG SELZENTRY TABS 150 5 (Use Fosamprenavir 5 MG, 300 MG Calcium) SELZENTRY TABS 25 5 QL(30 day(s) 2 QL(12.5 ml MG, 75 MG limit) lopinavir-ritonavir soln daily) stavudine caps 2 QL(2 ea daily) nevirapine tabs 200 mg 2 QL(2 ea daily) STRIBILD TABS 4 nevirapine tb24 100 mg 2 SUSTIVA CAPS 200 MG 5 QL(2 ea daily) nevirapine tb24 400 mg 2 QL(1 ea daily) (Use Efavirenz) SUSTIVA CAPS 50 MG 5 QL(3 ea daily) NORVIR CAPS 100 MG 4 QL(12 ea daily) (Use Efavirenz) SUSTIVA TABS 600 MG 5 QL(1 ea daily) NORVIR PACK 100 MG 4 QL(12 ea daily) (Use Efavirenz)

NORVIR SOLN 80 MG/ML 4 QL(15 ml daily) SYMFI TABS 5 SYMTUZA TABS 5 NORVIR TABS 100 MG 5 QL(12 ea daily) (Use Ritonavir) tenofovir disoproxil 2 QL(1 ea daily) ODEFSEY TABS 5 fumarate tabs

PREZCOBIX TABS 4 TIVICAY TABS 4 TRIUMEQ TABS 4 PREZISTA SUSP 100 4 MG/ML TRIZIVIR TABS (Use QL(2 ea daily) PREZISTA TABS 75 MG, 4 SL(2 ea daily) Abacavir Sulfate- 5 150 MG, 600 MG Lamivudine-Zidovudine) PREZISTA TABS 800 MG 4 TROGARZO SOLN 5 RESCRIPTOR TABS 5 TRUVADA TABS 150MG- 100MG, 200MG-133MG, 4 RETROVIR CAPS 100 MG 5 QL(6 ea daily) 250MG-167MG (Use Zidovudine) TRUVADA TABS 300MG- 4 QL(1 ea daily) RETROVIR IV INFUSION 5 200MG SOLN TYBOST TABS 5 RETROVIR SYRP 50 5 QL(60 ml daily) MG/5ML (Use Zidovudine) QL(2 ea daily) REYATAZ CAPS 150 MG, SL(2 ea daily) VIDEX EC CPDR 125 MG 5 200 MG (Use Atazanavir 5 VIDEX EC CPDR 200 MG 5 QL(2 ea daily) Sulfate) (Use Didanosine) REYATAZ CAPS 300 MG QL(1 ea daily) 5 VIDEX EC CPDR 250 MG, 5 QL(1 ea daily) (Use Atazanavir Sulfate) 400 MG (Use Didanosine) REYATAZ PACK 50 MG 4 VIDEXPEDIATRIC SOLR 5 QL(12 ea daily) ritonavir tabs 2 VIRACEPT TABS 5 SELZENTRY SOLN 20 5 VIRAMUNE SUSP 50 5 QL(40 ml daily) MG/ML MG/5ML Updated August 1, 2018

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIRAMUNE TABS 200 MG 5 QL(2 ea daily) valganciclovir hcl solr 50 2 (Use Nevirapine) mg/ml VIRAMUNE XR TB24 100 5 valganciclovir hcl tabs 450 2 QL(4 ea daily) MG (Use Nevirapine) mg VIRAMUNE XR TB24 400 5 QL(1 ea daily) Hepatitis Agents ) MG (Use Nevirapine PA; QL(1 ea adefovir dipivoxil tabs 2 VIREAD POWD 40 MG/GM 5 daily); SP BARACLUDE SOLN 0.05 5 QL(20 ml daily) VIREAD TABS 150 MG, 5 MG/ML 200 MG, 250 MG BARACLUDE TABS 0.5 5 PA; QL(1 ea VIREAD TABS 300 MG QL(1 ea daily) MG, 1 MG (Use Entecavir) daily); SP (Use Tenofovir Disoproxil 5 Fumarate) COPEGUS TABS (Use 5 PA; QL(7 ea Ribavirin (Hepatitis C)) daily); SP VITEKTA TABS 5 DAKLINZA TABS 5 PA; SP ZERIT CAPS 15 MG, 20 QL(2 ea daily) PA; QL(1 ea MG, 30 MG, 40 MG (Use 5 entecavir tabs 2 Stavudine) daily); SP PA; SP ZERIT SOLR 1 MG/ML 5 QL(80 ml daily) EPCLUSA TABS 4 EPIVIR HBV SOLN 5 QL(60 ml daily) ZIAGEN SOLN 20 MG/ML 5 5 (Use Abacavir Sulfate) MG/ML EPIVIR HBV TABS 100 QL(3 ea daily) ZIAGEN TABS 300 MG 5 QL(2 ea daily) (Use Abacavir Sulfate) MG (Use Lamivudine 5 (HBV)) zidovudine caps 100 mg 2 QL(6 ea daily) HARVONI TABS 4 PA; SP zidovudine syrp 50 mg/5ml 2 QL(60 ml daily) HEPSERA TABS (Use 5 PA; QL(1 ea Adefovir Dipivoxil) daily); SP zidovudine tabs 300 mg 2 QL(2 ea daily) lamivudine (hbv) tabs 2 QL(3 ea daily) CMV Agents MAVYRET TABS 5 PA; SP cidofovir soln 2 MODERIBA 1200 DOSE 4 PA; QL(2 ea CYTOVENE SOLR (Use 5 PACK TABS daily); SP Ganciclovir Sodium) MODERIBA 800 DOSE 4 PA; QL(2 ea FOSCAVIR SOLN 5 PACK TABS daily); SP ganciclovir sodium solr 2 MODERIBA TBPK 5 PA; SP PREVYMIS TABS 5 OLYSIO CAPS 5 VALCYTE SOLR 50 PEG-INTRON REDIPEN 5 PA; QL(0.143 MG/ML (Use Valganciclovir 5 KIT ea daily); SP HCl) PEG-INTRON REDIPEN 5 PA; QL(0.143 PAK 4 KIT ea daily); SP VALCYTE TABS 450 MG 5 QL(4 ea daily) (Use Valganciclovir HCl) PEGASYS PROCLICK 5 PA; QL(0.0714 SOLN ml daily); SP

Updated August 1, 2018

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEGASYS SOLN 180 5 PA; QL(0.0714 acyclovir tabs 400 mg 2 QL(5 ea daily) MCG/0.5ML ml daily); SP QL(1.67 ea PEGASYS SOLN 180 5 PA; QL(0.143 acyclovir tabs 800 mg 2 MCG/ML ml daily); SP daily) 5 PA; QL(0.143 famciclovir tabs 2 PEGINTRON KIT ea daily); SP REBETOL CAPS 200 MG PA; QL(7 ea FAMVIR TABS (Use 5 (Use Ribavirin (Hepatitis 5 daily); SP Famciclovir) C)) SITAVIG TABS 5 REBETOL SOLN 40 5 QL(35 ml MG/ML daily); SP valacyclovir hcl tabs 1 gm, 2 QL(4 ea daily) 1000 mg RIBASPHERE RIBAPAK 4 PA; QL(2 ea TABS 400 MG, 600 MG daily); SP valacyclovir hcl tabs 500 2 QL(2 ea daily) mg RIBASPHERE RIBAPAK 5 TBPK VALTREX TABS 1 GM 5 QL(4 ea daily) (Use Valacyclovir HCl) RIBASPHERE TABS 4 PA; QL(2 ea daily); SP VALTREX TABS 500 MG 5 QL(2 ea daily) (Use Valacyclovir HCl) PA; QL(7 ea ribavirin (hepatitis c) caps 2 daily); SP ZOVIRAX CAPS OR 200 5 MG (Use Acyclovir) PA; QL(7 ea ribavirin (hepatitis c) tabs 2 daily); SP ZOVIRAX SUSP OR 200 5 QL(13.34 ml MG/5ML (Use Acyclovir) daily) SOVALDI TABS 5 PA; SP ZOVIRAX TABS OR 400 5 QL(5 ea daily) MG (Use Acyclovir) TECHNIVIE TABS 5 PA; SP ZOVIRAX TABS OR 800 5 QL(1.67 ea MG (Use Acyclovir) daily) TYZEKA TABS 5 Influenza Agents VEMLIDY TABS 4 SP FLUMADINE TABS (Use QL(2 ea daily) Rimantadine 5 VIEKIRA PAK TBPK 5 PA; SP Hydrochloride) PA; SP oseltamivir phosphate caps 2 QL(20 ea per VIEKIRA XR TB24 5 30 mg 30 days retail) PA; oseltamivir phosphate caps 2 QL(10 ea per VOSEVI TABS 4 45 mg, 75 mg 30 days retail) ZEPATIER TABS 5 PA; SP oseltamivir phosphate susr 2 QL(120 ml per 6 mg/ml 30 days retail) Herpes Agents RAPIVAB SOLN 5 acyclovir caps 200 mg 2 RELENZA DISKHALER 4 QL(0.6667 ea AEPB daily) acyclovir sodium soln 50 2 mg/ml rimantadine hydrochloride 2 QL(2 ea daily) tabs ACYCLOVIR SODIUM 4 SOLR 500 MG TAMIFLU CAPS 30 MG QL(20 ea per (Use Oseltamivir 5 30 days retail) 2 QL(13.34 ml acyclovir susp 200 mg/5ml daily) Phosphate)

Updated August 1, 2018

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAMIFLU CAPS 45 MG, 75 QL(10 ea per BREVIBLOC PREMIXED 5 MG (Use Oseltamivir 5 30 days retail) SOLN Phosphate) BREVIBLOC SOLN 100 TAMIFLU SUSR 6 MG/ML QL(120 ml per MG/10ML (Use Esmolol 5 (Use Oseltamivir 5 30 days retail) HCl) Phosphate) BREVIBLOC SOLN Respiratory Syncytial Virus (RSV) Agents 2000MG/100ML- 5 4.1MG/ML, ribavirin solr 2 2500MG/250ML-5.9MG/ML

VIRAZOLE SOLR (Use 5 BYSTOLIC TABS 4 Ribavirin) BETA BLOCKERS - Drugs to Treat High Blood esmolol hcl soln 2 Pressure ESMOLOL 5 Alpha-Beta Blockers HYDROCHLORIDE SOSY QL(1 ea daily) KAPSPARGO SPRINKLE 5 carvedilol phosphate cp24 2 CS24 carvedilol tabs 12.5 mg, 2 QL(3 ea daily) LOPRESSOR TABS 100 QL(2 ea daily) 6.25 mg, 3.125 mg MG (Use Metoprolol 5 Tartrate) carvedilol tabs 25 mg 2 QL(4 ea daily) LOPRESSOR TABS 50 QL(3 ea daily) MG (Use Metoprolol 5 COREG CR CP24 (Use 5 QL(1 ea daily) Carvedilol Phosphate) Tartrate) COREG TABS 12.5 MG, QL(3 ea daily) metoprolol succinate tb24 2 QL(2 ea daily) 6.25 MG, 3.125 MG (Use 5 200 mg Carvedilol) metoprolol succinate tb24 2 QL(1 ea daily) 25 mg, 50 mg, 100 mg COREG TABS 25 MG (Use 5 QL(4 ea daily) Carvedilol) METOPROLOL labetalol hcl soln iv 5 mg/ml 2 TARTRATE SOCT IV 5 5 MG/5ML QL(3 ea daily) labetalol hcl tabs or 100 mg 2 metoprolol tartrate soln iv 5 2 mg/5ml labetalol hcl tabs or 200 mg 2 QL(6 ea daily) METOPROLOL TARTRATE SOSY IV 5 5 labetalol hcl tabs or 300 mg 2 QL(8 ea daily) MG/5ML metoprolol tartrate tabs or 2 QL(2 ea daily) Beta Blockers Cardio-Selective 25 mg, 100 mg acebutolol hcl caps 2 metoprolol tartrate tabs or 2 QL(3 ea daily) 50 mg atenolol tabs 2 QL(2 ea daily) METOPROLOL TARTRATE TABS OR 75 5 betaxolol hcl tabs 2 MG, 37.5 MG SECTRAL CAPS (Use 5 bisoprolol fumarate tabs 2 QL(1 ea daily) Acebutolol HCl) BREVIBLOC PREMIXED TENORMIN TABS (Use 5 QL(2 ea daily) DOUBLESTRENGTH 5 Atenolol) SOLN Updated August 1, 2018

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPROL XL TB24 200 MG 5 QL(2 ea daily) timolol maleate tabs 2 (Use Metoprolol Succinate) TOPROL XL TB24 25 MG, QL(1 ea daily) CALCIUM CHANNEL BLOCKERS - Drugs to 50 MG, 100 MG (Use 5 Treat High Blood Pressure Metoprolol Succinate) Calcium Channel Blockers ZEBETA TABS (Use 5 QL(1 ea daily) Bisoprolol Fumarate) ADALAT CC TB24 30 MG, 5 QL(1 ea daily) 90 MG (Use Nifedipine) Beta Blockers Non-Selective ADALAT CC TB24 60 MG 5 QL(2 ea daily) BETAPACE AF TABS (Use 5 QL(2 ea daily) (Use Nifedipine) Sotalol HCl (AFIB/AFL)) amlodipine besylate tabs 2 QL(1 ea daily) BETAPACE TABS (Use 5 QL(2 ea daily) Sotalol HCl) CALAN SR TBCR (Use 5 QL(2 ea daily) Verapamil HCl) CORGARD TABS (Use 5 QL(2 ea daily) Nadolol) CALAN TABS (Use 5 QL(3 ea daily) Verapamil HCl) 5 QL(1 ml per fill HEMANGEOL SOLN retail) CARDENE IV SOLN 5 INDERAL LA CP24 (Use 5 QL(2 ea daily) Propranolol HCl) CARDIZEM CD CP24 120 QL(1 ea daily) MG, 180 MG (Use 5 INDERAL XL CP24 5 Diltiazem HCl Coated Beads) INNOPRAN XL CP24 5 CARDIZEM CD CP24 240 QL(2 ea daily) QL(2 ea daily) MG (Use Diltiazem HCl 5 nadolol tabs 2 Coated Beads) pindolol tabs 2 CARDIZEM CD CP24 360 MG (Use Diltiazem HCl 5 propranolol hcl cp24 or 60 QL(2 ea daily) Coated Beads) mg, 80 mg, 120 mg, 160 2 CARDIZEM LA TB24 120 5 mg MG propranolol hcl soln iv 1 2 CARDIZEM LA TB24 180 mg/ml MG, 240 MG, 300 MG, 360 PROPRANOLOL HCL MG, 420 MG (Use 5 SOLN OR 20 MG/5ML, 40 4 Diltiazem HCl Coated MG/5ML Beads) propranolol hcl tabs or 10 CARDIZEM TABS (Use 5 QL(3 ea daily) mg, 20 mg, 40 mg, 60 mg, 2 Diltiazem HCl) 80 mg diltiazem hcl coated beads QL(1 ea daily) QL(2 ea daily) cp24 120 mg, 180 mg, 300 2 sotalol hcl (afib/afl) tabs 2 mg sotalol hcl tabs 240 mg 2 diltiazem hcl coated beads 2 QL(2 ea daily) cp24 240 mg sotalol hcl tabs 80 mg, 120 QL(2 ea daily) 2 diltiazem hcl coated beads 2 mg, 160 mg cp24 360 mg SOTALOL 5 diltiazem hcl coated beads HYDROCHLORIDE SOLN tb24 180 mg, 240 mg, 300 2 SOTYLIZE SOLN 5 mg, 360 mg, 420 mg

Updated August 1, 2018

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diltiazem hcl cp12 or 60 2 QL(2 ea daily) PROCARDIA CAPS (Use 5 QL(4 ea daily) mg, 90 mg, 120 mg Nifedipine) diltiazem hcl cp24 or 120 2 QL(1 ea daily) PROCARDIA XL TB24 30 QL(1 ea daily) mg, 180 mg MG, 90 MG (Use 5 Nifedipine) diltiazem hcl cp24 or 240 2 QL(2 ea daily) mg PROCARDIA XL TB24 60 5 QL(2 ea daily) MG (Use Nifedipine) diltiazem hcl extended 2 QL(1 ea daily) release beads cp24 SULAR TB24 (Use 5 diltiazem hcl soln iv 25 Nisoldipine) mg/5ml, 50 mg/10ml, 125 2 TIAZAC CP24 (Use QL(1 ea daily) mg/25ml Diltiazem HCl Extended 5 Release Beads) DILTIAZEM HCL SOLR IV 5 100 MG verapamil hcl cp24 or 100 2 mg, 200 mg, 300 mg diltiazem hcl tabs or 30 mg, 2 QL(3 ea daily) 60 mg, 90 mg, 120 mg verapamil hcl cp24 or 120 2 QL(2 ea daily) DILTIAZEM mg, 180 mg, 240 mg HYDROCHLORIDE/DEXT 5 verapamil hcl soln iv 2.5 2 ROSE SOLN mg/ml DILTIAZEM VERAPAMIL HCL SR 4 QL(1 ea daily) HYDROCHLORIDE/SODIU 5 CP24 M CHLORIDE SOLN verapamil hcl tabs or 40 2 QL(3 ea daily) felodipine tb24 2 QL(1 ea daily) mg, 80 mg, 120 mg verapamil hcl tbcr or 120 2 QL(2 ea daily) isradipine caps 2 mg, 180 mg, 240 mg VERELAN CP24 120 MG, QL(2 ea daily) nicardipine hcl caps 2 180 MG, 240 MG (Use 5 Verapamil HCl) nicardipine hcl soln 2 VERELAN CP24 360 MG 4 QL(1 ea daily) NICARDIPINE HYDROCHLORIDE/DEXT 5 VERELAN PM CP24 (Use 5 ROSE SOLN Verapamil HCl) CARDIOTONICS - Drugs to Treat Heart Failure nifedipine caps 10 mg, 20 2 QL(4 ea daily) mg and Abnormal Heart Rhythm nifedipine tb24 30 mg, 90 2 QL(1 ea daily) Cardiac Glycosides mg digoxin soln ij 0.25 mg/ml 2 nifedipine tb24 60 mg 2 QL(2 ea daily) DIGOXIN SOLN OR 0.05 4 nimodipine caps 2 MG/ML digoxin tabs or 0.125 mg, NISOLDIPINE ER TB24 4 0.25 mg, 125 mcg, 250 2 mcg nisoldipine tb24 2 LANOXIN PEDIATRIC 5 SOLN NORVASC TABS (Use 5 QL(1 ea daily) Amlodipine Besylate) LANOXIN SOLN IJ 0.25 4 MG/ML (Use Digoxin) NYMALIZE SOLN 5

Updated August 1, 2018

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANOXIN TABS OR 125 TYVASO REFILL SOLN 5 PA; SP MCG, 250 MCG (Use 4 Digoxin) TYVASO SOLN 5 PA; SP LANOXIN TABS OR 62.5 5 MCG, 187.5 MCG TYVASO STARTER SOLN 5 PA; SP Phosphodiesterase Inhibitors VELETRI SOLR 5 PA; SP milrinone lactate in 2 dextrose soln VENTAVIS SOLN 5 PA; SP milrinone lactate soln 2 Pulmonary Hypertension - Endothelin Receptor CARDIOVASCULAR AGENTS - MISC. - Drugs to PA; SP Treat Heart and Circulation Conditions LETAIRIS TABS 4 Cardioplegic Solutions OPSUMIT TABS 4 SP cardioplegic soln soln 2 TRACLEER TABS 4 PA; SP PLEGISOL SOLN (Use 5 Cardioplegic Soln) TRACLEER TBSO 4 PA; SP Cardiovascular Agents Misc. - Combinations Pulmonary Hypertension - Phosphodiesterase amlodipine besylate- 2 QL(1 ea daily) PA; SP atorvastatin calcium tabs ADCIRCA TABS 5 BIDIL TABS 4 REVATIO SOLN IV 10 PA; SP MG/12.5ML (Use Sildenafil 5 CADUET TABS (Use QL(1 ea daily) Citrate (Pulmonary Amlodipine Besylate- 5 Hypertension)) Atorvastatin Calcium) REVATIO SUSR OR 10 5 PA; SP ENTRESTO TABS 4 MG/ML REVATIO TABS OR 20 PA; SP Impotence Agents MG (Use Sildenafil Citrate 5 (Pulmonary Hypertension)) CIALIS TABS 5 MG, 2.5 5 PA; QL(1 ea MG daily) sildenafil citrate (pulmonary 2 PA; SP Peripheral Vasodilators hypertension) soln sildenafil citrate (pulmonary 2 PA; SP papaverine hcl soln 2 hypertension) tabs PAPAVERINE HCL SOLN 4 Pulmonary Hypertension - Prostacyclin Receptor UPTRAVI TABS 5 Prostaglandin Vasodilators epoprostenol sodium solr 2 PA; SP UPTRAVI TBPK 5

FLOLAN SOLR (Use 5 PA; SP Pulmonary Hypertension - Sol Guanylate Cyclase Epoprostenol Sodium) ADEMPAS TABS 4 SP ORENITRAM TBCR 4 PA; SP Sinus Node Inhibitors REMODULIN SOLN 5 PA; SP CORLANOR TABS 5

Updated August 1, 2018

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Vasoactive Natriuretic Peptides DAXBIA CAPS 5 NATRECOR SOLR 5 KEFLEX CAPS (Use 5 Cephalexin) CEPHALOSPORINS - Drugs to Treat Bacterial Infections Cephalosporins - 2nd Generation cefaclor caps 250 mg, 500 2 Cephalosporin Combinations mg AVYCAZ SOLR 5 CEFACLOR ER TB12 5 ZERBAXA SOLR 5 CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, 4 Cephalosporins - 1st Generation 375 MG/5ML cefadroxil caps 2 CEFOTAN SOLR (Use 5 Cefotetan Disodium) cefadroxil susr 2 cefotetan disodium solr 2 cefadroxil tabs 2 CEFOTETAN SOLR 4 cefazolin sodium solr ij 1 2 CEFOTETAN/DEXTROSE 5 gm, 10 gm, 500 mg SOLR CEFAZOLIN SODIUM 5 cefoxitin sodium solr ij 10 2 SOLR IJ 100 GM, 300 GM gm CEFAZOLIN SODIUM 4 cefoxitin sodium solr iv 1 2 SOLR IJ 20 GM gm, 2 gm CEFAZOLIN SODIUM 4 CEFOXITIN SODIUM SOLR IV 1 GM SOLR IV 1GM-4%, 2GM- 5 CEFAZOLIN SODIUM 5 2.2% SOSY IV 2 GM/20ML cefprozil susr 125 mg/5ml, 2 CEFAZOLIN 250 mg/5ml SODIUM/DEXTROSE 5 cefprozil tabs 250 mg, 500 2 QL(20 ea per SOLN mg fill retail) CEFAZOLIN CEFTIN SUSR 125 5 SODIUM/DEXTROSE 5 MG/5ML, 250 MG/5ML SOLR CEFTIN TABS 500 MG 5 QL(20 ea per CEFAZOLIN (Use Cefuroxime Axetil) fill retail) SODIUM/SODIUM 5 CHLORIDE SOLN 2 QL(20 ea per cefuroxime axetil tabs fill retail) CEFAZOLIN SOLN 5 cefuroxime sodium solr 2 CEFAZOLIN/SODIUM 5 CHLORIDE SOLN ZINACEF SOLN IV 1.5GM 5 cephalexin caps 250 mg, 2 ZINACEF SOLR IJ 1.5 GM, 500 mg, 750 mg 7.5 GM, 750 MG (Use 5 cephalexin susr 125 2 Cefuroxime Sodium) mg/5ml, 250 mg/5ml ZINACEF SOLR IV 1.5 GM 5 CEPHALEXIN TABS 250 4 (Use Cefuroxime Sodium) MG, 500 MG

Updated August 1, 2018

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZINACEF SOLR IV 750 5 CLAFORAN SOLR IJ 2 MG GM, 10 GM, 500 MG (Use 5 Cefotaxime Sodium) Cephalosporins - 3rd Generation CLAFORAN SOLR IV 1 5 CEDAX CAPS 5 GM, 2 GM FORTAZ SOLN IV CEDAX SUSR 5 1GM/50ML-5%, 5 2GM/50ML-5% 2 QL(20 ea per cefdinir caps 300 mg fill retail) FORTAZ SOLR IJ 1 GM, 2 GM, 6 GM (Use 5 cefdinir susr 125 mg/5ml, 2 250 mg/5ml Ceftazidime) CEFDITOREN PIVOXIL 4 FORTAZ SOLR IJ 500 MG 5 TABS 200 MG, 400 MG FORTAZ SOLR IV 1 GM, 2 5 cefixime susr 2 GM (Use Ceftazidime) cefotaxime sodium solr 1 2 SPECTRACEF TABS 4 gm CEFOTAXIME SODIUM SUPRAX CAPS 400 MG 4 SOLR 2 GM, 10 GM, 500 4 SUPRAX CHEW 100 MG, 4 MG 200 MG cefpodoxime proxetil susr 2 SUPRAX SUSR 100 MG/5ML, 200 MG/5ML 5 cefpodoxime proxetil tabs 2 (Use Cefixime) SUPRAX SUSR 500 4 ceftazidime solr 2 MG/5ML TAZICEF SOLN CEFTAZIDIME/DEXTROS 5 5 E SOLR 1GM/50ML-4.4% TAZICEF SOLR 1 GM, 2 4 CEFTIBUTEN CAPS 5 GM CEFTIBUTEN SUSR 5 Cephalosporins - 4th Generation CEFTRIAXONE IN ISO- cefepime hcl solr 2 OSMOTIC DEXTROSE 4 SOLN CEFEPIME SOLN 5 ceftriaxone sodium solr ij 1 QL(0.1 ea 2 CEFEPIME/DEXTROSE 5 gm, 250 mg, 500 mg daily) SOLR CEFTRIAXONE SODIUM 5 MAXIPIME SOLR IJ 1 GM, 5 SOLR IJ 100 GM 2 GM (Use Cefepime HCl) ceftriaxone sodium solr ij 2 2 MAXIPIME SOLR IV 1 GM, 5 gm 2 GM ceftriaxone sodium solr iv 1 2 gm, 2 gm, 10 gm Cephalosporins - 5th Generation TEFLARO SOLR 5 CEFTRIAXONE/DEXTROS 5 E SOLR CHEMICALS

Updated August 1, 2018

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bulk Chemicals - A's desogestrel-ethinyl 6 QL(1 ea daily) estradiol (biphasic) tabs ALPHA-KETOGLUTARIC 5 ACID CRYS desogestrel-ethinyl 6 QL(1 ea daily) estradiol (triphasic) tabs ARNICA LG LIQD 5 drospirenone-ethinyl 6 estradiol tabs 3mg-0.02mg Bulk Chemicals - B's drospirenone-ethinyl 6 QL(1 ea daily) BELLADONNA TINC 4 estradiol tabs 3mg-0.03mg drospirenone-ethinyl Bulk Chemicals - I's estradiol-levomefolate 6 IODINE STRONG SOLN 4 RX/OTC calcium tabs XX ESTROSTEP FE TABS RX/OTC LUGOLS SOLN 4 (Use Norethindrone 5 Acetate-Ethinyl Estradiol- Bulk Chemicals - N's Fe) NALOXONE ethynodiol diacet & eth 6 QL(1 ea daily) HYDROCHLORIDE 5 estrad tabs 1mg-35mcg DIHYDRATE POWD ethynodiol diacet & eth 6 Bulk Chemicals - P's estrad tabs 1mg-50mcg PANTOPRAZOLE 5 FALESSA KIT 5 SODIUM POWD XX FEMCON FE CHEW (Use Bulk Chemicals - S's Norethindrone & Ethinyl 5 Estradiol-Fe) SALICYLIC ACID SOLN 5 XX 50 % GENERESS FE CHEW (Use Norethindrone & 5 SODIUM L-ASPARTATE 5 POWD Ethinyl Estradiol-Fe) CONTRACEPTIVES - Drugs to Prevent levonorgestrel & eth 6 QL(1 ea daily) Pregnancy estradiol tabs levonorgestrel-eth estradiol 6 QL(1 ea daily) Combination Contraceptives - Oral (triphasic) tabs BALCOLTRA TABS 6 QL(1 ea daily) QL(1 ea levonorgestrel-ethinyl 6 daily,91 day(s) BEYAZ TABS (Use estradiol (91-day) tabs limit) Drospirenone-Ethinyl 5 Estradiol-Levomefolate levonorgestrel-ethinyl 6 PV Calcium) estradiol (91-day) tabs BREVICON-28 TABS (Use QL(1 ea daily) levonorgestrel-ethinyl 6 Norethindrone & Eth 5 estradiol (continuous) tabs Estradiol) LO LOESTRIN FE TABS 6 CYCLESSA TABS (Use QL(1 ea daily) Desogestrel-Ethinyl 5 LOESTRIN 1.5/30-21 QL(1 ea daily) Estradiol (Triphasic)) TABS (Use Norethindrone 5 Acet & Eth Estra) DESOGEN TABS (Use QL(1 ea daily) Desogestrel & Ethinyl 5 LOESTRIN 1/20-21 TABS QL(1 ea daily) Estradiol) (Use Norethindrone Acet & 5 Eth Estra) desogestrel & ethinyl 6 QL(1 ea daily) estradiol tabs Updated August 1, 2018

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOESTRIN FE 1.5/30 QL(1 ea daily) norgestrel & ethinyl 6 QL(2 ea daily) TABS (Use Norethin Acet & 5 estradiol tabs Estrad-Fe) NORINYL 1+35 TABS (Use QL(1 ea daily) LOESTRIN FE 1/20 TABS QL(1 ea daily) Norethindrone & Eth 5 (Use Norethin Acet & 5 Estradiol) Estrad-Fe) OGESTREL TABS 6 QL(1 ea daily) LOSEASONIQUE TABS QL(1 ea (Use Levonorgestrel- 5 daily,91 day(s) ORTHO TRI-CYCLEN LO Ethinyl Estradiol (91-Day)) limit) TABS (Use Norgestimate- 5 MIRCETTE TABS (Use QL(1 ea daily) Ethinyl Estradiol Desogestrel-Ethinyl 5 (Triphasic)) Estradiol (Biphasic)) ORTHO TRI-CYCLEN QL(1 ea daily) MODICON TABS (Use QL(1 ea daily) TABS (Use Norgestimate- 5 Norethindrone & Eth 5 Ethinyl Estradiol Estradiol) (Triphasic)) ORTHO-CYCLEN TABS QL(1 ea daily) NATAZIA TABS 6 (Use Norgestimate-Ethinyl 5 Estradiol) NECON 1/50-28 TABS 6 QL(1 ea daily) ORTHO-NOVUM 1/35 QL(1 ea daily) NECON 10/11-28 TABS 6 TABS (Use Norethindrone 5 & Eth Estradiol) norethin acet & estrad-fe 6 ORTHO-NOVUM 7/7/7 QL(1 ea daily) chew 75mg-20mcg-1mg TABS (Use Norethindrone- 5 Eth Estradiol (Triphasic)) norethin acet & estrad-fe 6 PV chew 75mg-20mcg-1mg OVCON-35 TABS (Use QL(1 ea daily) Norethindrone & Eth 5 norethin acet & estrad-fe 6 tabs 75mg-20mcg-1mg Estradiol) norethin acet & estrad-fe QL(1 ea daily) QUARTETTE TABS (Use PV tabs 75mg-20mcg-1mg, 6 Levonorgestrel-Ethinyl 5 75mg-30mcg-1.5mg Estradiol (91-Day)) SAFYRAL TABS (Use norethindrone & eth 6 QL(1 ea daily) estradiol tabs Drospirenone-Ethinyl 5 Estradiol-Levomefolate norethindrone & ethinyl 6 estradiol-fe chew Calcium) SEASONIQUE TABS (Use QL(1 ea norethindrone acet & eth 6 QL(1 ea daily) estra tabs Levonorgestrel-Ethinyl 5 daily,91 day(s) Estradiol (91-Day)) limit) norethindrone acetate- 6 ethinyl estradiol-fe tabs TAYTULLA CAPS 6 norethindrone-eth estradiol 6 QL(1 ea daily) TRI-NORINYL 28 TABS QL(1 ea daily) (triphasic) tabs (Use Norethindrone-Eth 5 norgestimate-ethinyl 6 Estradiol (Triphasic)) estradiol (triphasic) tabs YASMIN 28 TABS (Use QL(1 ea daily) norgestimate-ethinyl 6 QL(1 ea daily) Drospirenone-Ethinyl 5 estradiol (triphasic) tabs Estradiol) norgestimate-ethinyl 6 QL(1 ea daily) YAZ TABS (Use estradiol tabs Drospirenone-Ethinyl 5 Estradiol)

Updated August 1, 2018

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Combination Contraceptives - Transdermal medroxyprogesterone acetate (contraceptive) 6 6 QL(0.1071 ea susy XULANE PTWK daily) Progestin Contraceptives - Oral Combination Contraceptives - Vaginal NOR-QD TABS (Use QL(1 ea daily) NUVARING RING 6 QL(0.0357 ea Norethindrone 5 daily) (Contraceptive)) Copper Contraceptives - IUD norethindrone 6 QL(1 ea daily) PARAGARD (contraceptive) tabs INTRAUTERINE COPPER 5 ORTHO MICRONOR QL(1 ea daily) CONTRACEPTIVE T380A TABS (Use Norethindrone 5 IUD (Contraceptive)) Emergency Contraceptives CORTICOSTEROIDS - Steroid Hormone Drugs to ELLA TABS 6 Treat Systemic Swelling Conditions Glucocorticosteroids levonorgestrel (emergency 6 oc) tabs ACTIVE INJECTION KIT 5 BLM-1 KIT PLAN B ONE-STEP TABS (Use Levonorgestrel 5 ACTIVE INJECTION KIT 5 (Emergency OC)) BM KIT ACTIVE INJECTION KIT D 5 Progestin Contraceptives - IUD KIT KYLEENA IUD 6 SP ACTIVE INJECTION KIT 5 DL KIT LILETTA IUD 6 SP ACTIVE INJECTION KIT 5 DLM KIT MIRENA IUD 6 SP ACTIVE INJECTION KIT 5 KL-3 KIT SKYLA IUD 6 SP ACTIVE INJECTION KIT 5 Progestin Contraceptives - Implants KM KIT PA; SP ACTIVE INJECTION KIT L 5 NEXPLANON IMPL 6 KIT Progestin Contraceptives - Injectable ACTIVE INJECTION KIT 5 LM-DEP-1 KIT DEPO-PROVERA ACTIVE INJECTION KIT CONTRACEPTIVE SUSP 5 5 (Use Medroxyprogesterone LM-DEP-2 KIT Acetate (Contraceptive)) ACTIVE INJECTION KIT 5 DEPO-PROVERA M-1 KIT CONTRACEPTIVE SUSY 5 ARZE-JECT-A KIT 5 (Use Medroxyprogesterone Acetate (Contraceptive)) BETA 1 KIT KIT 5 DEPO-SUBQ PROVERA 6 104 SUSY BETA INJECT KIT KIT 5 medroxyprogesterone acetate (contraceptive) 6 BETALIDO KIT 5 susp

Updated August 1, 2018

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BETALOAN SUIK KIT 5 DEXAMETHASONE ACETATE/DEXAMETHAS 5 BETAMETHASONE ONE PHOSPHATE SUSP ACETATE/BETAMETHAS 5 dexamethasone elix 0.5 2 ONE SUSP mg/5ml BETAMETHASONE DEXAMETHASONE 5 COMBO SUSP 3MG/ML- 4 INTENSOL CONC 3MG/ML DEXAMETHASONE BETAMETHASONE SODIUM PHOSPHATE 4 COMBO SUSP 3MG/ML- 5 SOLN IJ 10 MG/ML 4MG/ML DEXAMETHASONE betamethasone sod 2 SODIUM PHOSPHATE phosphate & acetate susp SOLN IJ 10 MG/ML (Use 5 BETAMETHASONE Dexamethasone Sodium Phosphate) SODIUM 4 PHOSPHATE/BETAMETH dexamethasone sodium ASONE ACETATE SUSP phosphate soln ij 4 mg/ml, 2 BT INJECTION KIT KIT 5 10 mg/ml, 20 mg/5ml, 100 mg/10ml, 120 mg/30ml budesonide cpep 3 mg 1 DEXAMETHASONE SODIUM 5 budesonide tb24 9 mg 2 PHOSPHATE/SODIUM CHLORIDE SOLN BUPIVILOG KIT KIT 5 DEXAMETHASONE SOLN 4 0.5 MG/5ML CELESTONE-SOLUSPAN dexamethasone tabs 0.75 SUSP (Use 5 mg, 0.5 mg, 4 mg, 6 mg, 2 Betamethasone Sod 1.5 mg Phosphate & Acetate) DEXAMETHASONE TABS 4 CORTEF TABS (Use 5 1 MG, 2 MG Hydrocortisone) dexamethasone tbpk 1.5 2 CORTISONE ACETATE 4 mg TABS DEXLIDO KIT 5 DEPO-MEDROL SUSP 20 5 MG/ML DEPO-MEDROL SUSP 40 DEXLIDO-M KIT 5 MG/ML, 80 MG/ML (Use 5 DEXPAK 10 DAY TBPK 5 Methylprednisolone (Use Dexamethasone) Acetate) DEXPAK 13 DAY TBPK 5 DERMACINRX CINLONE-I 5 (Use Dexamethasone) CPI KIT DEXPAK 6 DAY TBPK 5 DEX COMBO SUSP 5 (Use Dexamethasone) DOUBLEDEX KIT 5 DEX LA 16 SUSP 5 DYURAL-40 KIT 5 DEXAMETHASONE (LA) 5 SUSP DYURAL-80 KIT 5

Updated August 1, 2018

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DYURAL-L KIT 5 METHYLPREDNISOLONE ACETATE SUSP 50 5 DYURAL-LM KIT 5 MG/ML METHYLPREDNISOLONE EMFLAZA SUSP 5 ACETATE/BUPIVACAINE 5 HYDROCHLORIDE SUSP EMFLAZA TABS 5 methylprednisolone sod 2 succ solr ENTOCORT EC CPEP 5 METHYLPREDNISOLONE 4 (Use Budesonide) SUSP IJ 80 MG/ML hydrocortisone tabs 2 methylprednisolone tabs or 2 4 mg, 8 mg, 16 mg, 32 mg INTERARTICULAR JOINT 5 KIT KIT methylprednisolone tbpk or 2 4 mg JTT PHYSICIANS KIT KIT 5 METHYLPREDNISOLONE/ 5 LIDOCAINE SUSP KENALOG-10 SUSP 5 MILLIPRED DP TBPK 5 KENALOG-40 SUSP (Use 5 Triamcinolone Acetonide) MILLIPRED SOLN 10 MG/5ML (Use 5 LIDOLOG KIT KIT 5 Prednisolone Sodium Phosphate) LT INJECTION KIT KIT 5 MILLIPRED TABS 5 MG 5 MARBETA-25 KIT 5 MLK F1 KIT KIT 5 MARBETA-L KIT 5 MLK F2 KIT KIT 5 MARDEX-25 KIT 5 MLK F3 KIT KIT 5 MAS CARE-PAK KIT 5 MLK F4 KIT KIT 5 MEDROL DOSEPAK TBPK 5 (Use Methylprednisolone) MLP A-1 KIT 5 MEDROL TABS 2 MG 5 MLP A-2 KIT 5 MEDROL TABS 4 MG, 8 MG, 16 MG, 32 MG (Use 5 MULTI-SPECIALTY KIT 5 Methylprednisolone) KIT ORAPRED ODT TBDP MEDROLOAN II SUIK KIT 5 (Use Prednisolone Sodium 5 Phosphate) MEDROLOAN SUIK KIT 5 P-CARE D40G KIT 5 METHYLPREDNISOLONE ACETATE SUSP 40 4 P-CARE D40MX KIT 5 MG/ML, 80 MG/ML P-CARE D80G KIT 5 methylprednisolone acetate 2 susp 40 mg/ml, 80 mg/ml

Updated August 1, 2018

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P-CARE D80MX KIT 5 PREDNISOLONE SOLN 4

P-CARE K40 KIT 5 prednisolone syrp 2

P-CARE K40G KIT 5 PREDNISONE INTENSOL 5 CONC P-CARE K40MX KIT 5 PREDNISONE SOLN 5 4 MG/5ML P-CARE K80 KIT 5 prednisone tabs 1 mg, 5 2 mg, 10 mg, 20 mg, 2.5 mg P-CARE K80G KIT 5 PREDNISONE TABS 50 4 MG P-CARE K80MX KIT 5 PREDNISONE TBPK 5 4 PEDIAPRED SOLN (Use MG, 10 MG Prednisolone Sodium 5 PRO-C-DURE 1 KIT KIT 5 Phosphate) PHYSICIANS EZ USE PRO-C-DURE 2 KIT KIT 5 JOINT TUNNEL AND 5 TRIGGER KIT PRO-C-DURE 3 KIT KIT 5 PHYSICIANS EZ USE M- 5 PRED KIT PRO-C-DURE 4 KIT KIT 5

POD-CARE 100C KIT 5 PRO-C-DURE 5 KIT KIT 5

POD-CARE 100CG KIT 5 PRO-C-DURE 6 KIT KIT 5

POD-CARE 100CMX KIT 5 RAYOS TBEC 5 POD-CARE 100K KIT 5 READYSHARP ANESTHETICS 5 POD-CARE 100KG KIT 5 +BETAMETHASONE KIT READYSHARP POD-CARE 100KMX KIT 5 ANESTHETICS 5 +DEXAMETHASONE KIT prednisolone sodium QL(240 ml per phosphate soln or 15 2 fill retail) READYSHARP mg/5ml ANESTHETICS 5 +METHYLPREDNISOLON PREDNISOLONE SODIUM E 80 KIT PHOSPHATE SOLN OR 4 25 MG/5ML READYSHARP 5 BETAMETHASONE KIT prednisolone sodium READYSHARP phosphate soln or 5 2 5 mg/5ml, 10 mg/5ml, 20 DEXAMETHASONE KIT mg/5ml READYSHARP prednisolone sodium METHYLPREDNISOLONE 5 phosphate tbdp or 10 mg, 2 80 KIT 15 mg, 30 mg READYSHARP 5 TRIAMCINOLONE KIT prednisolone soln 2

Updated August 1, 2018

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits READYSHARP-K KIT 5 COUGH/COLD/ALLERGY - Drugs to Treat Cough, Cold and Allergy Symptoms READYSHARP-P40 KIT 5 Antitussives READYSHARP-P80 KIT 5 benzonatate caps 2

hydrocodone w/ 2 SOLU-CORTEF SOLR 5 homatropine syrp SOLU-MEDROL SOLR 2 5 hydrocodone w/ 2 GM, 500 MG homatropine tabs SOLU-MEDROL SOLR 40 TESSALON PERLES 5 MG, 125 MG, 1000 MG 5 CAPS (Use Benzonatate) (Use Methylprednisolone Sod Succ) Cough/Cold/Allergy Combinations TAPERDEX 12-DAY TBPK 5 ACTIDOM DMX LIQD 5 ALAHIST DM LIQD TAPERDEX 6-DAY TBPK 5 4MG/5ML-15MG/5ML- 7.5MG/5ML (Use 5 TOPIDEX KIT 5 Phenylephrine- Brompheniramine-DM) TRIAMCINOLONE 5 ACETONIDE SUSP ALLEGRA-D 12 HOUR QL(2 ea daily) ALLERGY & triamcinolone acetonide 2 CONGESTION TB12 (Use 5 susp Fexofenadine- TRIAMCINOLONE Pseudoephedrine) ACETONIDE/BUPIVACAIN 5 ALLEGRA-D 24 HOUR E HYDROCHLORIDE ALLERGY & SUSP CONGESTION TB24 (Use 5 TRIAMCINOLONE 5 Fexofenadine- DIACETATE SUSP Pseudoephedrine) TRIAMCINOLONE SUSP 5 AMBI 60PSE/400GFN 5 TABS TRILOAN II SUIK KIT 5 AP-HIST DM LIQD 5

TRILOAN SUIK KIT 5 BALAMINE DM SYRP 5 UCERIS TB24 OR 9 MG 5 (Use Budesonide) BIODESP DM SYRP 5 VERIPRED 20 SOLN (Use Prednisolone Sodium 5 BIOSPEC DMX LIQD 5 Phosphate) brompheniramine & ZODEX 12-DAY TBPK 5 phenyleph susp 6mg/5ml- 2 10mg/5ml ZODEX 6-DAY TBPK 5 CARBAPHEN 12 LIQD 5

Mineralocorticoids CARBAPHEN 12 PED 5 SUSP fludrocortisone acetate 2 tabs

Updated August 1, 2018

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cetirizine-pseudoephedrine 2 dextromethorphan- tb12 guaifenesin tb12 30mg- 2 CHERACOL PLUS LIQD 600mg, 60mg-1200mg (Use Dextromethorphan- 5 DOMETUSS-DMX LIQD 5 Guaifenesin) CHERACOL-D COUGH DRIXORAL 5 COLD/ALLERGY TB12 LIQD (Use 5 Dextromethorphan- DURAFLU TABS 60MG- 5 Guaifenesin) 20MG-500MG-200MG chlorpheniramine & ED A-HIST LIQD (Use phenylephrine liqd 2 Chlorpheniramine & 5 4mg/5ml-10mg/5ml Phenylephrine) chlorpheniramine & 2 ENTRE-B SUSP 5 pseudoeph tabs CLARINEX-D 12 HOUR 5 ENTRE-HIST PSE LIQD 5 TB12 EXACTUSS LIQD (Use 5 RX/OTC CODAR AR LIQD 5 Phenylephrine w/ DM-GG) RX/OTC CODITUSSIN AC LIQD 5 EXACTUSS TR TABS 5 CONGESTAC TABS (Use EXAPHEX TR TABS 5 RX/OTC Pseudoephedrine- 5 Guaifenesin) fexofenadine- QL(2 ea daily) pseudoephedrine tb12 2 DECON-A ELIX 2MG/5ML- 5 5MG/5ML 60mg-120mg fexofenadine- DECON-G LIQD 5 pseudoephedrine tb24 2 DESGEN DM SYRP 180mg-240mg 15MG/5ML-100MG/5ML- 5 FLOWTUSS SOLN 5 5MG/5ML dextromethorphan- GILPHEX TR TABS 5 RX/OTC guaifenesin liqd 10mg/5ml- 100mg/5ml, 20mg/10ml- GILTUSS COUGH & COLD 5 RX/OTC 200mg/10ml, 15mg/7.5ml- 2 TABS 28MG-388MG-10MG 150mg/7.5ml, 10mg/5ml- GILTUSS LIQD (Use 5 RX/OTC 10mg/5ml-100mg/5ml- Phenylephrine w/ DM-GG) 100mg/5ml GILTUSS SINUS & 5 RX/OTC dextromethorphan- CONGESTION TABS guaifenesin soln 10mg/5ml- 2 RX/OTC 100mg/5ml, 20mg/10ml- GILTUSS TR TABS 5 200mg/10ml guaifenesin-codeine liqd 2 dextromethorphan- 100mg/5ml-10mg/5ml guaifenesin syrp guaifenesin-codeine soln 10mg/5ml-100mg/5ml, 2 100mg/5ml-10mg/5ml, 2 10mg/5ml-10mg/5ml- 100mg/5ml-6.3mg/5ml 100mg/5ml-100mg/5ml guaifenesin-codeine syrp 2 100mg/5ml-10mg/5ml

Updated August 1, 2018

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HISTEX-PE SYRP 5 phenylephrine- brompheniramine-dm liqd HYCOFENIX SOLN 5 4mg/5ml-20mg/5ml- 2 10mg/5ml, 4mg/5ml- HYDROCODONE 15mg/5ml-7.5mg/5ml BITARTRATE/CHLORPHE 4 phenylephrine-chlorphen- NIRAMINE MALEATE/PSE dm liqd 15mg/5ml- 2 SOLN 4mg/5ml-10mg/5ml hydrocodone polistirex- PHENYLEPHRINE/GUAIF 4 chlorpheniramine polistirex 2 ENESIN LIQD suer PHENYLHISTINE DH LIQD 5 LEXUSS 210 LIQD 5 promethazine & 2 QL(240 ml per LOHIST-D LIQD 5 phenylephrine soln fill retail) promethazine & 2 QL(240 ml per LOHIST-DM SYRP 5 phenylephrine syrp fill retail) promethazine w/codeine 2 MUCINEX D MAXIMUM soln STRENGTH TB12 (Use 5 Pseudoephedrine- promethazine w/codeine 2 Guaifenesin) syrp MUCINEX D TB12 (Use promethazine-dm syrp 2 Pseudoephedrine- 5 Guaifenesin) promethazine- 2 MUCINEX DM MAXIMUM phenylephrine-codeine syrp PROMETHAZINE/PHENYL QL(240 ml per STRENGTH TB12 (Use 5 4 Dextromethorphan- EPHRINE SYRP fill retail) Guaifenesin) pseudoephed-bromphen- MUCINEX DM TB12 (Use dm syrp 2mg/5ml- 2 Dextromethorphan- 5 30mg/5ml-10mg/5ml Guaifenesin) pseudoephed-cpm w/ 2 hydrocod soln NEOTUSS PLUS LIQD 5 pseudoephedrine w/ 2 NORTUSS-EX LIQD 5 codeine-gg soln pseudoephedrine- OBREDON SOLN 5 guaifenesin tb12 60mg- 2 600mg, 120mg-1200mg phenylephrine w/ dm-gg liqd 5mg/5ml-75mg/5ml- 2 RELHIST CHEW 5 2.5mg/5ml phenylephrine w/ dm-gg RX/OTC REZIRA SOLN 5 liqd 5mg/ml-50mg/ml- ROBITUSSIN CHILDRENS 5 2.5mg/ml, 7.5mg/ml- COUGH & COLD CF LIQD 88mg/ml-2.5mg/ml, 15mg/5ml-300mg/5ml- 2 ROBITUSSIN DM SYRP 10mg/5ml, 28mg/5ml- (Use Dextromethorphan- 5 388mg/5ml-10mg/5ml, Guaifenesin) 7.5mg/2.5ml-150mg/2.5ml- 5mg/2.5ml

Updated August 1, 2018

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROBITUSSIN PEAK COLD Misc. Respiratory Inhalants DM SYRP (Use 5 HYPER-SAL NEBU (Use 5 Dextromethorphan- )) Guaifenesin) Sodium Chloride (Inhalant 5 SEMPREX-D CAPS 5 HYPERSAL NEBU 3.5 % HYPERSAL NEBU 7 % SORBUTUSS NR LIQD 5 (Use Sodium Chloride 5 (Inhalant)) TUSNEL C SYRP 5 NEBUSAL NEBU 5 TUSSI-PRES PEDIATRIC LIQD (Use Phenylephrine 5 sodium chloride (inhalant) w/ DM-GG) nebu 0.9 %, 3 %, 7 %, 10 2 % TUSSICAPS CP12 5 Mucolytics TUSSIONEX PENNKINETIC acetylcysteine soln 2 EXTENDED RELEASE DERMATOLOGICALS - Drugs to Treat Skin SUER (Use Hydrocodone 5 Conditions Polistirex- Chlorpheniramine Acne Products Polistirex) ABSORICA CAPS 10 MG, 4 QL(2 ea daily) TUZISTRA XR SUER 5 20 MG, 30 MG, 40 MG ABSORICA CAPS 25 MG, 5 VITUZ SOLN 5 35 MG ACANYA GEL 4 Z-TUSS AC LIQD 5 ACZONE GEL 5 % (Use 5 ZUTRIPRO SOLN (Use Dapsone (Topical)) Pseudoephed-CPM w/ 5 Hydrocod) ACZONE GEL 7.5 % 5 ZYRTEC-D adapalene crea 0.1 % 2 ALLERGY/CONGESTION 5 TB12 (Use Cetirizine- RX/OTC Pseudoephedrine) adapalene gel 0.1 % 2 Expectorants adapalene gel 0.3 % 2 guaifenesin liqd 100 mg/5ml, 200 mg/10ml, 400 2 ADAPALENE LOTN 0.1 % 4 mg/20ml guaifenesin soln 100 adapalene-benzoyl 2 mg/5ml, 200 mg/10ml, 300 2 peroxide gel mg/15ml AKTIPAK PACK 5 guaifenesin tabs 200 mg, 2 400 mg ATRALIN GEL (Use 5 Tretinoin) guaifenesin tb12 600 mg 2 AVAR FOAM 5 MUCINEX TB12 (Use 5 Guaifenesin)

Updated August 1, 2018

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVAR LS CLEANSER benzoyl peroxide foam 5.3 2 RX/OTC LIQD (Use Sulfacetamide 5 % Sodium w/ Sulfur) benzoyl peroxide foam 9.8 2 AVAR LS FOAM 5 % benzoyl peroxide gel 10 % 2 RX/OTC AVAR LS PADS 5 BENZOYL PEROXIDE 5 AVAR PADS 5 GEL 2.5 % AVAR-E LS CREA (Use benzoyl peroxide gel 5 % 2 Sulfacetamide Sodium w/ 5 benzoyl peroxide liqd 4 %, 2 Sulfur) 7 % AZELEX CREA 5 benzoyl peroxide liqd 5 %, 2 RX/OTC 10 %, 2.5 % BENZAC AC WASH LIQD 5 RX/OTC (Use Benzoyl Peroxide) benzoyl peroxide lotn 6 % 2 BENZACLIN GEL (Use Clindamycin Phosphate- 5 benzoyl peroxide misc 6 % 2 Benzoyl Peroxide) benzoyl peroxide- 2 BENZACLIN WITH PUMP erythromycin gel GEL (Use Clindamycin 5 Phosphate-Benzoyl BP CLEANSING WASH 4 Peroxide) EMUL BENZAMYCIN GEL (Use BPO CREAMY WASH 5 Benzoyl Peroxide- 5 COMPLETEPACK KIT Erythromycin) BPO GEL 5 BENZEFOAM FOAM (Use 5 RX/OTC Benzoyl Peroxide) CLEOCIN-T GEL (Use Clindamycin Phosphate 5 BENZEFOAM ULTRA (Topical)) FOAM (Use Benzoyl 5 Peroxide) CLEOCIN-T LOTN (Use Clindamycin Phosphate 5 BENZIQ GEL 5 (Topical)) CLEOCIN-T SOLN (Use BENZIQ LS GEL 5 Clindamycin Phosphate 5 (Topical)) BENZIQ WASH LIQD 4 CLEOCIN-T SWAB (Use Clindamycin Phosphate 5 BENZOYL PEROXIDE 8% 5 GEL (Topical)) benzoyl peroxide bar 10 % 2 CLINDACIN ETZ KIT 5 BENZOYL PEROXIDE CLINDACIN PAC KIT 5 CLEANSER LOTN 3 %, 9 5 % CLINDAGEL GEL 4 BENZOYL PEROXIDE 4 CLEANSER LOTN 6 % clindamycin phosphate 2 (topical) foam benzoyl peroxide crea 10 2 % clindamycin phosphate 2 (topical) gel Updated August 1, 2018

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate 2 erythromycin (acne aid) 2 (topical) lotn soln clindamycin phosphate 2 EVOCLIN FOAM (Use (topical) soln Clindamycin Phosphate 5 (Topical)) clindamycin phosphate 2 (topical) swab FABIOR FOAM 5 CLINDAMYCIN 4 PHOSPHATE GEL EX 1 % INOVA 4/1 ACNE 5 clindamycin phosphate- CONTROL THERAPY KIT benzoyl peroxide 2 INOVA 8/2 ACNE 5 (refrigerate) gel CONTROL THERAPY KIT clindamycin phosphate- 2 INOVA KIT 5 benzoyl peroxide gel QL(2 ea daily) clindamycin phosphate- 2 isotretinoin caps 2 tretinoin gel KLARON LOTN (Use QL(120 ml per CLINDAMYCIN Sulfacetamide Sodium 5 fill retail) PHOSPHATE/BENZOYL 4 (Acne)) PEROXIDE GEL NEUAC KIT KIT 5 CLINOIN CREA 5 NEUTROGENA CLEAR dapsone (topical) gel 2 PORE CLEANSER/MASK 5 LIQD DESQUAM-X WASH LIQD 5 RX/OTC (Use Benzoyl Peroxide) OC8 GEL 5 DIFFERIN CREA 0.1 % 5 (Use Adapalene) ONEXTON GEL 5 DIFFERIN GEL 0.1 % (Use RX/OTC 5 PANOXYL LIQD (Use 5 RX/OTC Adapalene) Benzoyl Peroxide) DIFFERIN GEL 0.3 % (Use 5 PANOXYL-4 CREAMY Adapalene) WASH LIQD (Use Benzoyl 5 DIFFERIN LOTN 0.1 % 4 Peroxide) PLEXION CLEANSER DUAC GEL (Use LIQD (Use Sulfacetamide 5 Clindamycin Phosphate- 5 Sodium w/ Sulfur) Benzoyl Peroxide PLEXION CLEANSING 5 (Refrigerate)) CLOTHS PADS EPIDUO FORTE GEL 4 PLEXION CREA (Use Sulfacetamide Sodium w/ 5 EPIDUO GEL (Use Sulfur) Adapalene-Benzoyl 5 Peroxide) PLEXION LOTN (Use Sulfacetamide Sodium w/ 5 ERYGEL GEL (Use 5 Sulfur) Erythromycin (Acne Aid)) resorcinol-sulfur lotn 2 RX/OTC erythromycin (acne aid) gel 2 RETIN-A CREA (Use 5 erythromycin (acne aid) 2 Tretinoin) pads

Updated August 1, 2018

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETIN-A GEL (Use 5 sulfacetamide sodium w/ 2 Tretinoin) sulfur susp RETIN-A MICRO GEL 0.04 sulfacetamide sodium- 2 %, 0.1 % (Use Tretinoin 5 sulfur w/ skin cleanser kit Microsphere) sulfacetamide sodium- 2 RETIN-A MICRO GEL 0.06 4 QL(1.67 gm sulfur-sunscreen kit % daily) SUMADAN KIT KIT (Use RETIN-A MICRO PUMP Sulfacetamide Sodium- 5 GEL 0.04 %, 0.1 % (Use 5 Sulfur w/ Skin Cleanser) Tretinoin Microsphere) SUMADAN WASH LIQD RETIN-A MICRO PUMP 4 (Use Sulfacetamide 5 GEL 0.08 % Sodium w/ Sulfur) REZAMID LOTN (Use 5 RX/OTC SUMADAN XLT KIT (Use Resorcinol-Sulfur) Sulfacetamide Sodium- 5 Sulfur-Sunscreen) RIAX FOAM 5 SUMAXIN CP KIT KIT 5 ROSULA LIQD 4.5%-10% 5 SUMAXIN PADS (Use ROSULA PADS 5%-10% 4 Sulfacetamide Sodium w/ 5 Sulfur) SODIUM SUMAXIN TS SUSP (Use SULFACETAMIDE/SULFU 5 Sulfacetamide Sodium w/ 5 R CLEANSER IN UREA Sulfur) EMUL SUMAXIN WASH LIQD SODIUM (Use Sulfacetamide 5 SULFACETAMIDE/SULFU 4 Sodium w/ Sulfur) R IN UREA GEL SODIUM TRETIN-X CREA 5 SULFACETAMIDE/SULFU 4 R LOTN tretinoin crea 2 SODIUM tretinoin gel 2 SULFACETAMIDE/SULFU 5 R SUSP tretinoin microsphere gel 2 SSS 10-5 FOAM 4 VELTIN GEL 4 sulfacetamide sodium 2 QL(120 ml per (acne) lotn fill retail) ZACARE 4% KIT KIT 5 sulfacetamide sodium w/ 2 sulfur crea ZACARE 8% KIT KIT 5 sulfacetamide sodium w/ 2 sulfur emul ZACLIR CLEANSING 5 LOTN sulfacetamide sodium w/ 2 sulfur liqd ZIANA GEL (Use Clindamycin Phosphate- 5 sulfacetamide sodium w/ 2 Tretinoin) sulfur lotn Agents for External Genital and Perianal Warts sulfacetamide sodium w/ 2 sulfur pads VEREGEN OINT 5

Updated August 1, 2018

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Analgesics - Topical DICLOZOR THPK 5 A.A.G.C. KIT IN 5 TERODERM CREA DIPENTOCAINE CREA 5 ACTIVE-PREP KIT IV 5 CREA DS PREP PAK THPK 5 ACTIVE-TRAMADOL KIT 5 CREA DST PLUS PAK KIT 5 BACLOFEN CREA EX 2 % 5 DUAL COMPLEX 5 FORMULA 1 KIT CREA ENOVARX-BACLOFEN 5 ENOVARX-DICLOFENAC 5 CREA SODIUM CREA ENOVARX-TRAMADOL 5 ENOVARX-IBUPROFEN 5 CREA CREA EQUIPTO-BACLOFEN 5 ENOVARX-NAPROXEN 5 CREA CREA Anti-inflammatory Agents - Topical EQUIPTO-NAPROXEN 5 CREA ACTIVE-KETOPROFEN 5 RX/OTC KIT CREA FBL KIT CREA 5 ACTIVE-PREP KIT I CREA 5 FLECTOR PTCH 5 ACTIVE-PREP KIT II 5 CREA INFLAMMA-K KIT KIT 5 ACTIVE-PREP KIT III 5 CREA K.B.G.L. IN TERODERM 5 CREAM CREA AIF #2 DRUG 5 PREPARATIONKIT CREA KETOPHENE RAPIDPAQ 5 CREA AIF #3 DRUG 5 PREPARATION KIT CREA KETOROLAC 2% GEL 5 GEL DERMACINRX LEXITRAL PA PHARMAPAK THPK (Use 5 LEXIXRYL THPK 5 Diclofenac Sodium- Capsaicin (Topical)) LIDOPROFEN CREA 5 DICLO GEL PAK KIT 5 NAPRO 15% COMPOUNDING KIT 5 DICLO GEL/XRYLIX 5 CREA SHEETS THPK NP #2 DRUG 5 diclofenac sodium (topical) 2 PREPARATION KIT CREA gel PENNSAID SOLN 5 diclofenac sodium (topical) 2 soln REXAPHENAC CREA 5 DICLOFENAC SODIUM 5 CREA EX 3 % VOLTAREN GEL (Use diclofenac sodium- 2 PA Diclofenac Sodium 5 capsaicin (topical) thpk (Topical)) diclofenac sodium- 2 VOPAC 5 CREA 5 RX/OTC capsaicin (topical) thpk Updated August 1, 2018

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VOPAC CREA 5 butenafine hcl crea 2 RX/OTC

VOPAC GB CREA 5 CICLODAN CREAM KIT 5 KIT VOPAC KT CREA 5 CICLODAN SOLUTION 5 KIT KIT (Use Ciclopirox) VOPAC MDS KIT 5 ciclopirox gel 2

VP FC KIT CREA 5 ciclopirox kit 2

XRYLIX THPK 5 ciclopirox olamine crea 2 Antibiotics - Topical ciclopirox olamine susp 2 ALTABAX OINT 5 ciclopirox sham 2 BACTROBAN CREA (Use Mupirocin Calcium 5 ciclopirox soln 2 (Topical)) RX/OTC CENTANY AT KIT 5 clotrimazole (topical) crea 2 RX/OTC CENTANY OINT 5 clotrimazole (topical) soln 2 clotrimazole w/ 2 CORTISPORIN CREA 5 betamethasone crea CORTISPORIN OINT 5 clotrimazole w/ 2 betamethasone lotn gentamicin sulfate (topical) 2 crea CNL8 NAIL KIT KIT 5 DERMACINRX gentamicin sulfate (topical) 2 5 oint THERAZOLE PAK THPK mupirocin calcium (topical) 2 DERMASORB AF KIT 5 crea mupirocin oint 2 econazole nitrate crea 2

NEO-SYNALAR CREA 5 ECOZA FOAM 5

NEO-SYNALAR KIT KIT 5 ERTACZO CREA 5 Antifungals - Topical EXELDERM CREA 5 ACTIVE-PREP KIT V 5 CREA EXELDERM SOLN 5 ALA-QUIN CREA 5 EXODERM LOTN 25%-1% 5 ALCORTIN A GEL (Use EXTINA FOAM (Use 5 Iodoquinol-Hydrocortisone- 5 Ketoconazole (Topical)) Aloe Polysaccharide) FUNGIMEZ SOLN 5 RX/OTC ALOQUIN GEL 5

Updated August 1, 2018

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits G-MYCO NAIL SOLN 5 RX/OTC LULICONAZOLE CREA 4

GENTIAN VIOLET SOLN 1 5 LUZU CREA 4 % RX/OTC GNP GENTIAN VIOLET 5 MENTAX CREA 5 SOLN MICATIN CREA (Use HALOTIN CREA 5 Miconazole Nitrate 5 (Topical)) iodoquinol-hydrocortisone- 2 aloe polysaccharide gel miconazole nitrate (topical) 2 crea JUBLIA SOLN 4 MYCO NAIL SOLN 5 RX/OTC KERYDIN SOLN 5 MYCO-NAIL SOLN 5 RX/OTC ketoconazole (topical) crea 2 naftifine hcl crea 2 ketoconazole (topical) foam 2 NAFTIN CREA 2 % (Use 5 Naftifine HCl) ketoconazole (topical) 2 QL(120 ml per sham fill retail) NAFTIN GEL 1 %, 2 % 4 KETODAN KIT KIT 5 NIZORAL SHAM (Use 5 QL(120 ml per Ketoconazole (Topical)) fill retail) LAMISIL AT SPRAY SOLN 5 NYATA KIT 5 LOPROX CREA 0.77 % 5 (Use Ciclopirox Olamine) nystatin (topical) crea 2 LOPROX KIT 0.77% 5 nystatin (topical) oint 2 LOPROX SHAMPOO 5 SHAM (Use Ciclopirox) nystatin (topical) powd 2 LOPROX SUSP 0.77 % 5 (Use Ciclopirox Olamine) nystatin-triamcinolone crea 2 LOTRIMIN AF CREA 1 % RX/OTC (Use Clotrimazole 5 nystatin-triamcinolone oint 2 (Topical)) LOTRIMIN AF FOR HER RX/OTC oxiconazole nitrate crea 2 CREA (Use Clotrimazole 5 OXISTAT CREA (Use 5 (Topical)) Oxiconazole Nitrate) LOTRIMIN AF JOCK ITCH RX/OTC CREA (Use Clotrimazole 5 OXISTAT LOTN 5 (Topical)) PENLAC NAIL LACQUER 5 LOTRIMIN ULTRA CREA 5 RX/OTC SOLN (Use Ciclopirox) QUINJA GEL 5 LOTRIMIN ULTRA CREA 5 RX/OTC (Use Butenafine HCl) LOTRISONE CREA (Use RECURA CREA 5 Clotrimazole w/ 5 Betamethasone) VUSION OINT 5

Updated August 1, 2018

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XOLEGEL COREPAK KIT 5 DOXEPIN 4 HYDROCHLORIDE CREA XOLEGEL DUO/HEAD & 5 SHOULDERS KIT PRUDOXIN CREA 4 XOLEGEL DUO/XOLEX 5 ZONALON CREA 4 KIT XOLEGEL GEL 5 Antipsoriatics 8-MOP CAPS 5 Antihistamines-Topical acitretin caps 10 mg, 17.5 2 QL(1 ea daily) ALLO-PAX CREA 5 mg Antineoplastic or Premalignant Lesion Agents - acitretin caps 25 mg 2 QL(2 ea daily) AMELUZ GEL 5 2 QL(60 gm per calcipotriene crea fill retail) CARAC CREA 5 calcipotriene oint 2 diclofenac sodium (actinic 2 keratoses) gel 2 QL(60 ml per calcipotriene soln fill retail) EFUDEX CREA (Use 5 QL(40 gm per Fluorouracil (Topical)) fill retail) CALCITRIOL OINT EX 3 4 MCG/GM FLUOROPLEX CREA 5 COSENTYX 4 PA; SP QL(40 gm per SENSOREADY PEN SOAJ fluorouracil (topical) crea 2 fill retail) COSENTYX SOSY 4 PA; SP FLUOROURACIL CREA 5 EX 0.5 % DOVONEX CREA (Use 5 QL(60 gm per Calcipotriene) fill retail) FLUOROURACIL SOLN 4 QL(10 ml per EX 2 %, 5 % fill retail) DRITHO-CREME HP 5 CREA HYALUCIL-4 CREA 5 methoxsalen rapid caps 2 QL(4 ea daily) LEVULAN KERASTICK 5 SOLR OXSORALEN ULTRA QL(4 ea daily) CAPS (Use Methoxsalen 5 PANRETIN GEL 5 Rapid) PA PICATO GEL 4 SILIQ SOSY 5 SOLARAZE GEL (Use SORIATANE CAPS 10 QL(1 ea daily) Diclofenac Sodium (Actinic 5 MG, 17.5 MG (Use 5 Keratoses)) Acitretin) PA; SP SORIATANE CAPS 25 MG 5 QL(2 ea daily) TARGRETIN GEL EX 1 % 5 (Use Acitretin) TOLAK CREA 5 SORILUX FOAM 5

STELARA SOLN SC 45 4 PA; SP VALCHLOR GEL 5 MG/0.5ML Antipruritics - Topical STELARA SOSY SC 90 4 PA; SP MG/ML, 45 MG/0.5ML

Updated August 1, 2018

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TALTZ SOAJ 5 PROMISEB CREA 5 RX/OTC

TALTZ SOSY 5 2 QL(120 ml per selenium sulfide lotn 2.5 % fill retail) tazarotene crea 2 SODIUM SULFACETAMIDE WASH 5 TAZORAC CREA 0.05 % 4 LIQD sulfacetamide sodium gel 2 TAZORAC CREA 0.1 % 5 ex (Use Tazarotene) sulfacetamide sodium liqd 2 TAZORAC GEL 0.05 %, 4 ex 0.1 % sulfacetamide sodium 2 TREMFYA SOSY 5 PA sham ex Antivirals - Topical VECTICAL OINT 4 acyclovir topical oint 2 QL(1 gm daily) ZITHRANOL SHAM 5 DENAVIR CREA 4 ZITHRANOL-RR CREA 5 XERESE CREA 5 Antiseborrheic Products ZOVIRAX CREA EX 5 % 5 DERMAZINC CREAM 5 RX/OTC CREA ZOVIRAX OINT EX 5 % 5 QL(1 gm daily) GLYCOLIC ACID 70% 5 RX/OTC (Use Acyclovir Topical) HIGH PURITY SOLN Burn Products GLYCOLIC ACID SOLN 5 RX/OTC mafenide acetate pack 2 LOUTREX CREA 5 RX/OTC SILVADENE CREA (Use 5 Silver Sulfadiazine) OVACE PLUS CREA 10 % 5 silver sulfadiazine crea 2 OVACE PLUS FOAM 9.8 5 % SULFAMYLON CREA 85 5 MG/GM OVACE PLUS LOTN 9.8 % 5 SULFAMYLON PACK 5 % 5 OVACE PLUS SHAM 10 % (Use Mafenide Acetate) (Use Sulfacetamide 5 Cauterizing Agents Sodium) ARZOL SILVER NITRATE 4 OVACE PLUS WASH GEL APPLICATORS MISC (Use Sulfacetamide 5 Sodium) SILVER NITRATE OINT 5 OVACE PLUS WASH LIQD (Use Sulfacetamide 5 SILVER NITRATE SOLN 5 Sodium) TRI-CHLOR LIQD 5 OVACE WASH LIQD (Use 5 Sulfacetamide Sodium) Corticosteroids - Topical PROMISEB COMPLETE 5 KIT Updated August 1, 2018

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACLOVATE CREA (Use betamethasone valerate 2 Alclometasone 5 oint 0.1 % Dipropionate) calcipotriene- 2 ADVANCED ALLERGY 5 betamethasone COLLECTION KIT KIT dipropionate oint ALA SCALP LOTN (Use 5 CAPEX SHAM 5 Hydrocortisone (Topical)) alclometasone dipropionate 2 clobetasol propionate crea 2 crea clobetasol propionate alclometasone dipropionate 2 2 oint emollient base crea clobetasol propionate 2 AMCINONIDE CREA 4 emulsion foam AMCINONIDE LOTN 4 clobetasol propionate foam 2

AMCINONIDE OINT 5 clobetasol propionate gel 2

APEXICON E CREA 5 clobetasol propionate liqd 2 AUGMENTED clobetasol propionate lotn 2 BETAMETHASONE 4 DIPROPIONATE GEL clobetasol propionate oint 2 betamethasone 2 dipropionate (topical) crea clobetasol propionate sham 2 betamethasone 2 QL(60 ml per dipropionate (topical) lotn fill retail) clobetasol propionate soln 2 betamethasone 2 CLOBEX LIQD (Use 5 dipropionate (topical) oint Clobetasol Propionate) betamethasone CLOBEX LOTN (Use 5 dipropionate augmented 2 Clobetasol Propionate) crea CLOBEX SHAM (Use 5 betamethasone Clobetasol Propionate) dipropionate augmented 2 gel CLOCORTOLONE 4 PIVALATE CREA betamethasone dipropionate augmented 2 CLOCORTOLONE 4 lotn PIVALATE PUMP CREA betamethasone CLODAN KIT KIT 5 dipropionate augmented 2 oint CLODERM CREA 4 betamethasone valerate 2 crea 0.1 % CLODERM PUMP CREA 4 betamethasone valerate 2 CORDRAN CREA 0.05 % 5 foam 0.12 % (Use Flurandrenolide) betamethasone valerate QL(60 ml per 2 CORDRAN LOTN 0.05 % 5 lotn 0.1 % fill retail) (Use Flurandrenolide)

Updated August 1, 2018

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORDRAN OINT 0.05 % 5 desoximetasone oint 2 (Use Flurandrenolide) DIFLORASONE CORDRAN TAPE 4 5 4 MCG/SQCM DIACETATE CREA DIFLORASONE 4 CORDRAN TAPE TAPE 5 DIACETATE OINT CORTANE-B LOTN 5 DIPROLENE AF CREA (Use Betamethasone 5 Dipropionate Augmented) CUTIVATE LOTN (Use 5 Fluticasone Propionate) DIPROLENE LOTN (Use DERMA-SMOOTHE/FS Betamethasone 5 BODY OIL (Use 5 Dipropionate Augmented) Fluocinolone Acetonide) DIPROLENE OINT (Use DERMA-SMOOTHE/FS Betamethasone 5 SCALP OIL (Use 5 Dipropionate Augmented) Fluocinolone Acetonide) ELOCON CREA (Use 5 DERMACINRX SILAPAK Mometasone Furoate) KIT (Use Triamcinolone 5 ELOCON LOTN (Use 5 Acetonide-Dimethicone- Mometasone Furoate) Silicone) ELOCON OINT (Use 5 DERMASORB HC KIT 5 Mometasone Furoate) ENSTILAR FOAM 5 DERMASORB TA KIT 5 EPIFOAM FOAM 5 DERMATOP CREA (Use 5 Prednicarbate) FIRST- 5 DERMATOP OINT (Use 5 HYDROCORTISONE GEL Prednicarbate) fluocinolone acetonide crea 2 DERMAZONE THPK 5 PA 0.025 %, 0.01 % fluocinolone acetonide oil 2 DESONATE GEL 5 0.01 % fluocinolone acetonide oint 2 desonide crea 2 0.025 % fluocinolone acetonide soln 2 QL(60 ml per desonide lotn 2 0.01 % fill retail) desonide oint 2 fluocinonide crea 2 fluocinonide emulsified DESOWEN CREA (Use 5 2 Desonide) base crea DESOWEN LOTN (Use 5 fluocinonide gel 2 Desonide) desoximetasone crea 2 fluocinonide oint 2 desoximetasone gel 2 fluocinonide soln 2 desoximetasone liqd 2 flurandrenolide crea 2

Updated August 1, 2018

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flurandrenolide lotn 2 IMPOYZ CREA 5 flurandrenolide oint 2 KENALOG AERS (Use Triamcinolone Acetonide 5 fluticasone propionate crea 2 (Topical)) LOCOID CREA (Use 5 fluticasone propionate lotn 2 Hydrocortisone Butyrate) LOCOID LIPOCREAM fluticasone propionate oint 2 CREA (Use Hydrocortisone 5 Butyrate Hydrophilic Lipo HALAC KIT 5 Base) LOCOID LOTN (Use 5 halobetasol propionate 2 Hydrocortisone Butyrate) crea LOCOID OINT (Use 5 halobetasol propionate oint 2 Hydrocortisone Butyrate) LOCOID SOLN (Use 5 HALOG CREA 5 Hydrocortisone Butyrate) LUXIQ FOAM (Use 5 HALOG OINT 5 Betamethasone Valerate) hydrocortisone (topical) 2 RX/OTC MICORT-HC CREA 5 crea 1%, 1 % hydrocortisone (topical) 2 mometasone furoate crea 2 crea 2.5 % mometasone furoate oint 2 hydrocortisone (topical) 2 lotn 1 %, 2 %, 2.5 % mometasone furoate soln 2 hydrocortisone (topical) 2 QL(2 gm daily); oint 1 % RX/OTC MONISTAT SOOTHING RX/OTC hydrocortisone (topical) 2 CARE ITCH RELIEF CREA 5 oint 2.5 % (Use Hydrocortisone (Topical)) hydrocortisone (topical) 2 soln 1 % NOVACORT GEL 5 hydrocortisone butyrate 2 crea NOXIPAK THPK 5 hydrocortisone butyrate 2 hydrophilic lipo base crea NUCORT LOTN 5 hydrocortisone butyrate 2 lotn OLUX FOAM (Use 5 Clobetasol Propionate) hydrocortisone butyrate 2 oint OLUX-E FOAM (Use Clobetasol Propionate 5 hydrocortisone butyrate 2 Emulsion) soln PANDEL CREA 5 hydrocortisone valerate 2 crea PRAMOSONE CREA 1%- 5 hydrocortisone valerate 2 1% oint PRAMOSONE E CREA 5

Updated August 1, 2018

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRAMOSONE LOTN 1%- 5 TEMOVATE E CREA (Use 1%, 1%-2.5% Clobetasol Propionate 5 Emollient Base) PRAMOSONE OINT 1%- 5 1%, 1%-2.5% TEMOVATE OINT (Use 5 Clobetasol Propionate) pramoxine-hc gel 1%-2% 2 TEXACORT SOLN 5 PREDNICARBATE CREA 4 TOPICORT CREA (Use 5 prednicarbate crea 2 Desoximetasone) TOPICORT GEL (Use 5 PREDNICARBATE OINT 4 Desoximetasone) TOPICORT LIQD (Use 5 PSORCON CREA 4 Desoximetasone) TOPICORT OINT (Use 5 RRB PAK THPK 5 Desoximetasone) triamcinolone acetonide 2 SCALACORT DK KIT 5 (topical) aers 0.147 mg/gm triamcinolone acetonide SERNIVO EMUL 5 (topical) crea 0.025 %, 0.1 2 % SILAZONE PHARMAPAK 5 PA THPK triamcinolone acetonide 2 QL(15 gm per (topical) crea 0.5 % fill retail) SILAZONE-II THPK 5 PA triamcinolone acetonide QL(60 ml per SYNALAR CREA 0.025 % (topical) lotn 0.025 %, 0.1 2 fill retail) (Use Fluocinolone 5 % Acetonide) triamcinolone acetonide SYNALAR CREAM KIT KIT 5 (topical) oint 0.025 %, 0.1 2 % SYNALAR OINT 0.025 % triamcinolone acetonide 2 QL(15 gm per (Use Fluocinolone 5 (topical) oint 0.5 % fill retail) Acetonide) triamcinolone acetonide- 2 SYNALAR OINTMENT KIT 5 dimethicone-silicone kit KIT TRIAMSIL COMBIPAK 5 SYNALAR SOLN 0.01 % QL(60 ml per THPK (Use Fluocinolone 5 fill retail) TRIAMSIL MULTIPAK 5 Acetonide) THPK SYNALAR TS KIT 5 TRIANEX OINT 5 TACLONEX OINT (Use TRIDESILON CREA (Use 5 Calcipotriene- 5 Desonide) Betamethasone Dipropionate) ULTRAVATE CREA (Use 5 Halobetasol Propionate) TACLONEX SUSP 5 ULTRAVATE LOTN 5 TEMOVATE CREA (Use 5 Clobetasol Propionate) ULTRAVATE OINT (Use 5 Halobetasol Propionate)

Updated August 1, 2018

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRAVATE X KIT 5 URAMAXIN GT KIT KIT 5

VANOS CREA (Use 5 URAMAXIN LOTN 45 % 5 Fluocinonide) (Use Urea) VERDESO FOAM 5 urea crea 39 %, 41 %, 47 2 %, 50 % WESTCORT OINT (Use 5 RX/OTC Hydrocortisone Valerate) urea crea 40 % 2 XILAPAK KIT 5 UREA CREA 45 % 4

Eczema Agents urea foam 40 % 2 DUPIXENT SOSY 4 PA; SP urea gel 40 %, 45 % 2 Emollient/Keratolytic Agents urea in lactic acid vehicle 2 ALUVEA CREA (Use Urea) 5 foam urea in zinc undecylenate- 2 CEM-UREA SOLN 5 lactic acid vehicle emul UREA IN ZINC DERMASORB XM KIT 5 UNDECYLENATE/LACTIC 4 ACID VEHICLE EMUL GORDONS UREA OINT 40 5 % urea lotn 40 %, 45 % 2 HYDRO 35 FOAM (Use 5 Urea in Lactic Acid Vehicle) UREA LOTN 45 % 4 HYDRO 40 FOAM FOAM 5 (Use Urea) UREA NAIL KIT KIT 5 KERALAC CREA 4 UREA NAIL STCK 5

LATRIX XM EMUL 5 urea susp 50%, 40 % 2

RYNODERM CREA 5 UREA TOPICAL SUSP 4

SALRIX SUSP 5 URESOL CREA 5

UMECTA EMUL 5 UREVAZ CREA 5

UMECTA NAIL FILM SUSP 5 UTOPIC CREA (Use Urea) 5 (Use Urea) URAMAXIN CREA 45 % 5 Emollients (Use Urea) A + D PERSONAL CARE 5 RX/OTC URAMAXIN FOAM 20% 5 LOTION LOTN ALBOLENE CREA 5 RX/OTC URAMAXIN GEL 45 % 5 (Use Urea) ALEVAMAX CREA 5 RX/OTC URAMAXIN GT GEL (Use 5 Urea) ALOE AFTERSUN 5 RX/OTC LOTION LOTN

Updated August 1, 2018

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMLACTIN CERAPEUTIC 5 RX/OTC AVEENO POSITIVELY 5 RX/OTC LOTN RADIANT LOTN AMLACTIN ULTRA CREA 5 RX/OTC AVEENO POSITIVELY RX/OTC RADIANTOVERNIGHT 5 HYDRATING FACIAL AQUA GLYCOLIC FACE 5 RX/OTC CREAM CREA MOISTURI CREA AVEENO STRESS RELIEF RX/OTC AQUA GLYCOLIC HAND & 5 RX/OTC 5 BODYLOTION LOTN MOISTURIZING LOTN AQUA LACTEN LOTN 5 RX/OTC BASLE CREA 5 RX/OTC

AQUADERM RX/OTC BETA CARE CREA 5 RX/OTC TREATMENT/MOISTURIZ 5 ER LOTN BETA CARE LOTN 5 RX/OTC AQUAMED LOTN 5 RX/OTC BETA XMA CREA 5 RX/OTC AVEENO ACTIVE RX/OTC RX/OTC NATURALS DAILY 5 CAM LOTN 5 MOISTURIZING BODY YOGURT LOTN CERAVE AM SPF 30 5 RX/OTC AVEENO ACTIVE RX/OTC LOTN RX/OTC NATURALS DAILY 5 CERAVE CREA 5 MOISTURIZING BODY YOGURT/APRICO LOTN CERAVE LOTN 5 RX/OTC AVEENO ACTIVE RX/OTC RX/OTC NATURALS SKIN RELIEF 5 CERAVE PM LOTN 5 MOISTURE REPAIR CREA CERAVE RENEWING SA 5 RX/OTC AVEENO DAILY RX/OTC CREA MOISTURIZINGSPF 15 5 CERAVE SA RENEWING 5 RX/OTC LOTN LOTN RX/OTC AVEENO INTENSE 5 RX/OTC CETAPHIL CREA 5 RELIEF HAND CREA AVEENO POSITIVELY RX/OTC CETAPHIL DAILY RX/OTC AGELESSFIRMING BODY 5 ADVANCE ULTRA 5 LOTN HYDRATING LOTN AVEENO POSITIVELY RX/OTC CETAPHIL DAILY FACIAL 5 RX/OTC MOISTURIZER LOTN AGELESSSKIN 5 STRENGTHENING BODY CETAPHIL RX/OTC CREAM CREA DERMACONTROL 5 AVEENO POSITIVELY RX/OTC MOISTURIZER/SPF 30 LOTN AGELESSSKIN 5 STRENGTHENING HAND CETAPHIL RX/OTC CREAM CREA MOISTURIZING CREA 5 AVEENO POSITIVELY RX/OTC (Use Emollient) CETAPHIL RX/OTC NOURISHING 24-HOUR 5 5 ULTRA-HYDRATING MOISTURIZING LOTN CREA CETAPHIL 5 RX/OTC RESTORADERM LOTN

Updated August 1, 2018

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CETAPHIL THERAPEUTIC 5 RX/OTC DIABETIDERM FOOT 5 RX/OTC HAND CREA REJUVENATING CREA CLEAN & CLEAR RX/OTC DIABETIDERM HAND & 5 RX/OTC MORNING BURST 5 BODY LOTN HYDRATING RX/OTC MOISTURIZER GEL DIABETIDERM LOTN 5 CLN FACIAL RX/OTC DMAE CREA 5 RX/OTC MOISTURIZER 5 NOURISHING LOTN DML FORTE CREA 5 RX/OTC COCOA BUTTER HAND & 5 RX/OTC BODYLOTION LOTN DROXY CREAM CREA 5 RX/OTC COCOA BUTTER LOTN 5 RX/OTC ELON SKIN REPAIR 5 RX/OTC SYSTEM CREA COCOA BUTTER 5 RX/OTC PETROLEUM JELLY GEL EMOLLIA-CREME CREA 5 RX/OTC COCONUT OIL BEAUTY 5 RX/OTC CREA EMOLLIA-LOTION LOTN 5 RX/OTC COPASIL GEL 5 RX/OTC emollient crea 2 RX/OTC CVS DAILY ULTRA 5 RX/OTC MOISTURELOTION LOTN emollient lotn 1.25 %, 2 RX/OTC CVS MOISTURIZING 5 RX/OTC RX/OTC CREAM CREA EPILYT LOTN 5 DERMABASEOIL IN RX/OTC 5 EQ THERAPEUTIC DRY 5 RX/OTC WATER CREA SKIN CREA DERMAIDE ALOE CREA 5 RX/OTC EQ THERAPEUTIC RX/OTC MOISTURIZING CREAM 5 DERMAL THERAPY RX/OTC CREA EXTRA STRENGTH BODY 5 EQL ADVANCED RX/OTC LOTION LOTN RECOVERY SKIN CARE 5 DERMAL THERAPY FACE RX/OTC LOTN CAREMOISTURIZING 5 EQL MOISTURIZING 5 RX/OTC LOTION LOTN CREAM CREA DERMAL THERAPY FOOT 5 RX/OTC EQL ULTRA RX/OTC MASSAGE LOTN MOISTURIZING DAILY 5 DERMAL THERAPY HAND RX/OTC LOTION LOTN ELBOW & KNEE CREAM 5 RX/OTC LOTN EUCERIN BABY LOTN 5 DERMAL THERAPY HEEL 5 RX/OTC EUCERIN CALMING RX/OTC CARE LOTN DAILY MOISTURIZER 5 DERMEND RX/OTC CREA (Use Emollient) MOISTURIZING BRUISE 5 EUCERIN DAILY RX/OTC FORMULA CREA PROTECTION/SPF 30 5 DHEA CREA EX 1% 5 RX/OTC LOTN EUCERIN INTENSIVE 5 RX/OTC DIABETIDERM CREA 5 RX/OTC REPAIR LOTN

Updated August 1, 2018

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EUCERIN INTENSIVE 5 RX/OTC GOLD BOND ULTIMATE 5 RX/OTC REPAIRHAND CREA HEALING CREA EUCERIN LOTN 5 RX/OTC GOLD BOND ULTIMATE 5 RX/OTC HEALING LOTN EUCERIN ORIGINAL RX/OTC GOLD BOND ULTIMATE 5 RX/OTC HEALINGSOOTHING 5 LOTN REPAIR LOTN GOLD BOND ULTIMATE 5 RX/OTC EUCERIN PLUS CREA 5 RX/OTC PROTECTION LOTN GOLD BOND ULTIMATE 5 RX/OTC EUCERIN PLUS RX/OTC RESTORING LOTN INTENSIVE REPAIR 5 CREA (Use Emollient) GOLD BOND ULTIMATE RX/OTC SHEERRIBBONS 5 EUCERIN PLUS LOTN 5 RX/OTC PEARLRADIANCE LOTN EUCERIN RX/OTC GOLD BOND ULTIMATE RX/OTC PROFESSIONAL REPAIR 5 SHEERRIBBONS 5 RICH FEEL LOTN SILKSOFTNESS LOTN EUCERIN SKIN CALMING RX/OTC GOLD BOND ULTIMATE 5 RX/OTC DAILY MOISTURIZING 5 SOFTENING LOTN CREA (Use Emollient) GOLD BOND ULTIMATE 5 RX/OTC EUCERIN SMOOTHING RX/OTC SOOTHING CREA REPAIRADVANCED 5 GOLD BOND ULTIMATE 5 RX/OTC FORMULA LOTN SOOTHING LOTN RX/OTC FORMULA 405 5 RX/OTC GRX VITAMIN E LOTN 5 ENRICHED EYE CREA HPR PLUS/MB FORMULA 405 FACE 5 RX/OTC 5 CREAM CREA HYDROGEL KIT FORMULA 405 LIGHT RX/OTC hyaluronate sodium 2 TEXTURED 5 (emollient) gel MOISTURIZER CREA HYDRASYN25 CREA 5 RX/OTC FORMULA 405 5 RX/OTC MOISTURIZING LOTN HYDRAZONE LOTION 5 RX/OTC LOTN GENTLE CREA 5 RX/OTC HYDRO-LAN CREA 5 RX/OTC GNP ADVANCED 5 RX/OTC RECOVERY LOTN HYLIRA GEL 0.2 % (Use Hyaluronate Sodium 5 GOLD BOND MEDICATED RX/OTC (Emollient)) BODYLOTION EXTRA 5 STRENGTH LOTN HYLIRA LOTN 0.1 % 5 GOLD BOND MEDICATED 5 RX/OTC BODYLOTION LOTN J & J BURN CREAM CREA 5 RX/OTC GOLD BOND ULTIMATE RX/OTC RX/OTC DIABETICS DRY SKIN 5 KERADAN CREA 5 RELIEF LOTN KERI ADVANCED RX/OTC GOLD BOND ULTIMATE RX/OTC MOISTURE THERAPY 5 DIABETICS' DRY RELIEF 5 LOTN LOTN

Updated August 1, 2018

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KERI BASIC ESSENTIALS 5 RX/OTC LUBRIDERM DAILY RX/OTC LOTN MOISTURE/NORMAL TO 5 DRY SKIN LOTN KERI LONG LASTING 5 RX/OTC CREA LUBRIDERM DAILY RX/OTC MOISTURESHEA + KERI NOURISHING SHEA 5 RX/OTC 5 BUTTER LOTN CALMING LAVENDER JASMINE LOTN KERI ORIGINAL LOTN 5 RX/OTC LUBRIDERM INTENSE 5 RX/OTC SKIN REPAIR LOTN KERI OVERNIGHT LOTN 5 RX/OTC LUBRIDERM LOTN 5 RX/OTC KERI RENEWAL MILK 5 RX/OTC BODY LOTN LUBRIDERM MENS 3-IN-1 5 RX/OTC LOTN KERI RENEWAL SKIN 5 RX/OTC FIRMING LOTN LUBRIDERM SERIOUSLY 5 RX/OTC KERI RENEWAL RX/OTC SENSITIVE LOTN STRETCH MARK 5 LUBRIDERM SKIN RX/OTC MINIMIZER LOTN NOURISHINGWITH SHEA 5 AND COCOA BUTTERS KERI SENSITIVE SKIN 5 RX/OTC LOTN LOTN LAC-HYDRIN CREA (Use RX/OTC LUBRISOFT LOTN 5 RX/OTC Lactic Acid (Ammonium 5 Lactate)) MAXAM LOTN 5 RX/OTC LAC-HYDRIN LOTN (Use RX/OTC Lactic Acid (Ammonium 5 MEDELA TENDER CARE 5 RX/OTC Lactate)) LANOLIN CREA LAC-HYDRIN TWELVE RX/OTC MEDERMA AG FACE 5 RX/OTC LOTN (Use Lactic Acid 5 CREAM CREA (Ammonium Lactate)) MEDERMA AG HAND & 5 RX/OTC BODY LOTION LOTN lactic acid (ammonium 2 RX/OTC lactate) crea 12 % MEDERMA STRETCH 5 RX/OTC MARKS THERAPY CREA lactic acid (ammonium 2 lactate) lotn 10 % MOISTURIZING CREAM 5 RX/OTC CREA lactic acid (ammonium 2 RX/OTC lactate) lotn 12 % MOTHERS FRIEND CREA 5 RX/OTC lactic acid w/ vitamin e crea 2 MOTHERS FRIEND LOTN 5 RX/OTC LACTINOL HX CREA 5 RX/OTC MSM SKIN LOTION LOTN 5 RX/OTC LADY ESTHER 4 RX/OTC PURPOSE FACE CREAM 5 NEOSALUS LOTN 5 RX/OTC CREA NEUTROGENA BODY RX/OTC LANOLOR CREA 5 RX/OTC LIGHT SESAME 5 FORMULA LOTN LEADER FINGER CREAM 5 RX/OTC CREA NEUTROGENA HAND 5 RX/OTC CREA LUBRIDERM ADVANCED 5 RX/OTC THERAPY LOTN

Updated August 1, 2018

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEUTROGENA RX/OTC NUTRASEB CREA 5 RX/OTC HAND/NORWEGIANFOR 5 MULA/FAST ABSORBING PEN-KERA CREA 5 RX/OTC CREA RX/OTC NEUTROGENA HEALTHY 5 RX/OTC PENTRAVAN CREA 5 SKIN CREA RX/OTC NEUTROGENA HEALTHY 5 RX/OTC PENTRAVAN PLUS CREA 5 SKIN FACE SPF 15 LOTN NEUTROGENA RX/OTC PRETTY FEET & HANDS 5 RX/OTC MOISTURE SENSITIVE 5 CREA SKIN LOTN RA DAYLOGIC HEALING RX/OTC NISEKO HYDRATING RX/OTC DRY SKIN THERAPY 5 FACIAL MOISTURIZER 5 LOTN CREA RA GENTLE SKIN CREAM 5 RX/OTC CREA NIVEA CREA 5 RX/OTC RA RENEWAL DRY SKIN 5 RX/OTC THERAPY LOTN NIVEA EXTRA ENRICHED 5 RX/OTC LOTION LOTN RADIAGUARD 5 RX/OTC ADVANCED LOTN NIVEA EXTRA ENRICHED 5 RX/OTC LOTN REMIGEN CREAM CREA 5 RX/OTC NIVEA GENTLE BODY 5 RX/OTC EXFOLIATOR LOTN RESTA CREA 5 RX/OTC NIVEA LIGHT CREA 5 RX/OTC RESTA LITE LOTN 5 RX/OTC NIVEA LIGHT LOTN 5 RX/OTC RISABAL-PH CREA 5 RX/OTC NIVEA LOTN 5 RX/OTC ROC DEEP WRINKLE 5 RX/OTC RX/OTC SERUM LOTN NIVEA ORIGINAL LOTN 5 ROC MULTI CORREXION RX/OTC 5 IN1 RESTORING EYE 5 NIVEA ORIGINAL 5 RX/OTC MOISTURE LOTN CREAM CREA RX/OTC ROC MULTI CORREXION RX/OTC NIVEA SOFT CREA 5 5 IN1 RESTORING NIGHT 5 CREAM CREA NIVEA VISAGE CREA 5 RX/OTC ROC RETINOL 5 RX/OTC NIVEA VISAGE INNER RX/OTC CORREXION CREA BEAUTY NIGHTTIME 5 ROC RETINOL 5 RX/OTC RENEWAL CREA CORREXION MAX CREA NIVEA VISAGE LOTN 5 RX/OTC ROC RETINOL RX/OTC CORREXION NIGHT 5 NUTRADERM ADVANCED 5 RX/OTC CREA FORMULA LOTN ROC RETINOL RX/OTC NUTRADERM CREA RX/OTC CORREXION SENSITIVE 5 2.5%-2.5%-2.5%-2.5%- 5 EYE CREA 2.5%-2.5% ROC RETINOL RX/OTC 5 NUTRADERM LOTN 2.5%- 5 RX/OTC CORREXION SENSITIVE 2.5%-2.5%-2.5%-2.5% NIGHT CREA Updated August 1, 2018

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROSE MILK LOTN 5 RX/OTC VP DERMABASE CREA 5 RX/OTC

SKIN REPAIR LOTN 5 RX/OTC WIBI LOTN 5 RX/OTC

SOOTHE & COOL RX/OTC ZIMS CRACK CREME 5 RX/OTC MOISTURIZING BODY 5 DAYTIME CREA LOTION WITH ALOE LOTN Enzymes - Topical SOOTHE & COOL SKIN RX/OTC SANTYL OINT 5 CREAMWITH ALOE & 5 VITAMINS A, D & E CREA Immunomodulating Agents - Topical RX/OTC ALDARA CREA (Use 5 QL(0.2667 ea SORBOLENE CREA 5 Imiquimod) daily) SPECIAL CARE CREAM 5 RX/OTC 2 QL(0.2667 ea CREA imiquimod crea daily) ST IVES SWISS RX/OTC 4 QL(0.934 gm FORMULA 24HOUR 5 ZYCLARA CREA daily) MOISTURE LOTN ZYCLARA PUMP CREA 4 STUDIO 35 EXTRA RX/OTC 2.5 % MOISTURIZING LOTION 5 ZYCLARA PUMP CREA 4 QL(0.934 gm LOTN 3.75 % daily) STUDIO 35 RX/OTC MOISTURIZING SKIN 5 Immunosuppressive Agents - Topical CREA ELIDEL CREA 4 QL(1 gm daily) THERABETIC SKIN CARE 5 RX/OTC LOTN PROTOPIC OINT (Use 5 QL(1 gm daily) Tacrolimus (Topical)) THERAPEUTIC 5 RX/OTC MOISTURIZING CREA tacrolimus (topical) oint 2 QL(1 gm daily) THERAPLEX 5 RX/OTC HYDROLOTION LOTN Keratolytic/Antimitotic Agents TRIPLE CREAM CREA 5 RX/OTC BENSAL HP OINT 5

TROPAZONE LOTN 5 RX/OTC CONDYLOX GEL 5 CONDYLOX SOLN (Use QL(4 ml per fill UDDERLY SMOOTH 5 RX/OTC 5 CREA Podofilox) retail) UDDERLY SMOOTH 5 RX/OTC GORDOFILM SOLN 5 EXTRA CARE CREA KERALYT GEL 6 % (Use 5 UDDERLY SMOOTH 5 RX/OTC Salicylic Acid) EXTRA CARE20 CREA KERALYT SCALP KIT 5 VANICREAM CREA 5 RX/OTC PODOCON 25 IN VANICREAM LITE LOTN 5 RX/OTC BENZOIN TINCTURE 5 SOLN VELVACHOL CREA 5 RX/OTC 2 QL(4 ml per fill podofilox soln retail) VITAMIN E WITH 5 RX/OTC PANTHENOL CREA Updated August 1, 2018

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PYROGALLIC ACID OINT 5 REMATEX CREA 5

SALEX CREAM KIT (Use 5 SILMANIX PAIN 5 Salicylic Acid w/ Cleanser) RELIEIVINGCREAM CREA SALEX LOTION KIT (Use 5 TURPENTINE SPIRITS 5 Salicylic Acid w/ Cleanser) SPRT SALEX SHAM (Use 5 Local Anesthetics - Topical Salicylic Acid) 1ST RELIEF TOPICAL 5 salicylic acid crea ex 6 % 2 SPRAY LIQD ACCUCAINE KIT 5 salicylic acid foam ex 6 % 2 ADAZIN CREA 5 salicylic acid gel ex 6 % 2 ALIVIO PATCH PTCH 5 RX/OTC salicylic acid liqd ex 26 %, 2 27.5 % ALOCANE EMERGENCY RX/OTC salicylic acid lotn ex 6 % 2 BURN MAXIMUM 5 STRENGTH GEL salicylic acid sham ex 6 % 2 ANACAINE OINT 5 salicylic acid soln ex 26 %, 2 28.5 % ANASTIA LOTN 5 salicylic acid w/ cleanser kit 2 ANODYNERX PTCH 5

SALIMEZ FORTE CREA 5 ASTERO GEL 5 RX/OTC

SALISOL SOLN 5 AVADERM CREA 5 RX/OTC

SALITECH LOTN 5 CADIRAMD KIT 5

SALVAX DUO PLUS KIT 5 capsaicin-menthol disk 2 SALVAX FOAM (Use 5 Salicylic Acid) capsaicin-menthol ptch 2 ULTRASAL-ER SOLN 5 CAPSIDERM PTCH 5 RX/OTC (Use Salicylic Acid) VIRASAL LIQD (Use 5 CETACAINE AERO 5 Salicylic Acid) CLEVER CHOICE Liniments COMFORT EZPATCH 5 MEDI-DERM CREA 5 RX/OTC PTCH CMX PATCH PTCH 5 RX/OTC MEDI-DERM-RX CREA 5 RX/OTC COCAINE HCL SOLN 4 MEDROX-RX OINT 5 DERMACINRX METHYL SALICYLATE 5 RX/OTC DUOPATCH PHARMAPAK 5 LIQD THPK

Updated August 1, 2018

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACINRX LENZAPATCH PTCH (Use 5 RX/OTC NEUROTRAL 5 Lidocaine-Menthol) PHARMAPAK THPK LEVATIO PATCH PTCH 5 RX/OTC DERMACINRX PHN PAK 5 THPK LEVIGOLT CREA 5 RX/OTC DERMACINRX ZRM PAK 5 THPK LIDO-RX 4.1 CREA 5 DERMAZYL THPK 5 LIDOCAINE AND RX/OTC TETRACAINECREAM 4 EHA LOTION 4% LOTN 5 CREA RX/OTC EHA LOTION LOTN 5 RX/OTC lidocaine hcl crea ex 3 % 2 lidocaine hcl crea ex 3.88 ENOVARX-LIDOCAINE 5 2 HCL CREA % RX/OTC ETHYL CHLORIDE AERO 4 lidocaine hcl gel ex 2 % 2

ETHYL CHLORIDE/FINE 4 lidocaine hcl lotn ex 3 % 2 PINPOINT AERO ETHYL CHLORIDE/FINE 4 lidocaine hcl soln ex 4 % 2 STREAM AERO ETHYL lidocaine oint 5 % 2 CHLORIDE/MEDIUM JET 4 STREAM AERO lidocaine ptch 4 % 2 ETHYL PA CHLORIDE/MEDIUM 4 lidocaine ptch 5 % 2 STREAM AERO lidocaine-menthol ptch 1%- 2 RX/OTC ETHYL CHLORIDE/MIST 4 4% AERO lidocaine-menthol ptch 4%- 2 FLEXIN PTCH 5 RX/OTC 4% lidocaine-prilocaine crea 2 GEBAUERS INSTANT ICE 5 RX/OTC AERO lidocaine-prilocaine kit 2 GEBAUERS PAIN EASE 5 RX/OTC AERO LIDOCARE ARM/NECK/LEG PTCH 5 GEBAUERS SPRAY AND 5 RX/OTC STRETCH AERO (Use Lidocaine) LIDOCARE ICY HOT LIDOCAINE 5 RX/OTC PLUS MENTHOL CREA BACK/SHOULDER PTCH 5 (Use Lidocaine) ICY HOT PM PTCH 5%- 5 0.025% LIDODERM PTCH (Use 5 PA Lidocaine) IV INFUSION CPI KIT 5 LIDODOSE GEL 5 RX/OTC IV NOVICE PACK KIT 5 LIDOPAC KIT 5 LDO PLUS GEL 5 RX/OTC LIDOPIN CREA 5

Updated August 1, 2018

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIDORX GEL 5 RX/OTC QUTENZA KIT 5

LIDOTHOL PTCH 5 RELEEVIA MC PTCH 5 RX/OTC

LIDOTRAL CREA (Use 5 RELEEVIA PTCH 5 RX/OTC Lidocaine HCl) REMAXAZON EXTERNAL 5 LIDOTRANS 5 PAK KIT 5 PATCH PTCH LIDOVEX CREA 5 RENOVO PTCH 5 RX/OTC

LIDOVIN CREA 5 RENUU PATCH PTCH 5

LIDOZOL CREA 5 SILVERA PAIN RELIEF 5 PTCH LIDTOPIC MAX CREA 5 SOLUPAK THPK 5 RX/OTC MAC PATCH PTCH 5 SOOTHEE PTCH 5

MAL PATCH PTCH 5 SYNERA PTCH 5 RX/OTC MEDI-DERM/L CREA 5 SYNVEXIA TC CREA 5 RX/OTC RX/OTC MEDI-DERM/L-RX CREA 5 TEROCIN PTCH 4%-4% 5 (Use Lidocaine-Menthol) RX/OTC MEDI-PATCH RX PTCH 5 TRANZAREL GEL 5 RX/OTC MEDI-PATCH/LIDOCAINE 5 RX/OTC VEINPUNCTURE PX1 PTCH PHLEBOTOMY SYSTEM 5 MEDROX PTCH 5%- 5 RX/OTC KIT 0.038% VELMA PAIN RELIEF 5 MENTHO-CAINE KIT KIT 5 PTCH VELTRIX CREA 5 RX/OTC NEURCAINE THPK 5 VENIPUNCTURE CPI KIT 5 NUMBONEX LOTN 5 WPR PLUS WOUND 5 PERMAVAN EXTERNAL 5 HEALING SYSTEM THPK PATCH PTCH XRYLIDERM KIT 5 PHARMACIST CHOICE 5 TSX PATCH PTCH ZEYOCAINE KIT 5 PLIAGLIS CREA 4 Misc. Dermatological Products pramoxine hcl gel 2 RX/OTC 5 DAY LIQD 5 RX/OTC PREMIUM SCAR PATCH 5 PTCH ALEVICYN ANTIPRURITIC 5 RX/OTC GEL GEL PREPIV SUPPLY KIT 5 ALEVICYN ANTIPRURITIC 5 RX/OTC SG GEL

Updated August 1, 2018

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALEVICYN PLUS KIT 5 RX/OTC HYLATOPIC PLUS CREA 5 RX/OTC

ATOPADERM CREA 5 RX/OTC HYLATOPIC PLUS FOAM 5

ATOPICLAIR CREA 5 RX/OTC HYLATOPIC PLUS LOTN 5 RX/OTC

BROMI-LOTION LOTN 5 RX/OTC ITCH-ENDER! LOTN 5 RX/OTC

CALICYLIC CREA 5 RX/OTC JOBST IT STAYS/ROLL- 5 RX/OTC ON LIQD CERACADE EMUL 5 KAMDOY EMUL 5 RX/OTC COLLADERM LOTN 5 KERASAL FUNGAL NAIL 5 RX/OTC RENEWAL LIQD RX/OTC CURE-ALL CREA 5 LEVICYN GEL 5 RX/OTC dermatological products, 2 RX/OTC misc. liqd LOYON SOLN 5 RX/OTC DEXERYL CREA 5 MB HYDROGEL KIT 5 RX/OTC DIABETIDERM MASSAGE RX/OTC 5 MIADERM RADIATION 5 RX/OTC STIMULATOR LIQD RELIEF LOTN RX/OTC ELETONE CREA 5 MOISTURE CREAM CREA 5 RX/OTC ELETONE TWINPACK 5 RX/OTC RX/OTC CREA NAIL SCRUB LIQD 5 EMULSION SB EMUL 5 NASALGUARD GEL 5 RX/OTC

ENTTY SPRAY 5 NEOCERA CREA 5 RX/OTC EMULSION EMUL RX/OTC EPICERAM EMUL 5 NEOSALUS CP CREA 5 RX/OTC EPIMIDE LOTN 5 RX/OTC NEOSALUS CREA 5

GENADUR KIT KIT 5 NEOSALUS FOAM 5 RX/OTC GENADUR LIQD 5 RX/OTC NIVATOPIC PLUS CREA 5 RX/OTC HEAL AID PLUS CREA 5 RX/OTC NONYX GEL 5

HPR FOAM 5 NUVAIL SOLN 5 RX/OTC HPR PLUS CREA 5 RX/OTC OC8 GEL 5

HPR PLUS FOAM 5 PHLAG SPRAY EMUL 5 RX/OTC HPR PLUS HYDROGEL 5 RX/OTC PR CREAM KIT 5 KIT KIT

Updated August 1, 2018

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRESERA FOAM 5 BORIC ACID GRAN 5 RX/OTC

PRUCLAIR CREA 5 RX/OTC CARRINGTON MOISTURE 4 RX/OTC BARRIER CREA RX/OTC PRUMYX CREA 5 CARRINGTON MOISTURE 4 RX/OTC BARRIER/ZINC CREA RADIADERM SYSTEM RX/OTC 5 CVS ISOPROPYL 5 RX/OTC R1+R2 KIT ALCOHOL WIPES MISC RADIADERM SYSTEM R2 RX/OTC 5 DERMACINRX 5 LOTN CLORHEXACIN KIT REMOVE ADHESIVE RX/OTC 5 DERMACINRX SURGICAL 5 REMOVER LIQD COMBOPAK KIT RX/OTC SEBUDERM GEL 5 DERMACINRX SURGICAL 5 PHARMAPAK KIT SYNERDERM EMUL 5 DERMAWERX SURGICAL 5 PLUS PAK KIT TETRIX CREA 5 RX/OTC DRYSOL SOLN 4 RX/OTC THUM LIQD 5 ESSENTRA WIPES 9X9" RX/OTC RX/OTC CLEANROOM 5 XERALUX CREA 5 SUPPLIES/PRESATURAT ED MISC YODORA DEODORANT 5 RX/OTC CREA EUCERIN CREA (Use Skin 5 RX/OTC Protectants, Misc.) Misc. Topical GNP ISOPROPYL 5 RX/OTC ACUICYN RX/OTC ALCOHOL WIPES MISC ANTIMICROBIAL EYELID 5 & EYELASH HYGIENE GREEN SOAP TINC 5 LIQD RX/OTC ACUICYN DAILY EYELID RX/OTC HYDROCERIN CREA 4 & EYELASH CLEANSER 5 LIQD ISOPROPYL ALCOHOL 5 RX/OTC WIPES MISC ARNICA FLOWER TINC 5 NUSRUGEPAK SURGICAL 5 AVENOVA SOLN 5 RX/OTC PREP/CAREPAK KIT OCUSOFT HYPOCHLOR RX/OTC AVENOVA/NEUTROX 5 RX/OTC 5 SOLN LIQD OCUSOFT LID SCRUB RX/OTC BASIS FACIAL 4 RX/OTC 5 MOISTURIZER CREA FOAMING SOLN RX/OTC OCUSOFT LID SCRUB 5 RX/OTC BASIS OVERNIGHT CREA 4 ORIGINAL LIQD RX/OTC PHARMACIST CHOICE RX/OTC benzoin compound tinc 2 ALCOHOL PRED PADS 5 PADS BENZOIN TINCTURE 5 RX/OTC PLAIN TINC RA ISOPROPYL 5 RX/OTC ALCOHOL WIPES MISC BENZOIN TINCTURE 5 RX/OTC TINC Updated August 1, 2018

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENSI-CARE 4 RX/OTC RHOFADE CREA 5 MOISTURIZING CREA skin protectants, misc. crea 2 RX/OTC ROSADAN KIT KIT 5

SM BENZOIN TINCTURE 5 RX/OTC SOOLANTRA CREA 4 TINC Scabicides & Pediculicides SORBIDON HYDRATE 4 RX/OTC CREA crotamiton lotn 2 SURE COMFORT RX/OTC ALCOHOL PREP PADS 5 ELIMITE CREA (Use 5 PADS EX Permethrin) witch hazel (hamamelis 2 EURAX CREA 5 virginiana) liqd 86 %, EURAX LOTN (Use 5 WITCH HAZEL LIQD 5 Crotamiton) Phosphodiesterase 4 (PDE4) Inhibitors - Topical LINDANE SHAM 4 EUCRISA OINT 5 PA lindane sham 2 Rosacea Agents LYCELLE GEL 5 DOXYCYCLINE CPDR 4 QL(59 ml per malathion lotn 2 FINACEA FOAM 4 fill retail) NATROBA SUSP 4 FINACEA GEL 4 METROCREAM CREA QL(45 gm per nit remover gel 2 (Use Metronidazole 5 fill retail) OVIDE LOTN (Use 5 QL(59 ml per (Topical)) Malathion) fill retail) METROGEL GEL (Use 5 Metronidazole (Topical)) permethrin crea ex 5 % 2 METROLOTION LOTN (Use Metronidazole 5 SKLICE LOTN 5 (Topical)) SPINOSAD SUSP 4 metronidazole (topical) 2 QL(45 gm per crea 0.75 % fill retail) SULFURATED LIME SOLN 5 metronidazole (topical) gel 2 QL(45 gm per 0.75 % fill retail) ULESFIA LOTN 5 metronidazole (topical) gel 2 1 % Scar Treatment Products RX/OTC metronidazole (topical) lotn 2 BEAU RX GEL 4 0.75 % RX/OTC MIRVASO GEL 5 DERMOVIX PTCH 5 RX/OTC NORITATE CREA 5 KELARX GEL 4

ORACEA CPDR 4

Updated August 1, 2018

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDERMA FOR KIDS RX/OTC ACTIMARIS WOUND GEL 5 RX/OTC GEL (Use Scar Treatment 5 GEL Products) ADAPTIC NON- RX/OTC MEDERMA GEL (Use Scar 5 RX/OTC ADHERING DRESSING 3" 5 Treatment Products) X 3" PADS RECEDO GEL 4 RX/OTC ALLEVYN ADHESIVE 5 RX/OTC PADS RX/OTC RENUU NL PTCH 5 ALLEVYN AG ADHESIVE 5 RX/OTC PADS RX/OTC scar treatment products gel 2 ALLEVYN AG GENTLE 5 RX/OTC BORDER PADS SP SCAR MANAGEMENT 4 RX/OTC GEL ALLEVYN AG NON- 5 RX/OTC ADHESIVE PADS Tar Products ALLEVYN AG SACRUM 5 RX/OTC COAL TAR SOLN 4 PADS ALLEVYN COMPRESSION 5 RX/OTC Wound Care Products PADS 2ND SKIN MOIST BURN RX/OTC 5 ALLEVYN GENTLE 5 RX/OTC PADS1.5"X2" PADS BORDER HEEL PADS 2ND SKIN MOIST BURN RX/OTC 5 ALLEVYN GENTLE 5 RX/OTC PADS2"X3" PADS BORDER LITE PADS 2ND SKIN MOIST BURN 5 RX/OTC ALLEVYN GENTLE RX/OTC PADS3"X4" PADS BORDER MULTISITE 5 PADS 2ND SKIN MOIST 5 RX/OTC DRESSING KIT PADS ALLEVYN GENTLE 5 RX/OTC BORDER PADS 2ND SKIN MOIST GEL 5 RX/OTC PADS 1"X1" PADS ALLEVYN GENTLE 5 RX/OTC BORDER SACRUM PADS 2ND SKIN MOIST GEL 5 RX/OTC PADS 3" ROUND PADS ALLEVYN GENTLE PADS 5 RX/OTC 2ND SKIN QUICK HEAL 5 GEL ALLEVYN HEEL PADS 5 RX/OTC ACTICOAT 7 2"X2" PADS 5 RX/OTC ALLEVYN LIFE HEEL 5 RX/OTC PADS ACTICOAT 7 4"X5" PADS 5 RX/OTC ALLEVYN LIFE PADS 5 RX/OTC ACTICOAT ABSORBENT RX/OTC ANTIMICROBIAL 5 ALLEVYN LIFE SACRUM 5 RX/OTC DRESSING 4"X5" PADS PADS ACTICOAT RX/OTC ALLEVYN NON- 5 RX/OTC ANTIMICROBIAL 5 ADHESIVE PADS DRESSING 2"X2" PADS ALLEVYN PLUS 5 RX/OTC ACTICOAT RX/OTC ADHESIVE PADS ANTIMICROBIAL 5 ALLEVYN PLUS CAVITY 5 RX/OTC DRESSING 4"X4" PADS PADS EX ACTICOAT FLEX 3 RX/OTC ALLEVYN PLUS SACRUM 5 RX/OTC BARRIER DRESSING 5 PADS 4"'X4" PADS Updated August 1, 2018

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALLEVYN SACRUM PADS 5 RX/OTC AQUASITE RX/OTC IMPREGNATED GAUZE 5 ALLEVYN RX/OTC 4"X4" PADS TRACHEOSTOMY 3- 5 AQUASITE SHEET 5 RX/OTC 1/2"X3-1/2" PADS DRESSING 4"X4" PADS AMERIGEL WOUND RX/OTC 5 ARGLAES FILM 2-3/8" X 3- 5 RX/OTC DRESSING GEL 1/8" PADS AQUACEL RX/OTC ARGLAES FILM 3" X 14" 5 RX/OTC EXTRA/HYDROFIBER 5 PADS PADS ARGLAES FILM 4" X 4-3/4" 5 RX/OTC AQUACEL RX/OTC PADS EXTRA/HYDROFIBER2 X 5 ARGLAES FILM 4-3/4" X 5 RX/OTC 2 PADS 10" PADS AQUACEL RX/OTC ARGLAES ISLAND 2-3/8" 5 RX/OTC EXTRA/HYDROFIBER6 X 5 X 3-1/8" PADS 6 PADS ARGLAES ISLAND 4" X 4- 5 RX/OTC AQUACEL FOAM 5 RX/OTC 3/4" PADS 3.2"X3.2" PADS ARGLAES ISLAND 4-3/4" 5 RX/OTC AQUACEL FOAM 4"X4" 5 RX/OTC X 10" PADS PADS ATRAPRO ANTIPRURITIC 5 RX/OTC AQUACEL FOAM 5"X5" 5 RX/OTC HYDROGEL GEL PADS ATRAPRO CP KIT 5 RX/OTC AQUACEL FOAM 6"X6" 5 RX/OTC PADS ATRAPRO DERMAL 5 RX/OTC AQUACEL FOAM 6"X8" 5 RX/OTC SPRAY LIQD PADS AVOGEL DRESSING/4" X 5 RX/OTC AQUACEL FOAM 7"X7" 5 RX/OTC 4" MISC PADS AVOGEL DRESSING/6" X 5 RX/OTC AQUACEL FOAM 8"X5.5" 5 RX/OTC 48" MISC PADS AVOGEL DRESSING/8" X 5 RX/OTC AQUACEL FOAM 8"X7" 5 RX/OTC 8" MISC PADS AVOGEL SHEET/8" X 8" 5 RX/OTC AQUACEL HYDROFIBER RX/OTC MISC WOUNDDRESSING/0.39X 5 18" MISC BIOBRANE 10"X15" PADS 5 RX/OTC AQUASITE RX/OTC RX/OTC IMPREGNATED 5 BIOBRANE 15"X20" PADS 5 DRESSING 2"X2" PADS RX/OTC AQUASITE RX/OTC BIOBRANE 5"X15" PADS 5 IMPREGNATED 5 RX/OTC DRESSING 4"X4" PADS BIOBRANE 5"X5" PADS 5 AQUASITE RX/OTC BIOBRANE GLOVES 5 RX/OTC IMPREGNATED 5 LARGE MISC DRESSING 4"X8" PADS RX/OTC BIOBRANE GLOVES 5 AQUASITE RX/OTC MEDIUM MISC IMPREGNATED GAUZE 5 BIOBRANE GLOVES 5 RX/OTC 2"X2" PADS PEDIATRIC MISC Updated August 1, 2018

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BIOBRANE GLOVES 5 RX/OTC COMFEEL PLUS 5 RX/OTC SMALL MISC ULCERDRESSING PADS BIOBRANE-L 10"X15" 5 RX/OTC COMFEEL ULCER 5 RX/OTC PADS CAREDRESSING PADS BIOBRANE-L 5"X15" 5 RX/OTC COMFORT-AID 1.5"X2.5" 5 RX/OTC PADS PADS BIOBRANE-L 5"X5" PADS 5 RX/OTC CONFORMANT 2 WOUND 5 RX/OTC VEIL 12"X12" MISC CARBOFLEX ODOR RX/OTC CONFORMANT 2 WOUND 5 RX/OTC CONTROL DRESSING 5 VEIL 12"X24" MISC PADS CONFORMANT 2 WOUND 5 RX/OTC CARRADRES MISC 5 RX/OTC VEIL 24"X36" MISC CONFORMANT 2 WOUND 5 RX/OTC CARRAGAUZE 2 X 2 5 RX/OTC VEIL 3"X5YD MISC PADS CONFORMANT 2 WOUND 5 RX/OTC CARRAGAUZE 4 X 4 5 RX/OTC VEIL 4"X12" MISC PADS CONFORMANT 2 WOUND 5 RX/OTC CARRAGAUZE STRIPS 5 RX/OTC VEIL 4"X4" MISC MISC CONFORMANT 2 WOUND 5 RX/OTC CARRASMART GEL EX 5 RX/OTC VEIL 6"X2YD MISC CONTREET FOAM RX/OTC CARRASORB M DRIGEL 5 RX/OTC 5 MISC CAVITY PADS CONTREET FOAM HEEL RX/OTC CARRASYN HYDROGEL 5 RX/OTC 5 WOUND DRESSING GEL PADS CARRASYN V RX/OTC CONTREET FOAM PADS 5 RX/OTC HYDROGEL 5 WOUNDDRESSING GEL CONTREET FOAM 5 RX/OTC SACRAL PADS CELACYN POST- 5 RX/OTC PROCEDURE PACK KIT CONTREET 5 RX/OTC HYDROCOLLOID PADS CICA-CARE SHEE 5 RX/OTC COOLMAGIC SHEE 5 RX/OTC COMFEEL FILM SHEE 5 RX/OTC COOLMAGIC TUBE SITE 5 RX/OTC DRESSING SHEE COMFEEL PLUS 5 RX/OTC CLEARDRESSING PADS CURAFIL GEL WOUND 5 RX/OTC COMFEEL PLUS RX/OTC DRESSING GEL CONTOURDRESSING 5 CURITY HEAVY 5 RX/OTC PADS DRAINAGE PACK PADS CURITY HYPERTONIC RX/OTC COMFEEL PLUS 5 RX/OTC DRESSING PADS SODIUMCHLORIDE 5 COMFEEL PLUS RX/OTC PACKING STRIP 1/2"X15' TRIANGLEDRESSING 5 MISC PADS CURITY SALINE 5 RX/OTC DRESSING 8"X4" PADS COMFEEL PLUS ULCER 5 RX/OTC DRESSING PADS

Updated August 1, 2018

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY SODIUM RX/OTC DERMAGRAN RX/OTC CHLORIDE DRESSING 5 HYDROPHILIC WOUND 5 6"X6-3/4" PADS DRESSING 8"X4" PADS CURITY UNNA BOOT 5 RX/OTC DERMAGRAN-B RX/OTC 3"X10YD MISC HYDROPHILIC WOUND 5 DRESSING GEL CURITY UNNA BOOT 5 RX/OTC 4"X10YD MISC DERMAPLEX GEL 5 CUTICERIN 3"X16" MISC 5 RX/OTC DERMASYN GEL 5 RX/OTC CUTICERIN 3"X3" MISC 5 RX/OTC DIAB CREA 5 RX/OTC CUTICERIN 3"X8" MISC 5 RX/OTC DIAB DAILY CARE GEL 5 RX/OTC CUTICERIN 4"X4" MISC 5 RX/OTC DIAB F.D.G. FREEZE- 5 RX/OTC DRIED GEL CUTICERIN 8"X16" MISC 5 RX/OTC DIAB GEL 5 RX/OTC CUTINOVA HYDRO 2"X2- 5 RX/OTC 3/8" MISC DOCTORS CHOICE RX/OTC BURNS/SCALDS/ABRASI 5 CUTINOVA HYDRO 4"X4" 5 RX/OTC MISC ONS PADS DOCTORS CHOICE RX/OTC CUTINOVA HYDRO 6"X8" 5 RX/OTC MISC DIABETIC SLOW 5 HEALING BANDAGES KIT CVS MANUKA HONEY 5 RX/OTC WOUND GEL GEL DOCTORS CHOICE SKIN 5 RX/OTC CLOSURE KIT RX/OTC CVS SILVER GEL GEL 5 DOCTORS CHOICE RX/OTC DERMA PAK-ITS RX/OTC SLOW HEALING 5 IODOFORM PACKING 5 BANDAGES KIT STRIPS MISC DOCTORS CHOICE 5 RX/OTC ULTRA-FLEX MISC DERMA-GEL 4" X 4" PADS 5 RX/OTC DOME-PASTE BANDAGE 5 RX/OTC PADS DERMAGAUZE 5 RX/OTC DRESSING PADS DRAWTEX ADVANCED RX/OTC DERMAGAUZE RX/OTC WOUND CARE 2"X2" 5 PADS HYDROGEL 5 WOUNDDRESSING 4" X DRAWTEX ADVANCED RX/OTC 4" MISC WOUND CARE 3"X3" 5 DERMAGRAN RX/OTC PADS HYDROGEL 5 DRAWTEX ADVANCED RX/OTC WOUNDDRESSING GEL WOUND CARE 3"X39" 5 DERMAGRAN RX/OTC MISC HYDROPHILIC WOUND 5 DRAWTEX ADVANCED RX/OTC DRESSING 2"X2" PADS WOUND CARE 4"X39" 5 DERMAGRAN RX/OTC MISC HYDROPHILIC WOUND 5 DRAWTEX ADVANCED RX/OTC DRESSING 4"X4" PADS WOUND CARE 4"X4" 5 PADS Updated August 1, 2018

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRAWTEX ADVANCED RX/OTC ELASTO-GEL FACE 5 RX/OTC WOUND CARE 6"X8" 5 MASK PADS PADS ELASTO-GEL PLUS 2"X3" 5 RX/OTC DRAWTEX ADVANCED RX/OTC PADS WOUND CARE 8"X39" 5 ELASTO-GEL PLUS 4"X4" 5 RX/OTC MISC PADS DRAWTEX ADVANCED RX/OTC ELASTO-GEL PLUS 8"X8" 5 RX/OTC WOUND CARE 8"X8" 5 PADS PADS EXCEL-GEL GEL 5 RX/OTC DUDRESS ISLAND 5 RX/OTC DRESSING 4"X4" PADS EXU-DRY 15"X18" PADS 5 RX/OTC DUDRESS ISLAND 5 RX/OTC DRESSING 6"X6" PADS EXU-DRY 15"X24" PADS 5 RX/OTC DUODERM 5 RX/OTC HYDROACTIVE MISC EXU-DRY 20"X28" PADS 5 RX/OTC DURAFIBER 2"X2" MISC 5 RX/OTC EXU-DRY 3"X4" PADS 5 RX/OTC DURAFIBER 3/4"X18" 5 RX/OTC MISC EXU-DRY 4"X6" PADS 5 RX/OTC DURAFIBER 4"X4" MISC 5 RX/OTC EXU-DRY 6"X9" PADS 5 RX/OTC DURAFIBER 6"X6" MISC 5 RX/OTC EXU-DRY 9"X15" PADS 5 RX/OTC ELASTO-GEL 12"X12" 5 RX/OTC PADS EXU-DRY ARM 27"X31" 5 RX/OTC PADS RX/OTC ELASTO-GEL 2"X3" PADS 5 EXU-DRY RX/OTC ARM/SHOULDER TIES 5 ELASTO-GEL 3" ROUND 5 RX/OTC PADS 27"X31" PADS RX/OTC EXU-DRY BOOT/FOOT 5 RX/OTC ELASTO-GEL 4"X4" PADS 5 DRESSING/CHILD MISC RX/OTC EXU-DRY BURN JACKET 5 RX/OTC ELASTO-GEL 5"X5" PADS 5 31"X32" PADS RX/OTC EXU-DRY BURN JACKET 5 RX/OTC ELASTO-GEL 6"X8" PADS 5 36"X40" MISC ELASTO-GEL 8"X16" RX/OTC 5 EXU-DRY BURN JACKET 5 RX/OTC PADS CHILD 17"X20" PADS ELASTO-GEL RX/OTC EXU-DRY BURN VEST 5 RX/OTC CAST/SPLINT 12"X12" 5 26"X38" MISC PADS EXU-DRY BURN VEST 5 RX/OTC ELASTO-GEL 5 RX/OTC CHILD 15"X20" MISC CAST/SPLINT 4"X4" PADS EXU-DRY BUTTOCKS 5 RX/OTC ELASTO-GEL 5 RX/OTC 23"X53" PADS CAST/SPLINT 6"X8" PADS EXU-DRY DISC 3" MISC 5 RX/OTC ELASTO-GEL RX/OTC CAST/SPLINT 8"X16" 5 PADS

Updated August 1, 2018

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXU-DRY RX/OTC EXUDERM SACRUM 4" X 5 RX/OTC ELBOW/KNEE/HEEL 5 3.6" PADS 10"X17" PADS EXUDERM SATIN 2" X 2" 5 RX/OTC EXU-DRY FACE 9"X14" 5 RX/OTC PADS PADS EXUDERM SATIN 4" X 4" 5 RX/OTC EXU-DRY INCISION 3"X9" 5 RX/OTC PADS PADS EXUDERM SATIN 6" X 6" 5 RX/OTC EXU-DRY LEG 34"X37" 5 RX/OTC PADS MISC EXUDERM SATIN 8" X 8" 5 RX/OTC EXU-DRY NON- RX/OTC PADS PERMEABLE PAD 5 EXUDERM ULTRA 4" X 4" 5 RX/OTC 24"X36" PADS PADS EXU-DRY NON- RX/OTC EXUDERM ULTRA RX/OTC PERMEABLE SHEET 5 HYDROCOLLOID WOUND 5 36"X72" SHEE DRESSING 4" X 4" PADS EXU-DRY PADDED HAND 5 RX/OTC FIBRACOL COLLAGEN- RX/OTC 12"X13" PADS ALGINATE WOUND 5 EXU-DRY PADDED HAND 5 RX/OTC DRESSING 4" X 4 & 3/8" CHILD 8"X8" PADS MISC EXU-DRY PADDED NECK 5 RX/OTC FIBRACOL COLLAGEN- RX/OTC 6"X25" PADS ALGINATE WOUND 5 DRESSING/2" X 2" PADS EXU-DRY PERMEABLE 5 RX/OTC PAD 24"X36" PADS FIBRACOL COLLAGEN- RX/OTC ALGINATE WOUND EXU-DRY PERMEABLE 5 RX/OTC 5 QUILTED 36"X72" SHEE DRESSING/4" X 8-3/4" PADS EXU-DRY SCALP 3"X14" 5 RX/OTC PADS FIBRACOL COLLAGEN- RX/OTC ALGINATE WOUND 5 EXU-DRY SLIT DISC 3" 5 RX/OTC PACKING/3/8"X3/8"X15- MISC 3/4" MISC EXU-DRY SLIT TUBE RX/OTC 5 FOAM DRESSING 5 RX/OTC 2"X3" PADS BORDERED PADS EXU-DRY SLIT TUBE 5 RX/OTC FOAM DRESSING RX/OTC 3"X4" MISC CIRCULAR BORDERED 5 EXU-DRY SLIT TUBE 5 RX/OTC PADS 4"X6" MISC FOAM DRESSING NON- 5 RX/OTC EXUDERM LP 4" X 4" 5 RX/OTC BORDERED PADS PADS GELOCAST UNNAS 5 RX/OTC EXUDERM LP 6" X 6" 5 RX/OTC BOOT MISC PADS GRX HYDROGEL GAUZE 5 RX/OTC EXUDERM RCD 4" X 4" 5 RX/OTC 2X2 PADS PADS GRX HYDROGEL GAUZE 5 RX/OTC EXUDERM RCD 6" X 6" 5 RX/OTC 4X4 PADS PADS GRX WOUND GEL 5 RX/OTC EXUDERM RCD 8" X 8" 5 RX/OTC PADS HYCOLOID-GRX PADS 5 RX/OTC

Updated August 1, 2018

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROCOL II PADS 5 RX/OTC HYDROFERA BLUE RX/OTC HEAVY DRAINAGE 4"X4" 5 PADS HYDROCOL II SACRAL 5 RX/OTC PADS HYDROFERA BLUE RX/OTC HYDROCOL II THIN PADS 5 RX/OTC HEAVY DRAINAGE 6"X6" 5 PADS HYDROFERA BLUE 4"X4" 5 RX/OTC HYDROFERA BLUE RX/OTC PADS READY FOAMDRESSING 5 HYDROFERA BLUE RX/OTC 2.5"X2.5" PADS FOAM DRESSING 2"X2" 5 HYDROFERA BLUE RX/OTC PADS READY FOAMDRESSING 5 HYDROFERA BLUE RX/OTC 4"X5" PADS FOAM DRESSING 4"X4" 5 HYDROFERA BLUE RX/OTC PADS READY FOAMDRESSING 5 HYDROFERA BLUE RX/OTC 8"X8" PADS FOAM DRESSING 6"X6" 5 RX/OTC PADS HYDROGEL AG GEL 5 RX/OTC HYDROFERA BLUE 5 RX/OTC HYDROGEL GEL 5 FOAM DRESSING PADS HYDROFERA BLUE RX/OTC HYPAFIX/5 CM X 10M/2" 5 RX/OTC X11 YDS PADS FOAM 5 DRESSING/MOISTURE INTERDRY AG TEXTILE 5 RX/OTC RETENTIVE FILM PADS 10"X12' ROLL MISC HYDROFERA BLUE RX/OTC INTRASITE GEL 5 RX/OTC FOAM APPLIPAK GEL DRESSING/MOISTURE 5 KALTOSTAT FORTEX 5 RX/OTC RETENTIVE FILM/2-1/4X8 PADS PADS RX/OTC HYDROFERA BLUE RX/OTC KALTOSTAT PADS 5 FOAM RX/OTC DRESSING/MOISTURE 5 KALTOSTAT ROPE MISC 5 RETENTIVE FILM/4"X4" KALTOSTAT WOUND 5 RX/OTC PADS DRESSING PADS HYDROFERA BLUE RX/OTC KENDALL ALGINATE RX/OTC FOAM HYDROCOLLOID 5 DRESSING/MOISTURE 5 DRESSING 4"X4" PADS RETENTIVE FILM/ISLAND PADS KENDALL ALGINATE RX/OTC HYDROCOLLOID 5 HYDROFERA BLUE RX/OTC DRESSING 4"X5" PADS FOAM DRESSING/MOISTURE 5 KENDALL ALGINATE RX/OTC RETENTIVE/OSTOMY/2.5" HYDROCOLLOID 5 PADS DRESSING 6"X6" PADS HYDROFERA BLUE RX/OTC KENDALL ALGINATE RX/OTC HYDROCOLLOID 5 FOAM 5 DRESSING/TUNNELING/9 DRESSING 6"X7" PADS MM PADS KENDALL ALGINATE RX/OTC HYDROCOLLOID 5 DRESSING 8"X8" PADS Updated August 1, 2018

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KENDALL AMORPHOUS RX/OTC KERLIX SUPER SPONGE 5 RX/OTC HYDROGEL WOUND 5 SALINE DRESSING PADS DRESSING GEL LAVARE WOUND WASH 5 KENDALL RX/OTC GEL ANTIMICROBIAL 5 BANDAGE 4-1/2"X4-1/8YD LIDOTREX GEL 5 MISC LUXAMEND CREA 5 RX/OTC KENDALL HYDROGEL RX/OTC IMPREGNATED GAUZE 5 MAXORB EXTRA AG+ 5 RX/OTC 2"X2" PADS PADS KENDALL HYDROGEL RX/OTC RX/OTC IMPREGNATED GAUZE 5 MEDFIX EZ MISC 5 4"X4" PADS MEDI-PAK RX/OTC KENDALL HYDROGEL RX/OTC PERFORMANCE 5 IMPREGNATED GAUZE 5 PLUSCOMBINE ABD 4"X8" PADS PAD/8" X 7.5" PADS KENDALL HYDROGEL RX/OTC MEDIHONEY CALCIUM RX/OTC WOUND DRESSING 3" 5 ALGINATE DRESSING 5 DISK MISC 4"X5" PADS KENDALL HYDROGEL RX/OTC MEDIHONEY CALCIUM RX/OTC WOUND DRESSING 4- 5 ALGINATE 5 3/4" DISK MISC DRESSING/2"X2" PADS KENDALL ZINC CALCIUM RX/OTC MEDIHONEY WOUND & RX/OTC ALGINATE DRESSING 5 BURN DRESSING 5 2"X2" PADS 3/4"X12" PADS KENDALL ZINC CALCIUM RX/OTC MEDIHONEY RX/OTC ALGINATE DRESSING 5 WOUND/BURNDRESSING 5 4"X4" PADS 4"X5" PADS KENDALL ZINC CALCIUM RX/OTC MEDIHONEY RX/OTC ALGINATE DRESSING 5 WOUND/BURNDRESSING 5 4"X8" PADS GEL KENDALL ZINC CALCIUM RX/OTC MICROCYN GEL 3%- ALGINATE DRESSING 5 0.4%-0.008%-0.002%- 5 ROPE 12" MISC 0.066% KERAGEL GEL 5 RX/OTC MICROCYN LIQD 0.023 %, 5 RX/OTC

KERAGELT GEL 5 RX/OTC MICROCYN SKIN AND 5 WOUND HYDROGEL GEL KERAMATRIX REPLICINE 5 RX/OTC MICROKLENZ RX/OTC 10CMX10CM PADS ANTISEPTIC WOUND 5 CLEANSER LIQD KERAMATRIX REPLICINE 5 RX/OTC 10CMX10CM SHEE MIRODERM FENESTRATED KERAMATRIX REPLICINE 5 RX/OTC 5 5CMX5CM PADS BIOLOGIC WOUND MATRIX 2X2CM SHEE KERAMATRIX REPLICINE 5 RX/OTC 5CMX5CM SHEE

Updated August 1, 2018

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIRODERM MIRODERM MESHED FENESTRATED 5 BIOLOGICWOUND 5 BIOLOGIC WOUND MATRIX 3X3CM SHEE MATRIX 2X3CM SHEE MIRODERM MESHED MIRODERM BIOLOGICWOUND 5 FENESTRATED 5 MATRIX 3X7CM SHEE BIOLOGIC WOUND MIRODERM MESHED MATRIX 3X3CM SHEE BIOLOGICWOUND 5 MIRODERM MATRIX 4X4CM SHEE FENESTRATED 5 MIRODERM MESHED BIOLOGIC WOUND BIOLOGICWOUND 5 MATRIX 4X4CM SHEE MATRIX 5X5CM SHEE MIRODERM MIRODERM MESHED FENESTRATED 5 BIOLOGICWOUND 5 BIOLOGIC WOUND MATRIX 8X15CM SHEE MATRIX 5X5CM SHEE MIRODERM MESHED MIRODERM BIOLOGICWOUND 5 FENESTRATED 5 MATRIX 8X8CM SHEE BIOLOGIC WOUND MATRIX 8X15CM SHEE NEXCARE WOUND 5 RX/OTC CLEANSER LIQD MIRODERM NU-GEL COLLAGEN RX/OTC FENESTRATED 5 5 BIOLOGIC WOUND WOUND DRESSING GEL MATRIX 8X8CM SHEE NU-GEL WOUND RX/OTC MIRODERM DRESSING/3-3/4" X 3-3/4" 5 FENESTRATED PADS PLUSBIOLOGIC WOUND 5 NU-GEL WOUND 5 RX/OTC MATRIX 3X3CM/MESHED DRESSING/6"X 8" PADS SHEE PELEVERUS LIQD 5 RX/OTC MIRODERM FENESTRATED PICO SINGLE USE RX/OTC PLUSBIOLOGIC WOUND 5 NEGATIVEPRESSURE 5 MATRIX 4X4CM/MESHED WOUND THERAPY SHEE SYSTEM KIT MIRODERM POLYMEM ALGINATE 5 RX/OTC FENESTRATED DRESSING/3" X 3" PADS PLUSBIOLOGIC WOUND 5 POLYMEM ALGINATE 5 RX/OTC MATRIX 5X5CM/MESHED DRESSING/4" X 2" MISC SHEE POLYMEM ALGINATE 5 RX/OTC MIRODERM DRESSING/4" X 4" PADS FENESTRATED POLYMEM ALGINATE 5 RX/OTC PLUSBIOLOGIC WOUND 5 DRESSING/5" X 5" PADS MATRIX 8X15CM/MESHED SHEE POLYMEM ALGINATE RX/OTC DRESSING/6.5" X 7.5" 5 MIRODERM PADS FENESTRATED PLUSBIOLOGIC WOUND 5 POLYMEM SILVER RX/OTC MATRIX 8X8CM/MESHED DRESSING/4.25" X 4.25" 5 SHEE PADS

Updated August 1, 2018

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLYMEM SILVER RX/OTC REGENECARE GEL 5 ISLAND DRESSING/6" X 5 6" MISC REGRANEX GEL 5 POLYWIC SILVER RX/OTC WOUND FILLER/3" X 3" 5 REMEDY 4-IN-1 BODY RX/OTC MISC CLEANSER/FOAMER 5 LIQD PRIMACOL BORDERED 5 RX/OTC DRESSING 2"X2" PADS REPLICARE 1-1/2"X2-1/2" 5 RX/OTC PADS PRIMACOL BORDERED 5 RX/OTC DRESSING 4"X4" PADS REPLICARE 4"X4" PADS 5 RX/OTC PRIMACOL BORDERED 5 RX/OTC DRESSING 6"X6" PADS REPLICARE 6"X6" PADS 5 RX/OTC PRIMACOL DRESSING 5 RX/OTC 4"X4" PADS REPLICARE 8"X8" PADS 5 RX/OTC PRIMACOL DRESSING RX/OTC 5 REPLICARE THIN 5 RX/OTC 6"X6" PADS 2"X2.75" PADS PRIMACOL DRESSING RX/OTC 5 REPLICARE THIN 5 RX/OTC 8"X8" PADS 3.5"X5.5" PADS PRIMACOL SPECIALTY RX/OTC 5 REPLICARE THIN 6"X8" 5 RX/OTC DRESSING PADS PADS PRIMACOL THIN RX/OTC 5 REPLICARE ULTRA 4"X4" 5 RX/OTC DRESSING 4"X4" MISC PADS PRIMACOL THIN RX/OTC 5 REPLICARE ULTRA 6"X6" 5 RX/OTC DRESSING 6"X6" MISC PADS PRIMARY DRESSING RX/OTC 5 REPLICARE ULTRA 5 RX/OTC TRAY KIT SACRUM 7"X8" PADS PRIMER MODIFIED UNNA RX/OTC 5 RESTA WOUND 5 RX/OTC BOOT/4"X10YD MISC CLEANSER LIQD PURACYN PLUS DUO- 5 RX/OTC RESTORE CX WOUND RX/OTC CARE LIQD CARE DRESSING- 5 PURAPLY 2CM X 4CM 5 STERILE PADS SHEE RESTORE DRESSING RX/OTC PURAPLY 5CM X 5 CM 5 FOR PSORIASIS-STERILE 5 SHEE PADS PURAPLY 6CM X 9CM 5 RESTORE EXTRA THIN 5 RX/OTC SHEE DRESSING 4"X4" PADS RX/OTC PURILON GEL 5 RESTORE EXTRA THIN 5 RX/OTC DRESSING 6"X8" PADS RADIACARE POST RX/OTC 5 RESTORE EXTRA THIN 5 RX/OTC HEALING CREA DRESSING 8"X8" PADS RADIADRES GEL SHEET RX/OTC 5 RESTORE HYDROGEL 5 RX/OTC SHEE DRESSING GEL RX/OTC RADIAGEL GEL 5 RESTORE HYDROGEL 5 RX/OTC GAUZE PAD 4"X4" PADS RADIAPLEXRX GEL 5 RX/OTC

Updated August 1, 2018

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESTORE HYDROGEL RX/OTC RESTORE WOUND CARE RX/OTC GAUZE STRIP 2"X3.5YD 5 DRESSING 4"X4" 5 MISC ADHESIVE PADS RESTORE PLUS WOUND RX/OTC RESTORE WOUND CARE RX/OTC CARE DRESSING 4"X4" 5 DRESSING 4"X4" NON- 5 PADS ADHESIVE PADS RESTORE PLUS WOUND RX/OTC RESTORE WOUND CARE 5 RX/OTC CARE DRESSING 4"X4" 5 DRESSING 4"X4" PADS TAPERED EDGE PADS RESTORE WOUND CARE RX/OTC RESTORE PLUS WOUND RX/OTC DRESSING 4"X5" 5 CARE DRESSING 6"X6" 5 CONTACT LAYER PADS TAPERED EDGE PADS RESTORE WOUND CARE RX/OTC RESTORE PLUS WOUND RX/OTC DRESSING 6"X6" 5 CARE DRESSING 6"X8" 5 ADHESIVE PADS PADS RESTORE WOUND CARE RX/OTC RESTORE PLUS WOUND RX/OTC DRESSING 6"X8" 5 CARE DRESSING 6"X8" 5 ADHESIVE PADS TAPERED EDGE PADS RESTORE WOUND CARE RX/OTC RESTORE PLUS WOUND RX/OTC DRESSING 6"X8" 5 CARE DRESSING 8"X8" 5 CONTACT LAYER PADS PADS RESTORE WOUND CARE RX/OTC RESTORE PLUS WOUND RX/OTC DRESSING 6"X8" NON- 5 CARE DRESSING 8"X8" 5 ADHESIVE PADS TAPERED EDGE PADS RESTORE WOUND CARE 5 RX/OTC RESTORE PLUS WOUND RX/OTC DRESSING 6"X8" PADS CARE DRESSING 5 RESTORE WOUND CARE 5 RX/OTC TRIANGLE PADS DRESSING 8"X8" PADS RESTORE SILVER RX/OTC 5 REVITADERM WOUND 5 RX/OTC DRESSING 2"X2" PADS CARE GEL RESTORE SILVER RX/OTC RTD WOUND CARE 5 RX/OTC DRESSING 4"X4" NON- 5 DRESSING2" X 2" PADS ADHESIVE PADS RTD WOUND CARE 5 RX/OTC RESTORE SILVER RX/OTC DRESSING4" X 4" PADS DRESSING 4"X4.75" 5 PADS RTD WOUND CARE 5 RX/OTC DRESSING4" X 5" PADS RESTORE SILVER RX/OTC DRESSING 4"X5" 5 SAF-CLENS AF LIQD 5 RX/OTC CONTACT LAYER PADS RX/OTC RESTORE SILVER RX/OTC SAF-GEL GEL 5 DRESSING 6"X8" 5 SEA-CLENS WOUND 5 RX/OTC CONTACT LAYER PADS CLEANSER LIQD RESTORE SILVER RX/OTC RX/OTC DRESSING 6"X8" NON- 5 SEASORB-AG PADS 5 ADHESIVE PADS RX/OTC RESTORE SILVER RX/OTC SHUR-CLENS LIQD 5 DRESSING ROPE 12" 5 RX/OTC MISC SIL-K PAD/LARGE MISC 5

Updated August 1, 2018

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIL-K PAD/MEDIUM MISC 5 RX/OTC SPECTRAGEL GEL 5 RX/OTC

SIL-K PAD/SMALL MISC 5 RX/OTC STIMULEN GEL 5 RX/OTC

SILVASORB GEL 5 RX/OTC STRATASORB RX/OTC COMPOSITE ISLAND 5 SILVERMED GEL 5 RX/OTC DRESSING 4" X 4" PADS TEGADERM AG MESH RX/OTC SILVERMED LIQD 5 RX/OTC DRESSING WITH SILVER 5 2"X2" PADS SKINTEGRITY 2" X 2" 5 RX/OTC TEGADERM AG MESH RX/OTC PADS DRESSING WITH SILVER 5 SKINTEGRITY 4" X 4" 5 RX/OTC 4"X5" PADS PADS TEGADERM AG MESH RX/OTC SKINTEGRITY 5 RX/OTC DRESSING WITH SILVER 5 HYDROGEL GEL 4"X8" PADS SKINTEGRITY WOUND 5 RX/OTC TEGADERM AG MESH RX/OTC LIQD DRESSING WITH SILVER 5 SOLOSITE RX/OTC 8"X8" PADS CONFORMABLE WOUND 5 TEGADERM ALGINATE 5 RX/OTC 2"X2" PADS AG DRESSING PADS SOLOSITE RX/OTC TEGADERM ALGINATE 5 RX/OTC CONFORMABLE WOUND 5 AG ROPE MISC 4"X4" PADS TEGADERM HIGH RX/OTC RX/OTC SOLOSITE GEL 5 GELLING ALGINATE 5 DRESSING 12" ROPE MISC SORBACELL FOAM 5 RX/OTC DRESSING 4"X4" PADS TEGADERM HIGH RX/OTC SORBACELL FOAM RX/OTC GELLING ALGINATE 5 DRESSINGSTRIP 1"X8" 5 DRESSING 4"X4" PADS PADS TEGADERM HIGH RX/OTC SORBSAN TOPICAL RX/OTC INTEGRITY ALGINATE 5 WOUND DRESSING 12" 5 DRESSING 12" ROPE PADS MISC SORBSAN TOPICAL RX/OTC TEGADERM HIGH RX/OTC WOUND DRESSING 2" X 5 INTEGRITY ALGINATE 5 2" PADS DRESSING 4"X4" PADS SORBSAN TOPICAL RX/OTC TEGADERM RX/OTC WOUND DRESSING 3 X 3 5 HYDROCOLLIOD THIN 5 PADS DRESSING 5-1/8"X6" SORBSAN TOPICAL RX/OTC MISC WOUND DRESSING 4 X 4 5 TEGADERM RX/OTC PADS HYDROCOLLOID 5 SORBSAN TOPICAL RX/OTC DRESSING 4"X4" MISC WOUND DRESSING 4" X 5 TEGADERM RX/OTC 8" PADS HYDROCOLLOID 5 RX/OTC DRESSING 4"X4-3/4" SP ANTIPRURITIC GEL 5 MISC

Updated August 1, 2018

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGADERM RX/OTC TENDERWRAP UNNA 5 RX/OTC HYDROCOLLOID 5 BOOT BANDAGE MISC DRESSING 5-1/8"X6" TENDERWRAP UNNA 5 RX/OTC MISC BOOT MISC TEGADERM RX/OTC RX/OTC HYDROCOLLOID 5 THERAHONEY GEL 5 DRESSING 6"X6" MISC TOE-AID PADS 5 RX/OTC TEGADERM RX/OTC HYDROCOLLOID 5 TRIPLE HELIX RX/OTC DRESSING 6-3/4"X6-3/8" COLLAGEN 12"ROPE 5 MISC MISC TEGADERM RX/OTC TRIPLE HELIX 5 RX/OTC HYDROCOLLOID 5 COLLAGEN 2"X2" PADS DRESSING 6-3/4"X8" ULTEC HYDROCOLLOID 5 RX/OTC MISC DRESSING PADS TEGADERM RX/OTC UNNA-FLEX ELASTIC 5 RX/OTC HYDROCOLLOID THIN 5 UNNA BOOT MISC DRESSING 4"X4" MISC UNNA-FLEX PLUS 5 RX/OTC TEGADERM RX/OTC VENOUS ULCER KIT HYDROCOLLOID THIN 5 DRESSING 4"X4-3/4" VACUSTIM BLACK KIT 5 RX/OTC MISC TEGADERM RX/OTC VACUSTIM SILVER KIT 5 RX/OTC HYDROCOLLOID THIN 5 DRESSING 6-3/4"X8" VASCUDERM HYDROGEL 5 RX/OTC MISC WOUNDDRESSING GEL VASCUDERM STASIS KIT RX/OTC TEGADERM HYDROGEL 5 RX/OTC 5 WOUND FILLER GEL KIT VASELINE PETROLATUM RX/OTC TENDERWET ACTIVE 1.6" 5 RX/OTC 5 MISC GAUZE PADS VASELINE PETROLATUM RX/OTC TENDERWET ACTIVE 2.2" 5 RX/OTC MISC GAUZECISION 5 DRESSING OVERWRAP TENDERWET ACTIVE 5 RX/OTC PADS 3"X3" MISC VASELINE PETROLATUM RX/OTC TENDERWET ACTIVE 5 RX/OTC GAUZECISION 5 4"X5" MISC DRESSING PADS TENDERWET ACTIVE RX/OTC 5 VASELINE PETROLATUM 5 RX/OTC CAVITY 1.6" MISC GAUZEOVERWRAP PADS TENDERWET ACTIVE 5 RX/OTC VASELINE PETROLATUM RX/OTC CAVITY 2.2" MISC GAUZESTRIP 5 TENDERWET ACTIVE 5 RX/OTC OVERWRAP PADS CAVITY 3"X3" MISC VASELINE PETROLATUM 5 RX/OTC TENDERWET ACTIVE 5 RX/OTC GAUZESTRIP PADS CAVITY 3"X8" MISC VASELINE PETROLATUM RX/OTC TENDERWET ACTIVE 5 RX/OTC GAUZETUBE FOIL 5 CAVITY 4"X5" MISC OVERWRAP PADS

Updated August 1, 2018

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VENELEX OINT 5 XEROFORM NON- OCCLUSIVE OIL 5 VEXASYN GEL 5 RX/OTC EMULSION GAUZE STRIP 5"X9" PADS VIGILON PRIMARY RX/OTC XEROFORM NON- WOUND DRESSING/13" X 5 OCCLUSIVE OIL 5 24" PADS EMULSION PATCH 2"X2" VIGILON PRIMARY RX/OTC PADS WOUND DRESSING/3" X 5 XEROFORM NON- 8" PADS OCCLUSIVE OIL 5 VIGILON PRIMARY RX/OTC EMULSION ROLL 4"X9" WOUND DRESSING/4" X 5 MISC 4" PADS XEROFORM NON- VIGILON PRIMARY RX/OTC OCCLUSIVE OIL WOUND DRESSING/6" X 5 EMULSION 5 8" PADS STRIP/OVERWRAP 1"X8" WOUN'DRES COLLAGEN RX/OTC MISC HYDROGEL WOUND 5 XEROFORM OCCLUSIVE DRESSING GEL PETROLATUM GAUZE 5 RX/OTC ROLL 4"X9' MISC WOUND CLEANSER LIQD 5 XEROFORM OCCLUSIVE RX/OTC PETROLATUM GAUZE 5 wound cleansers liqd 2 STRIP 1"X8" MISC wound cleansers soln 2 RX/OTC XEROFORM OCCLUSIVE PETROLATUM GAUZE 5 STRIP 5"X9" MISC WOUND DEBRIDEMENT 5 RX/OTC KIT XEROFORM OCCLUSIVE RX/OTC PETROLATUM GAUZE 5 wound dressings pads 2 STRIP/OVERWRAP 1"X8" MISC WOUND GEL GEL 5 RX/OTC XEROFORM OCCLUSIVE WOUND GEL SPRAY GEL 5 RX/OTC PETROLATUM GAUZE 5 STRIP/OVERWRAP 5"X9" MISC WOUND WASH LIQD 5 RX/OTC XEROFORM OCCLUSIVE WOUNDGARD 2-1/2"X2- 5 RX/OTC PETROLTUM GAUZE 5 1/2" PADS PATCH 2"X2" PADS WOUNDGARD 4"X4-1/4" 5 RX/OTC XEROFORM OCCLUSIVE PADS PETROLTUM GAUZE 5 PATCH 4"X4" PADS WOUNDGARD 4"X6" 5 RX/OTC PADS XEROFORM PETROLATUM XEROFLO DRESSING 5 RX/OTC 5 1"X8" PADS DRESSING OVERWRAP 1"X8" MISC XEROFLO DRESSING 5 RX/OTC 2"X2" PADS XEROFORM PETROLATUM XEROFLO DRESSING 5 RX/OTC 5 5"X9" PADS DRESSING OVERWRAP 5"X9" MISC

Updated August 1, 2018

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XEROFORM DRIHEP ARTERIAL LINE PETROLATUM 5 SAMPLING SYR/1ML 5 DRESSING PADS LS/3ML WASTE SYR/2- XEROFORM CAP KIT PETROLATUM 5 DRIHEP ARTERIAL LINE DRESSING ROLL 4"X3YD SAMPLING SYR/1ML 5 MISC LS/SELF-VENT TIP CAP KIT ZANABIN ANTIPRURITIC 5 RX/OTC HYDROGEL GEL DRIHEP ARTERIAL LINE SAMPLING SYR/3ML 5 DIAGNOSTIC PRODUCTS LL/5ML WASTE SYR/2- CAP KIT Diagnostic Biologicals DRIHEP ARTERIAL LINE MOSQUITO EXTRACT 5 SAMPLING SYR/3ML 5 SOLN LL/SELF-VENT TIP CAP Diagnostic Drugs KIT DRIHEP ARTERIAL LINE CUSHINGS SYNDROME 5 DIAGNOSTIC KIT SAMPLING SYR/3ML 5 LS/5ML WASTE SYR/2- MACRILEN PACK 5 CAP KIT Diagnostic Products, Misc. DRIHEP ARTERIAL LINE SAMPLING SYR/3ML 5 3ML GLASS SYR KIT/1ML LS/SELF-VENT TIP CAP NAHEP/SWAB/GAUZE/TIP 5 KIT CAP/NDL STOPPER KIT DRIHEP ARTERIAL LINE 3ML GLASS SYR KIT/1ML SAMPLING SYR/5ML 5 NAHEP/SWAB/PREP/CAP/ 5 LL/SELF-VENT TIP CAP NDL ST/LABEL/DRAP KIT KIT 5ML GLASS SYR KIT/1ML DRIHEP PLUS 3ML LL NAHEP/SWAB/GAUZE/TIP 5 PREFILLED 5 CAP/NDL STOPPER KIT SYR/GZ/PREP/LABEL/CA 5ML GLASS SYR KIT/1ML P/NDL STOP KIT NAHEP/SWAB/PREP/CAP/ 5 DRIHEP PLUS 3ML LL NDL ST/LABEL/DRAP KIT PREFILLED 5 BD 3ML LL SYR/PREFILL SYR/GZ/PREP/LABEL/CA LITH 5 P/SAFTYCONE KIT HEP/GZ/SWAB/CAP/NDL DRIHEP PLUS 3ML LL STP/ICE BAG KIT PREFILLED SYR/NEEDLE 5 BD 3ML LL SYR/PREFILL STOPPER/SAFETYCONE LITH 5 KIT HEP/GZ/SWAB/CAP/NDL DRIHEP PLUS 3ML LL STP/LBL/ICE KIT PREFILLED SYR/TIP 5 BD 3ML LL SYR/PREFILL CAP/NDL LITH HEP/TIP CAP/NDL 5 STOP/SAFETYCONE KIT STOP/SAFETYCONE KIT DRIHEP PLUS 3ML LL BD 3ML LL SYR/PREFILL PREFILLED SYR/TIP 5 LITH HEP/TIP 5 CAP/NEEDLE CAP/NEEDLE STOPPER/22X1 KIT STOP/22GX1" KIT Updated August 1, 2018

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRIHEP PLUS 3ML PRESET 1ML LS PREFILLEDSYR/GZ/SWA 5 SYR/PREFILLLYOPHIL 5 B/TIP CAP/NDL ST/ICE LITH HEP/TIP BAG KIT CAP/SAFETYCONE KIT LIQUIHEP BD 3ML PRESET 3ML LL PREFIL 5 SYR/PREFILLLYOPH LITH 5 SYR/SWAB/GAUZE/CAP/ HEP/CAP/PREP/GZ/LABE NDL STOP/LBL/NDLS KIT L KIT LIQUIHEP BD 3ML PRESET 3ML LL PREFILLED SYR/TIP 5 SYR/PREFILLLYOPH LITH 5 CAP/NDL HEP/CAP/PREP/GZ/SFTY STOP/LABEL/23GX1" KIT CONE KIT LIQUIHEP BD 3ML PRESET 3ML LL PREFILLED SYRINGE/TIP 5 SYR/PREFILLLYOPHIL 5 CAP/NEEDLE STOPPER LITH HEP/TIP CAP/NDL KIT STOP KIT LIQUIHEP II BD 3ML LL PRESET 3ML LL SYR/LL/SWAB/GZ/CAP/N 5 SYR/PREFILLLYOPHIL 5 DL ST/SAFETYCONE KIT LITH HEP/TIP LIQUIHEP II BD 3ML CAP/SAFETYCONE KIT PREFILL 5 PRESET 3ML SYR/LL/SWAB/GZ/CAP/N SYR/PREFILL LYOPH DL ST/ICE BG KIT LITH 5 LIQUIHEP II BD 3ML HEP/SWAB/GZ/CAP/NDL STOP KIT PREFILL 5 SYR/SWAB/GAUZE/CAP/ PRESET 3ML NDL ST/ICE BG KIT SYR/PREFILL LYOPH LIQUIHEP II BD 3ML LITH 5 HEP/SWAB/GZ/CAP/SAFE PREFILL SYR/TIP 5 CAP/NDL TYCONE KIT STOP/LABEL/23GX1 KIT PRESET 3ML LIQUIHEP II BD 3ML SYR/PREFILLEDLYOPHIL 5 LITH HEP/TIP CAP/NDL PREFILLED SYRINGE/TIP 5 CAP/NEEDLE STOPPER STOP KIT KIT Diagnostic Tests PRESET 1ML LS BLOOD GLUCOSE TEST 3 QL(5 ea daily) SYR/PREFILLLYOPH LITH 5 STRIPS HEP/CAP/PREP/GZ/LABE L KIT CHEK-STIX COMBO PAK QL(100 ea per URINALYSIS CONTROL 3 fill retail) PRESET 1ML LS STRP SYR/PREFILLLYOPH LITH 5 HEP/CAP/PREP/GZ/SFTY CHEK-STIX CONTROL 3 QL(100 ea per CONE KIT STRP fill retail) PRESET 1ML LS 3 QL(100 ea per CHEMSTRIP-K STRP fill retail) SYR/PREFILLLYOPHIL 5 LITH HEP/TIP CAP/NDL KETOCARE STRP 3 QL(100 ea per STOP KIT fill retail) KETONE TEST STRIPS 3 QL(100 ea per STRP fill retail) Updated August 1, 2018

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALDACTAZIDE TABS KETOSTIX STRP 3 QL(100 ea per fill retail) 25MG-25MG (Use 5 Spironolactone & 3 QL(100 ea per RELION KETONE STRP fill retail) Hydrochlorothiazide) ALDACTAZIDE TABS RELION KETONE TEST 3 QL(100 ea per 5 STRIPS STRP fill retail) 50MG-50MG amiloride & 2 DIGESTIVE AIDS - Drugs to Treat Low Digestive hydrochlorothiazide tabs Enzymes DYAZIDE CAPS (Use QL(1 ea daily) Digestive Aids - Mixtures Triamterene & 5 KARBOZYME EC TBEC Hydrochlorothiazide) (Use Digestive Aids 5 MAXZIDE TABS (Use QL(1 ea daily) Mixture) Triamterene & 5 PROTEOLYTIC ENZYMES Hydrochlorothiazide) EC TBEC (Use Digestive 5 MAXZIDE-25 TABS (Use QL(1 ea daily) Aids Mixture) Triamterene & 5 Digestive Enzymes Hydrochlorothiazide) spironolactone & 2 CREON CPEP 4 hydrochlorothiazide tabs PANCREAZE CPEP 5 triamterene & 2 QL(1 ea daily) hydrochlorothiazide caps PERTZYE CPEP 5 triamterene & 2 QL(1 ea daily) hydrochlorothiazide tabs PA; SP SUCRAID SOLN 5 Loop Diuretics VIOKACE TABS 4 bumetanide soln 2

ZENPEP CPEP 4 bumetanide tabs 2 BUMEX TABS (Use 5 DIURETICS - Drugs to Treat Heart, Circulation Bumetanide) Conditions and Blood Pressure DEMADEX TABS 20 MG 5 QL(4 ea daily) Carbonic Anhydrase Inhibitors (Use Torsemide) acetazolamide cp12 2 DEMADEX TABS 5 MG, 10 5 QL(1 ea daily) MG (Use Torsemide) acetazolamide sodium solr 2 EDECRIN TABS (Use 5 Ethacrynic Acid) acetazolamide tabs 2 ethacrynate sodium solr 2 DIAMOX CP12 (Use 5 Acetazolamide) ethacrynic acid tabs 2

KEVEYIS TABS 5 furosemide soln ij 10 mg/ml 2 methazolamide tabs 2 furosemide soln or 10 2 mg/ml NEPTAZANE TABS (Use 5 Methazolamide) FUROSEMIDE SOLN OR 8 4 MG/ML Diuretic Combinations

Updated August 1, 2018

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits furosemide tabs or 20 mg, 2 MICROZIDE CAPS (Use 5 40 mg, 80 mg Hydrochlorothiazide) LASIX TABS (Use 5 SODIUM DIURIL SOLR Furosemide) (Use Chlorothiazide 5 Sodium) SODIUM EDECRIN SOLR 5 (Use Ethacrynate Sodium) ENDOCRINE AND METABOLIC AGENTS - torsemide tabs 20 mg 2 QL(4 ea daily) MISC. - Drugs to Treat Bone Disease and Regulate Hormones torsemide tabs 5 mg, 10 2 QL(1 ea daily) Bone Density Regulators mg, 100 mg ACTONEL TABS 35 MG, QL(0.143 ea Osmotic Diuretics 150 MG (Use Risedronate 5 daily) Sodium) mannitol soln 2 ACTONEL TABS 5 MG, 30 QL(1 ea daily) OSMITROL VIAFLEX 4 MG (Use Risedronate 5 SOLN Sodium) Potassium Sparing Diuretics ALENDRONATE SODIUM 4 QL(10.8 ml SOLN 70 MG/75ML daily) ALDACTONE TABS (Use 5 Spironolactone) alendronate sodium tabs 2 QL(0.15 ea 35 mg, 70 mg daily) amiloride hcl tabs 2 QL(4 ea daily) ALENDRONATE SODIUM 4 QL(1 ea daily) TABS 40 MG CAROSPIR SUSP 5 alendronate sodium tabs 5 2 QL(1 ea daily) DYRENIUM CAPS 5 mg, 10 mg ATELVIA TBEC (Use 5 spironolactone tabs 2 Risedronate Sodium) BINOSTO TBEF 5 Thiazides and Thiazide-Like Diuretics chlorothiazide sodium solr 2 BONIVA SOLN IV 3 SP MG/3ML (Use Ibandronate 5 Sodium) CHLOROTHIAZIDE TABS 4 QL(2 ea daily) 250 MG BONIVA TABS OR 150 MG 5 QL(0.0357 ea (Use Ibandronate Sodium) daily) chlorothiazide tabs 500 mg 2 QL(4 ea daily) QL(0.1233 ml calcitonin (salmon) soln 2 chlorthalidone tabs 2 daily) ETIDRONATE DISODIUM 4 DIURIL SUSP 5 TABS FORTEO SOLN 4 PA; SP hydrochlorothiazide caps 2 FORTICAL SOLN 4 QL(0.1233 ml hydrochlorothiazide tabs 2 daily) indapamide tabs 2 FOSAMAX PLUS D TABS 5 FOSAMAX TABS (Use 5 QL(0.15 ea methyclothiazide tabs 2 Alendronate Sodium) daily) ibandronate sodium soln iv 2 SP metolazone tabs 2 3 mg/3ml

Updated August 1, 2018

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ibandronate sodium tabs or 2 QL(0.0357 ea Fertility Regulators 150 mg daily) BRAVELLE SOLR 5 PA; SP MIACALCIN SOLN IJ 200 5 QL(0.0667 ml UNIT/ML daily) CHORIONIC 4 SP MIACALCIN SOLN NA 200 QL(0.1233 ml GONADOTROPIN SOLR UNIT/ACT (Use Calcitonin 5 daily) (Salmon)) clomiphene citrate tabs 2 PA; SP NATPARA CART 5 CLOMIPHENE CITRATE 4 TABS pamidronate disodium soln 2 SP SP 30 mg/10ml, 90 mg/10ml FOLLISTIM AQ SOLN 5 PAMIDRONATE PA; SP GONAL-F RFF REDIJECT 4 PA; SP DISODIUM SOLN 6 5 SOLN MG/ML GONAL-F RFF SOLR 4 PA; SP pamidronate disodium solr 2 SP 30 mg, 90 mg GONAL-F SOLR 4 PA; SP PROLIA SOLN 4 PA; SP MENOPUR SOLR 5 PA; SP RECLAST SOLN (Use 5 PA; SP Zoledronic Acid) NOVAREL SOLR 10000 4 SP UNIT risedronate sodium tabs 35 2 QL(0.143 ea mg, 150 mg daily) NOVAREL SOLR 5000 5 PA; SP UNIT risedronate sodium tabs 5 2 QL(1 ea daily) mg, 30 mg OVIDREL INJ 4 SP risedronate sodium tbec 35 2 mg PREGNYL W/DILUENT SP PA; SP BENZYLALCOHOL/NACL 4 TYMLOS SOPN 4 SOLR XGEVA SOLN 5 PA; SP GnRH/LHRH Antagonists CETROTIDE KIT 4 SP zoledronic acid conc 4 2 PA; SP mg/5ml GANIRELIX ACETATE 5 SP SOLN ZOLEDRONIC ACID SOLN 5 PA; SP 4 MG/100ML ORILISSA TABS 5 zoledronic acid soln 5 2 PA; SP mg/100ml Growth Hormone Receptor Antagonists ZOLEDRONIC ACID SOLR 5 PA; SP PA; SP 4 MG SOMAVERT SOLR 4 ZOMETA CONC 4 PA; SP Growth Hormone Releasing Hormones (GHRH) MG/5ML (Use Zoledronic 5 Acid) EGRIFTA SOLR 5 PA; SP ZOMETA SOLN 4 5 PA; SP MG/100ML Growth Hormones GENOTROPIN MINIQUICK 5 PA; SP Corticotropin SOLR PA; SP H.P. ACTHAR GEL 5 GENOTROPIN SOLR 5 PA; SP

Updated August 1, 2018

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMATROPE COMBO 4 PA; SP LUPRON DEPOT-PED (1- 5 PA; SP PACK SOLR MONTH) KIT HUMATROPE SOLR 4 PA; SP LUPRON DEPOT-PED (3- 5 PA; SP MONTH) KIT NORDITROPIN FLEXPRO 4 PA; SP PA; SP SOLN SUPPRELIN LA KIT 5 NUTROPIN AQ NUSPIN 5 PA; SP SYNAREL SOLN 5 PA; SP 10 SOLN PA; SP NUTROPIN AQ NUSPIN 5 PA; SP TRIPTODUR SRER 5 20 SOLN Metabolic Modifiers NUTROPIN AQ NUSPIN 5 5 PA; SP SOLN ALDURAZYME SOLN 5 PA; SP OMNITROPE SOLN 5 4 PA; SP MG/1.5ML, 10 MG/1.5ML AMMONUL SOLN (Use Sod Benzoate & Sod 5 OMNITROPE SOLR 5.8 5 PA; SP MG Phenylacetate) BUPHENYL POWD 3 PA; SP SAIZEN CLICK.EASY 5 PA; SP SOLR GM/TSP (Use Sodium 5 Phenylbutyrate) PA; SP SAIZEN SOLR 5 BUPHENYL TABS 500 MG SP SAIZENPREP PA; SP (Use Sodium 5 RECONSTITUTIONKIT 5 Phenylbutyrate) SOLR calcitriol caps or 0.25 mcg, 2 0.5 mcg SEROSTIM SOLR 5 PA; SP CALCITRIOL SOLN IV 1 4 MCG/ML ZOMACTON SOLR 5 PA; SP calcitriol soln iv 1 mcg/ml 2 ZORBTIVE SOLR 5 PA; SP calcitriol soln or 1 mcg/ml 2 Hormone Receptor Modulators QL(1 ea daily); CARBAGLU TABS 5 SP EVISTA TABS (Use 5 ) AL; At least 40 Raloxifene HCl yrs old CARNITOR SF SOLN (Use QL(30 ml daily) Levocarnitine (Metabolic 5 OSPHENA TABS 4 Modifiers)) QL(1 ea daily); CARNITOR SOLN IV 200 4 raloxifene hcl tabs 6 AL; At least 40 MG/ML yrs old CARNITOR SOLN OR 1 QL(30 ml daily) GM/10ML (Use 5 Insulin-Like Growth Factors (Somatomedins) Levocarnitine (Metabolic INCRELEX SOLN 5 PA; SP Modifiers)) CARNITOR TABS OR 330 QL(3 ea daily); LHRH/GnRH Agonist Analog Pituitary MG (Use Levocarnitine 5 RX/OTC (Metabolic Modifiers)) LUPANETA PACK KIT 5 PA; SP 11.25MG-5MG CRYSVITA SOLN 5 PA; SP LUPANETA PACK KIT 5 PA; SP 3.75MG-5MG CYSTADANE POWD 5 PA; SP

Updated August 1, 2018

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxercalciferol caps 2 ROCALTROL SOLN (Use 5 Calcitriol) doxercalciferol soln 2 SENSIPAR TABS 5 PA; SP PA; SP ELAPRASE SOLN 5 sod benzoate & sod 2 phenylacetate soln PA; SP FABRAZYME SOLR 5 sodium phenylbutyrate 2 PA; SP powd 3 gm/tsp HECTOROL CAPS OR 0.5 MCG, 1 MCG, 2.5 MCG 5 sodium phenylbutyrate tabs 2 SP (Use Doxercalciferol) 500 mg STRENSIQ SOLN 5 HECTOROL SOLN IV 2 5 MCG/ML PA; SP HECTOROL SOLN IV 4 VIMIZIM SOLN 5 MCG/2ML (Use 5 Doxercalciferol) XURIDEN PACK 5 KANUMA SOLN 5 ZEMPLAR CAPS OR 1 MCG, 2 MCG (Use 5 KUVAN PACK 5 PA; SP Paricalcitol) ZEMPLAR SOLN IV 2 SP KUVAN TBSO 5 PA; SP MCG/ML, 5 MCG/ML (Use 5 Paricalcitol) levocarnitine (metabolic 2 QL(30 ml daily) modifiers) soln 1 gm/10ml Posterior Pituitary Hormones DDAVP SOLN IJ 4 SP levocarnitine (metabolic 2 QL(3 ea daily); modifiers) tabs 330 mg RX/OTC MCG/ML (Use 5 Desmopressin Acetate) LUMIZYME SOLR 5 PA; SP 5 QL(5 ml per fill DDAVP SOLN NA 0.01 % retail) MYALEPT SOLR 5 PA; SP DDAVP SOLN NA 0.01 % QL(5 ml per fill PA; SP (Use Desmopressin 5 retail); SP NAGLAZYME SOLN 5 Acetate Spray) NITYR TABS 5 PA; SP DDAVP TABS OR 0.1 MG QL(6 ea daily) (Use Desmopressin 5 ORFADIN CAPS 5 Acetate) DDAVP TABS OR 0.2 MG QL(8 ea daily) ORFADIN SUSP 5 (Use Desmopressin 5 Acetate) paricalcitol caps or 1 mcg, 2 desmopressin acetate soln 2 SP 2 mcg, 4 mcg ij 4 mcg/ml paricalcitol soln iv 2 SP 2 desmopressin acetate 2 QL(5 ml per fill mcg/ml, 5 mcg/ml spray refrigerated soln retail) PA; SP RAVICTI LIQD 5 desmopressin acetate 2 QL(5 ml per fill spray soln retail); SP RAYALDEE CPCR 5 desmopressin acetate tabs 2 QL(6 ea daily) or 0.1 mg ROCALTROL CAPS (Use 5 Calcitriol) desmopressin acetate tabs 2 QL(8 ea daily) or 0.2 mg Updated August 1, 2018

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOCTIVA EMUL 5 Limit 8 patches COMBIPATCH PTTW 4 per STIMATE SOLN 5 PA; SP month;QL(0.29 ea daily) VASOPRESSIN/SODIUM 5 CHLORIDE SOLN DUAVEE TABS 4 VASOSTRICT SOLN 5 estradiol & norethindrone 2 acetate tabs 0.1mg-0.5mg Prolactin Inhibitors estradiol & norethindrone 2 QL(1 ea daily) acetate tabs 0.5mg-1mg cabergoline tabs 2 FEMHRT LOW DOSE Somatostatic Agents TABS (Use Norethindrone 5 Acetate-Ethinyl Estradiol) octreotide acetate soln 2 PA; SP norethindrone acetate- 2 ethinyl estradiol tabs SANDOSTATIN LAR 5 PA; SP DEPOT KIT PREFEST TABS 5 SANDOSTATIN SOLN 5 PA; SP (Use Octreotide Acetate) PREMPHASE TABS 4 QL(1 ea daily)

SIGNIFOR LAR SRER 5 PREMPRO TABS 4 QL(1 ea daily) SIGNIFOR SOLN 0.3 5 SP MG/ML Estrogens QL(0.29 ea SIGNIFOR SOLN 0.6 5 PA; SP ALORA PTTW 4 MG/ML, 0.9 MG/ML daily) CLIMARA PTWK (Use QL(0.143 ea SOMATULINE DEPOT 4 PA; SP 5 SOLN Estradiol) daily) DELESTROGEN OIL 10 5 Vasopressin Receptor Antagonists MG/ML SAMSCA TABS 5 PA; SP DELESTROGEN OIL 20 MG/ML, 40 MG/ML (Use 5 VAPRISOL SOLN 5 Estradiol Valerate) ESTROGENS - Hormone Replacement/Modifying DEPO-ESTRADIOL OIL 5 Drugs DIVIGEL GEL 4 Estrogen Combinations ACTIVELLA TABS 0.1MG- ELESTRIN GEL 5 0.5MG (Use Estradiol & 5 Norethindrone Acetate) ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (Use 5 ACTIVELLA TABS 0.5MG- QL(1 ea daily) Estradiol) 1MG (Use Estradiol & 5 Norethindrone Acetate) estradiol pttw td 0.0375 QL(0.29 ea mg/24hr, 0.025 mg/24hr, 2 daily) ANGELIQ TABS 5 0.075 mg/24hr, 0.05 mg/24hr, 0.1 mg/24hr BIEST/PROGESTERONE 5 CREA CLIMARA PRO PTWK 5

Updated August 1, 2018

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits estradiol ptwk td 0.025 QL(0.143 ea CIPRO SUSR 5 GM/100ML 4 mg/24hr, 0.075 mg/24hr, daily) 0.05 mg/24hr, 0.06 2 CIPRO SUSR 500 MG/5ML 5 mg/24hr, 0.1 mg/24hr, 37.5 (Use Ciprofloxacin) mcg/24hr CIPRO TABS 250 MG, 500 estradiol tabs or 0.5 mg, 1 2 MG (Use Ciprofloxacin 5 mg, 2 mg HCl) estradiol valerate oil 2 CIPRO XR TB24 (Use Ciprofloxacin-Ciprofloxacin 5 ESTROGEL GEL 5 HCl) CIPROFLOXACIN HCL 4 QL(6 ea per fill estropipate tabs 0.75 mg, 2 QL(1 ea daily) TABS 100 MG retail) 1.5 mg ciprofloxacin hcl tabs 250 2 estropipate tabs 3 mg 2 QL(2 ea daily) mg, 500 mg, 750 mg ciprofloxacin in d5w soln 2 EVAMIST SOLN 4 QL(0.27 ml daily) CIPROFLOXACIN SOLN MENEST TABS 5 IV 200 MG/20ML, 400 4 MG/40ML MENOSTAR PTWK 5 ciprofloxacin susr or 250 2 mg/5ml, 500 mg/5ml QL(0.29 ea MINIVELLE PTTW 4 daily) ciprofloxacin-ciprofloxacin 2 hcl tb24 PREMARIN SOLR IJ 25 5 MG FACTIVE TABS 5 PREMARIN TABS OR QL(1 ea daily) QL(1 ea 0.625 MG, 0.45 MG, 0.3 4 LEVAQUIN TABS (Use 5 ) daily,14 ea per MG, 0.9 MG, 1.25 MG Levofloxacin fill retail) VIVELLE-DOT PTTW (Use 5 QL(0.29 ea Estradiol) daily) levofloxacin in d5w soln 2 FLUOROQUINOLONES - Drugs to Treat Bacterial levofloxacin soln iv 25 2 Infections mg/ml Fluoroquinolones levofloxacin soln or 25 2 mg/ml AVELOX ABC PACK TABS 5 (Use Moxifloxacin HCl) QL(1 ea levofloxacin tabs or 250 2 daily,14 ea per mg, 500 mg, 750 mg AVELOX SOLN IV 5 fill retail) 400MG/250ML-0.8% moxifloxacin hcl in sodium 2 AVELOX SOLN IV chloride soln 400MG/250ML-0.8% (Use 5 Moxifloxacin HCl in Sodium MOXIFLOXACIN HCL 5 Chloride) SOLN IV 400 MG/250ML moxifloxacin hcl tabs or AVELOX TABS OR 400 5 2 MG (Use Moxifloxacin HCl) 400 mg OFLOXACIN TABS 300 4 BAXDELA TABS 5 MG QL(56 ea per CIPRO I.V.-IN D5W SOLN 5 ofloxacin tabs 400 mg 2 (Use Ciprofloxacin in D5W) fill retail)

Updated August 1, 2018

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GASTROINTESTINAL AGENTS - MISC. - METOZOLV ODT TBDP 5 Miscellaneous Gastrointestinal Drugs (Use Metoclopramide HCl) REGLAN TABS (Use 5 Agents for Chronic Idiopathic Constipation (CIC) Metoclopramide HCl) TRULANCE TABS 5 Inflammatory Bowel Agents Bile Acid Synthesis Disorder Agents APRISO CP24 4 CHOLBAM CAPS 5 ASACOL HD TBEC 5 Farnesoid X Receptor (FXR) Agonists ASACOL HD TBEC (Use 5 OCALIVA TABS 5 PA; SP Mesalamine) AZULFIDINE EN-TABS 5 Gallstone Solubilizing Agents TBEC (Use Sulfasalazine) AZULFIDINE TABS (Use ACTIGALL CAPS (Use 5 QL(3 ea daily) 5 Ursodiol) Sulfasalazine) CHENODAL TABS 5 balsalazide disodium caps 2 QL(9 ea daily)

URSO 250 TABS (Use 5 QL(7 ea daily) CANASA SUPP 4 Ursodiol) PA; SP URSO FORTE TABS (Use 5 CIMZIA KIT 5 Ursodiol) PA; SP ursodiol caps 300 mg 2 QL(3 ea daily) CIMZIA STARTER KIT KIT 5 QL(7 ea daily) COLAZAL CAPS (Use 5 QL(9 ea daily) ursodiol tabs 250 mg 2 Balsalazide Disodium) ursodiol tabs 500 mg 2 DELZICOL CPDR 5 Gastrointestinal Antiallergy Agents DIPENTUM CAPS 5 cromolyn sodium 2 PA; SP (mastocytosis) conc ENTYVIO SOLR 5 GASTROCROM CONC (Use Cromolyn Sodium 5 GIAZO TABS 5 (Mastocytosis)) INFLECTRA SOLR 5 Gastrointestinal Chloride Channel Activators LIALDA TBEC (Use 5 AMITIZA CAPS 5 Mesalamine) Gastrointestinal Stimulants mesalamine enem re 4 gm 2 QL(60 ml daily) metoclopramide hcl soln 2 mesalamine tbec or 1.2 2 gm, 800 mg metoclopramide hcl tabs 2 mesalamine w/ cleanser kit 2 METOCLOPRAMIDE ODT 5 TBDP 10 MG PENTASA CPCR 4 QL(8 ea daily) METOCLOPRAMIDE ODT 4 PA; SP TBDP 5 MG REMICADE SOLR 4

Updated August 1, 2018

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RENFLEXIS SOLR 5 PA FOSRENOL CHEW 500 MG, 750 MG, 1000 MG 5 (Use Lanthanum ROWASA KIT (Use 5 Mesalamine w/ Cleanser) Carbonate) SFROWASA ENEM 5 FOSRENOL PACK 750 5 MG, 1000 MG STELARA SOLN IV 130 5 MG/26ML lanthanum carbonate chew 2 sulfasalazine tabs 2 PHOSLYRA SOLN 4 sulfasalazine tbec 2 RENAGEL TABS 5

Intestinal Acidifiers RENVELA PACK (Use 5 Sevelamer Carbonate) lactulose (encephalopathy) 2 soln RENVELA TABS (Use 5 Sevelamer Carbonate) Irritable Bowel Syndrome (IBS) Agents sevelamer carbonate pack 2 alosetron hcl tabs 2 QL(2 ea daily) sevelamer carbonate tabs 2 LINZESS CAPS 4 VELPHORO CHEW 4 LOTRONEX TABS (Use 5 QL(2 ea daily) Alosetron HCl) Short Bowel Syndrome (SBS) Agents 4 VIBERZI TABS GATTEX KIT 5 SP Peripheral Opioid Receptor Antagonists Tryptophan Hydroxylase Inhibitors 5 ENTEREG CAPS XERMELO TABS 4 PA MOVANTIK TABS 4 GENERAL ANESTHETICS RELISTOR SOLN 5 Anesthetics - Misc. RELISTOR TABS 5 AMIDATE SOLN (Use 5 Etomidate) SYMPROIC TABS 5 DIPRIVAN EMUL (Use 5 Propofol) Phosphate Binder Agents etomidate soln 2 AURYXIA TABS 5 KETALAR SOLN (Use 5 Ketamine HCl) calcium acetate (phosphate 2 binder) caps ketamine hcl soln 2 calcium acetate (phosphate 2 RX/OTC binder) tabs propofol emul 2 ELIPHOS TABS (Use RX/OTC Calcium Acetate 5 Volatile Anesthetics (Phosphate Binder)) FORANE SOLN (Use 5 Isoflurane)

Updated August 1, 2018

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits isoflurane soln 2 UROCIT-K 5 TBCR (Use Potassium Citrate 5 sevoflurane soln 2 (Alkalinizer)) Cystinosis Agents ULTANE SOLN (Use 5 Sevoflurane) CYSTAGON CAPS 5 PA; SP GENITOURINARY AGENTS - MISCELLANEOUS PA; SP - Miscellaneous Drugs to Treat Reproductive PROCYSBI CPDR 25 MG 5 Organs and Urinary System PROCYSBI CPDR 75 MG 5 PA; QL(0.034 Acidifiers ea daily); SP K-PHOS NO 2 TABS 5 Genitourinary Irrigants acetic acid soln 2 Alkalinizers CYTRA-3 SYRP 4 glycine (gu irrigant) soln 2 neomycin/polymyxin b gu 2 ORACIT SOLN 5 soln NEOSPORIN GU pot & sod citrates w/citric 2 ac soln IRRIGANT SOLN (Use 5 Neomycin/Polymyxin B potassium citrate 2 (alkalinizer) tbcr GU) potassium citrate-citric acid 2 RENACIDIN SOLN 5 pack 3300mg-1002mg sodium chloride (gu 2 potassium citrate-citric acid RX/OTC irrigant) soln soln 1100mg/5ml- 334mg/5ml, 1100mg/5ml- 2 SORBITOL SOLN IR 3 %, 5 1100mg/5ml-334mg/5ml- 3.3 % 334mg/5ml SORBITOL-MANNITOL 5 POTASSIUM SOLN CITRATE/SODIUMCITRAT 4 Interstitial Cystitis Agents E/CITRIC ACID SOLN SHOHLS SOLUTION QL(16.67 ml ELMIRON CAPS 5 MODIFIED SOLN (Use 5 daily); RX/OTC Sodium Citrate & Citric RIMSO-50 SOLN 5 Acid) Prostatic Hypertrophy Agents sodium citrate & citric acid 2 QL(16.67 ml soln daily); RX/OTC alfuzosin hcl tb24 2 QL(1 ea daily) TRICITRATES SOLN 4 AVODART CAPS (Use 5 QL(1 ea daily) Dutasteride) UROCIT-K 10 TBCR (Use Potassium Citrate 5 CARDURA XL TB24 5 (Alkalinizer)) QL(1 ea daily) UROCIT-K 15 TBCR (Use dutasteride caps 2 Potassium Citrate 5 (Alkalinizer)) dutasteride-tamsulosin hcl 2 QL(1 ea daily) caps finasteride tabs 2 QL(1 ea daily)

Updated August 1, 2018

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLOMAX CAPS (Use 5 QL(2 ea daily) MITIGARE CAPS 5 Tamsulosin HCl) JALYN CAPS (Use QL(1 ea daily) ULORIC TABS 4 QL(1 ea daily) Dutasteride-Tamsulosin 5 HCl) ZURAMPIC TABS 5 PROSCAR TABS (Use 5 QL(1 ea daily) Finasteride) ZYLOPRIM TABS (Use 5 Allopurinol) RAPAFLO CAPS 4 Uricosurics QL(2 ea daily) tamsulosin hcl caps 2 probenecid tabs 2

UROXATRAL TB24 (Use 5 QL(1 ea daily) HEMATOLOGICAL AGENTS - MISC. - Drugs to Alfuzosin HCl) Treat Blood Disorders Urinary Analgesics Antihemophilic Products phenazopyridine hcl tabs 2 ADYNOVATE SOLR 750 5 100 mg, 200 mg UNIT, 1500 UNIT PYRIDIUM TABS (Use 5 Phenazopyridine HCl) Bradykinin B2 Receptor Antagonists PA; SP Urinary Stone Agents FIRAZYR SOLN 5 LITHOSTAT TABS 5 Complement Inhibitors PA; SP THIOLA TABS 5 BERINERT KIT 5 CINRYZE SOLR 5 PA; SP GOUT AGENTS - Drugs to Treat Gout PA Gout Agent Combinations HAEGARDA SOLR 5 colchicine w/ probenecid 2 PA; SP tabs RUCONEST SOLR 4 DUZALLO TABS 5 SOLIRIS SOLN 5 PA; SP Gout Agents Hematorheologic Agents allopurinol sodium solr 2 pentoxifylline tbcr 2 allopurinol tabs 2 Hemin PANHEMATIN SOLR 5 ALOPRIM SOLR (Use 5 Allopurinol Sodium) Plasma Kallikrein Inhibitors COLCHICINE CAPS 5 KALBITOR SOLN 5 PA; SP 4 QL(0.2 ea COLCHICINE TABS daily) Platelet Aggregation Inhibitors 4 QL(0.2 ea AGGRASTAT CONC 5 COLCRYS TABS daily) KRYSTEXXA SOLN 5 PA; SP AGGRASTAT SOLN 5

Updated August 1, 2018

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AGGRENOX CP12 (Use 5 QL(2 ea daily) CATHFLO ACTIVASE 5 Aspirin-Dipyridamole) SOLR AGRYLIN CAPS (Use 5 TNKASE KIT 5 Anagrelide HCl) anagrelide hcl caps 2 HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders QL(2 ea daily) aspirin-dipyridamole cp12 2 Agents for Gaucher Disease PA; SP BRILINTA TABS 4 CERDELGA CAPS 4 PA; SP cilostazol tabs 2 QL(2 ea daily) CEREZYME SOLR 4 clopidogrel bisulfate tabs or 2 ELELYSO SOLR 5 300 mg miglustat caps 2 PA; SP clopidogrel bisulfate tabs or 2 QL(1 ea daily) 75 mg VPRIV SOLR 5 PA; SP dipyridamole tabs or 25 2 mg, 50 mg, 75 mg ZAVESCA CAPS (Use 5 PA; SP DURLAZA CP24 5 Miglustat) Agents for Sickle Cell Anemia EFFIENT TABS (Use 5 QL(1 ea daily) Prasugrel HCl) DROXIA CAPS 5 eptifibatide soln 2 ENDARI PACK 5 INTEGRILIN SOLN (Use 5 Eptifibatide) Cobalamins B-12 COMPLIANCE 5 KENGREAL SOLR 5 INJECTIONKIT KIT PLAVIX TABS 300 MG 5 B-12 KIT KIT 5 (Use Clopidogrel Bisulfate) CYANOCOBALAMIN RX/OTC PLAVIX TABS 75 MG (Use 5 QL(1 ea daily) 5 Clopidogrel Bisulfate) CRYS XX QL(1 ea daily) CYANOCOBALAMIN 5 prasugrel hcl tabs 2 POWD XX REOPRO SOLN 5 cyanocobalamin soln ij 2 1000 mcg/ml YOSPRALA TBEC 5 HYDROXOCOBALAMIN 4 SOLN ZONTIVITY TABS 5 NASCOBAL SOLN 5 Protamine PHYSICIANS EZ USE B- 5 12 COMPLIANCE KIT KIT PROTAMINE SULFATE 4 SOLN VITAMIN DEFICIENCY Thrombolytic Enzymes INJECTABLE SYSTEM- 5 B12 KIT ACTIVASE SOLR 5 Folic Acid/Folates

Updated August 1, 2018

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOLIC ACID POWD XX 5 RX/OTC NEULASTA SOSY 5 PA; SP

FOLIC ACID SOLN IJ 5 4 NEUPOGEN SOLN 5 PA; SP MG/ML AL; At least 11 NEUPOGEN SOSY 5 PA; SP yrs old - Up to folic acid tabs or 1 mg 6 50 yrs old; NPLATE SOLR 5 PA; SP RX/OTC AL; At least 11 PROCRIT SOLN 2000 PA; SP folic acid tabs or 400 mcg 6 yrs old - Up to UNIT/ML, 3000 UNIT/ML, 5 50 yrs old; PV 4000 UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML AL; At least 11 folic acid tabs or 800 mcg 6 yrs old - Up to PROCRIT SOLN 40000 4 PA; SP 50 yrs old UNIT/ML PA; SP Hematopoietic Growth Factors PROMACTA TABS 5 ARANESP ALBUMIN SP PA; FREE SOLN 25 MCG/ML, ZARXIO SOSY 4 40 MCG/ML, 60 MCG/ML, 4 100 MCG/ML, 200 Hematopoietic Mixtures MCG/ML, 300 MCG/ML ABANEU-SL SUBL 5 ARANESP ALBUMIN PA; SP FREE SOSY 500 MCG/ML, ACTIVE FE TABS 5 10 MCG/0.4ML, 40 MCG/0.4ML, 60 ANIMI-3 CAPS 5 MCG/0.3ML, 100 4 MCG/0.5ML, 150 ANIMI-3/VITAMIN D CAPS 5 MCG/0.3ML, 200 MCG/0.4ML, 25 B-6 FOLIC ACID CAPS 5 RX/OTC MCG/0.42ML, 300 MCG/0.6ML B12 FOLATE CAPS 5 RX/OTC EPOGEN SOLN 5 PA; SP BIFERARX TABS 5 FULPHILA SOSY 5 BP VIT 3 CAPS 5 GRANIX SOSY 5 PA; SP CENFOL TABS 5 LEUKINE SOLR 5 PA; SP CENTRATEX CAPS 5 MIRCERA SOSY 30 MCG/0.3ML, 150 5 CIFEREX CAPS 5 MCG/0.3ML MIRCERA SOSY 50 PA; SP CIFRAZOL CAPS 5 MCG/0.3ML, 75 MCG/0.3ML, 100 5 CORVITE 150 TABS MCG/0.3ML, 200 150MG-25MG-15MCG- MCG/0.3ML 1.25MG-10MG-120MG 5 (Use Iron-Folic Acid- NEULASTA ONPRO KIT 5 PA; SP Vitamin C-Vitamin B6- PSKT Vitamin B12-Zinc)

Updated August 1, 2018

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORVITE 150 TABS RX/OTC FOCALGIN DSS TABS 5 300MCG-5MG-150MG- 120MG-10MG-25MG- 5 FOLGARD RX TABS (Use 20MCG-700MCG- Folic Acid-Vitamin B6- 5 100MCG-10MG Vitamin B12) CORVITE FE TABS 5 RX/OTC FOLI-D TABS 5

CYFOLEX CAPS 5 FOLIC + B12 TABS 5 RX/OTC

DERMACINRX 5 folic acid-vitamin b6-vitamin PUREFOLIX TABS b12 tabs 0.5mg-25mg- 2.2mg, 1mg-2.2mg-25mg, 2 DIVISTA CAPS 5 1mg-2.5mg-25mg, 1mg- 25mg-2.2mg, 500mcg- DURACHOL CAPS 5 2.2mg-25mg fe fum-iron polysacch FOLIKA-D TABS 5 complex-fa-b complex-c- 2 zn-mn-cu caps FOLITAB 500 TBCR 5 fe fumarate-vitamin c- 2 vitamin b12-folic acid caps FOLIVANE-F CAPS 5 FE PLUS PROTEIN TABS 5 RX/OTC FOLIVANE-PLUS CAPS 5 FERIVA 21/7 TABS 5 FOLIXAPURE TABS 5 FERIVA CAPS 5 FOLTRATE TABS 5 RX/OTC FERIVAFA CAPS 5 FUSION PLUS CAPS 5 FERRALET 90 TABS 5 FUSION SPRINKLES 5 PACK FERRAPLUS 90 TABS 5 HEMATOGEN FA CAPS 5 FERREX 150 FORTE 4 PLUS CAPS HEMATRON-AF TABS RX/OTC (Use Iron-Docusate-B12- 5 FERREX 28 MISC 4 Folic Acid-Vit C-Vit E- Copper-Biotin) FERRO-PLEX HEMATINIC 5 TABS HEMETAB TABS 5 FERROTRIN CAPS 5 HEMOCYTE PLUS CAPS 5 ferrous fumarate w/ b12-vit 2 c-fa-ifc caps I.L.X. B-12 ELIX 5 ferrous fumarate-fa-b ICAR-C PLUS TABS (Use RX/OTC complex-c-zn-mg-mn-cu 2 Iron-Vitamin C-Vitamin 5 tabs B12-Folic Acid) ferrous fumarate-folic acid 2 tabs INTEGRA F CAPS 5

Updated August 1, 2018

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INTEGRA PLUS CAPS 5 PRE-FOLIC TABS 5 iron combinations caps 2 RX/OTC PROFERRIN-FORTE 5 TABS iron polysaccharide complex-vit b12-folic acid 2 PROTECTIRON TABS 5 caps PUREFE PLUS CAPS 5 iron-docusate-b12-folic RX/OTC acid-vit c-vit e-copper-biotin 2 REVESTA CAPS 5 tabs iron-folic acid-vitamin c- ROXIFOL-D TABS 5 vitamin b6-vitamin b12-zinc 2 tabs TALIVA CAPS 5 iron-vitamin c-vitamin b12- 2 RX/OTC folic acid tabs TANDEM F CAPS 5 IROSPAN 24/6 MISC 5 TANDEM PLUS CAPS (Use Fe Fum-Iron 5 IS 24/6 MISC 5 Polysacch Complex-FA-B Complex-C-Zn-Mn-Cu) MAXFE TABS 1MG-12MG- 6.5MG-160MG-50MG- 5 TARON FORTE CAPS 5 60MCG-150MCG-100MG METHIONINE/INOSITOL/C VITAMEZ CAPS 5 HOLINE/CYANOCOBALA 5 MIN SOLN VITAMIN B12/FOLIC ACID 5 RX/OTC TABS MTX SUPPORT TABS 5 RX/OTC ZAVARA CAPS 5 MULTIGEN FOLIC TABS 5 ZOLATE CAPS 5 MULTIGEN PLUS TABS 5 Iron MULTIGEN TABS 5 carbonyl iron susp 15 6 mg/1.25ml NEPHRON FA TABS 5 FER-IN-SOL SOLN (Use 5 Ferrous Sulfate) NEURIN-SL SUBL 5 FERAHEME SOLN 5 NIFEREX TABS 5 RX/OTC FERRLECIT SOLN (Use Sodium Ferric Gluconate 5 NOXIFOL-D TABS 5 Complex in Sucrose) RX/OTC FERROUS SULFATE 5 RX/OTC NUFERA TABS 5 ANHYDROUS POWD ferrous sulfate elix or 220 OPURITY B12/FOLIC 5 RX/OTC 6 ACID TABS mg/5ml FERROUS SULFATE 5 RX/OTC ORTHO D CAPS 5 GRAN XX FERROUS SULFATE 5 RX/OTC ORTHO DF CAPS 5 HEPTAHYDRATE GRAN Updated August 1, 2018

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERROUS SULFATE 5 RX/OTC ASTRINGYN SOLN 5 POWD XX ferrous sulfate soln or 15 6 EVICEL KIT 5 mg/ml FERROUS SULFATE 6 EVITHROM SOLN 5 SYRP OR 300 MG/5ML MONSELS FERRIC 5 ICAR PEDIATRIC SUSP 5 SUBSULFATE SOLN (Use Carbonyl Iron) RAPLIXA POWD 5 INFED SOLN 4 RECOTHROM SOLR 5 INJECTAFER SOLN 5 RECOTHROM SPRAY KIT 5 polysaccharide iron 2 SOLR complex caps THROMBIN-JMI DILUENT 5 sodium ferric gluconate 2 SOLR complex in sucrose soln THROMBIN-JMI 5 TRIFERIC SOLN 27.2 5 EPISTAXIS KIT MG/5ML THROMBIN-JMI SYRINGE 5 VENOFER SOLN 5 SPRAY KIT KIT THROMBIN-JMI W/DIL Stem Cell Mobilizers SPRAYPUMP ACTUATOR 5 MOZOBIL SOLN 5 PA; SP KIT THROMBOGEN KIT 5 HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders THROMBOGEN SOLR 5 Hemostatics - Systemic TISSEEL KIT 5 AMICAR SOLN 0.25 5 GM/ML TISSEEL SOLN 5 AMICAR TABS 1000 MG 5 TISSEEL VH KIT 5 4 QL(24 ea per AMICAR TABS 500 MG fill retail) HYPNOTICS/SEDATIVES/SLEEP DISORDER AMINOCAPROIC ACID 4 AGENTS SOLN Barbiturate Hypnotics CYKLOKAPRON SOLN 5 (Use Tranexamic Acid) AMYTAL SODIUM SOLR 5 LYSTEDA TABS (Use 5 QL(6 ea daily) Tranexamic Acid) BUTISOL SODIUM TABS 5 tranexamic acid soln iv 2 NEMBUTAL SODIUM 1000 mg/10ml SOLN (Use Pentobarbital 5 tranexamic acid tabs or 2 QL(6 ea daily) Sodium) 650 mg pentobarbital sodium soln 2 Hemostatics - Topical phenobarbital elix 20 2 ARTISS SOLN 5 mg/5ml

Updated August 1, 2018

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PHENOBARBITAL midazolam hcl soln 2 SODIUM SOLN 130 4 MG/ML midazolam hcl syrp 2 PHENOBARBITAL 5 SODIUM SOLN 65 MG/ML MIDAZOLAM HYDROCHLORIDE/SODIU 5 phenobarbital soln 20 2 mg/5ml M CHLORIDE SOSY PHENOBARBITAL TABS PRECEDEX SOLN 200 15 MG, 30 MG, 60 MG, 4 MCG/2ML (Use 5 100 MG Dexmedetomidine HCl) phenobarbital tabs 16.2 PRECEDEX SOLN mg, 32.4 mg, 64.8 mg, 97.2 2 80MCG/20ML-0.9%, 5 mg 200MCG/50ML-0.9%, 400MCG/100ML-0.9% SECONAL SODIUM CAPS 5 QUAZEPAM TABS 4 Hypnotics - Tricyclic Agents RESTORIL CAPS (Use 5 QL(1 ea daily) SILENOR TABS 4 Temazepam) SONATA CAPS 10 MG 5 QL(2 ea daily) Non-Barbiturate Hypnotics (Use Zaleplon) AMBIEN CR TBCR (Use QL(1 ea daily) 5 SONATA CAPS 5 MG (Use 5 QL(1 ea daily) Zolpidem Tartrate) Zaleplon) AMBIEN TABS (Use 5 QL(1 ea daily) temazepam caps 2 QL(1 ea daily) Zolpidem Tartrate) TRIAZOLAM TABS 0.125 QL(1 ea daily) dexmedetomidine hcl soln 2 4 200 mcg/2ml MG DEXMEDETOMIDINE HCL triazolam tabs 0.25 mg 2 QL(1 ea daily) SOLN 400 MCG/4ML, 5 1000 MCG/10ML zaleplon caps 10 mg 2 QL(2 ea daily) DORAL TABS 4 zaleplon caps 5 mg 2 QL(1 ea daily) EDLUAR SUBL 5 zolpidem tartrate subl 2 QL(1 ea daily) estazolam tabs 2 zolpidem tartrate tabs 2 QL(1 ea daily) eszopiclone tabs 2 QL(1 ea daily) zolpidem tartrate tbcr 2 QL(1 ea daily) FLURAZEPAM HCL CAPS 5 15 MG ZOLPIMIST SOLN 5 FLURAZEPAM HCL CAPS 4 QL(1 ea daily) 30 MG Orexin Receptor Antagonists QL(1 ea daily) HALCION TABS (Use 5 QL(1 ea daily) BELSOMRA TABS 4 Triazolam) Selective Melatonin Receptor Agonists INTERMEZZO SUBL (Use 5 QL(1 ea daily) Zolpidem Tartrate) HETLIOZ CAPS 5 PA; SP LUNESTA TABS (Use 5 QL(1 ea daily) Eszopiclone) ROZEREM TABS 5

Updated August 1, 2018

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAXATIVES - Bowel Treatment Drugs GIALAX KIT 5 Laxative Combinations KRISTALOSE PACK 5 bisacodyl-peg 3350-pot chloride-sod bicarb-sod 2 lactulose soln 2 chloride kit MIRALAX PACK (Use 5 RX/OTC CLENPIQ SOLN 5 Polyethylene Glycol 3350) COLYTE-FLAVOR PACKS MIRALAX POWD (Use 5 QL(35.134 gm Polyethylene Glycol 3350) daily); RX/OTC SOLR (Use PEG 3350- 5 KCl-Sod Bicarb-Sod polyethylene glycol 3350 2 RX/OTC Chloride-Sod Sulfate) pack GOLYTELY SOLR AL; At least 50 polyethylene glycol 3350 2 QL(35.134 gm 227.1GM-21.5GM-5.53GM- 6 yrs old - Up to powd daily); RX/OTC 2.82GM-6.36GM 75 yrs old Lubricant Laxatives GOLYTELY SOLR 236GM- AL; At least 50 mineral oil oil or 100 %, 2 RX/OTC 22.74GM-5.86GM-2.97GM- yrs old - Up to 99.9 %, 6.74GM (Use PEG 3350- 5 75 yrs old KCl-Sod Bicarb-Sod Saline Laxatives Chloride-Sod Sulfate) OSMOPREP TABS 5 MOVIPREP SOLR 4 Stimulant Laxatives NULYTELY/FLAVOR CASCARA SAGRADA 5 PACKS SOLR (Use PEG EXTR 1 GM/ML 3350-Potassium Chloride- 5 Sod Bicarbonate-Sod LOCAL ANESTHETICS-Parenteral - Drugs for Chloride) Numbing PCP 100 KIT 5 Local Anesthetic Combinations ACTIVE INJECTION KIT 5 peg 3350-kcl-sod bicarb- AL; At least 50 LM-2 KIT sod chloride-sod sulfate 6 yrs old - Up to solr 236gm-22.74gm- 75 yrs old articaine-epinephrine soln 2 5.86gm-2.97gm-6.74gm peg 3350-kcl-sod bicarb- BL INJECTION KIT KIT 5 sod chloride-sod sulfate 2 BUFFERED solr 240gm-22.72gm- LIDOCAINE/SODIUM 5 5.84gm-2.98gm-6.72gm BICARBONATE SOSY peg 3350-potassium BUFFERED chloride-sod bicarbonate- 2 LIDOCAINE/SODIUMBICA 5 sod chloride solr RBONATE SOSY AL; At least 50 bupivacaine w/ epinephrine 2 PREPOPIK PACK 6 yrs old - Up to soln 75 yrs old CITANEST FORTE 5 AL; At least 50 DENTAL SOLN SUPREP BOWEL PREP 6 KIT SOLN yrs old - Up to 75 yrs old LETS KIT KIT 5 Laxatives - Miscellaneous

Updated August 1, 2018

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIDOCAINE bupivacaine in dextrose 2 HYDROCHLORIDE/SODIU 5 soln M BICARBONATE SOSY CARBOCAINE SOLN (Use 5 lidocaine w/ epinephrine 2 Mepivacaine HCl) soln CITANEST PLAIN 5 MARCAINE/EPINEPHRIN DENTAL SOLN E SOLN (Use Bupivacaine 5 DURASAFE RX/OTC w/ Epinephrine) SPINAL/EPIDURALTRAY/ MARLIDO KIT KIT 5 1% 5 XYLOCAINE/19GX36"CLO MARLIDO-25 KIT 5 SE CATH KIT DURASAFE RX/OTC MARVONA SUIK KIT 5 SPINAL/EPIDURALTRAY/ 1% 5 MLD KIT KIT 5 XYLOCAINE/19GX36"OPE N CATH KIT ORABLOC SOLN (Use 5 DURASAFE RX/OTC Articaine-Epinephrine) SPINAL/EPIDURALTRAY/ P-CARE 100MX KIT 5 1% 5 XYLOCAINE/20GX36"CLO SE CATH KIT P-CARE MG KIT 5 DURASAFE RX/OTC READYSHARP-A KIT 5 SPINAL/EPIDURALTRAY/ 1% 5 XYLOCAINE/20GX36"OPE SENSORCAINE- 5 MPF/EPINEPHRINE SOLN N CATH KIT XYLOCAINE- EXPAREL SUSP 5 MPF/EPINEPHRINE SOLN 5 1%-1:200000 lidocaine hcl (local anesth.) 2 XYLOCAINE- soln MPF/EPINEPHRINE SOLN LIDOCAINE HCL SOLN IJ 4 2%-1:200000, 1.5%- 5 4 % 1:200000 (Use Lidocaine LIDOCAINE 5 w/ Epinephrine) HCL/DEXTROSE SOLN XYLOCAINE/EPINEPHRIN LIDOCAINE 5 E SOLN (Use Lidocaine w/ 5 HYDROCHLORIDE SOSY Epinephrine) MARCAINE SOLN (Use 5 Local Anesthetics - Amides Bupivacaine HCl) BD PUDENDAL/LOCAL RX/OTC MARCAINE SPINAL SOLN BLOCKTRAY 1% 5 (Use Bupivacaine in 5 LIDOCAINE KIT Dextrose) bupivacaine hcl soln 2 mepivacaine hcl soln 2

BUPIVACAINE 4 MONOJECT BONE RX/OTC HYDROCHLORIDE SOLN MARROW BIOPSY 5 BUPIVACAINE PREPPING TRAY KIT HYDROCHLORIDE/SODIU 5 M CHLORIDE SOLN Updated August 1, 2018

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT BONE RX/OTC chloroprocaine hcl soln 2 MARROW BIOPSY 5 TRAY/BIOP ASPIR NESACAINE SOLN 5 NEEDLE 11GX4" KIT MONOJECT BONE RX/OTC NESACAINE-MPF SOLN 5 (Use Chloroprocaine HCl) MARROW BIOPSY 5 TRAY/BIOP ASPIR NEEDLE 8GX4" KIT TETRACAINE HCL SOLN 4 MONOJECT BONE RX/OTC MACROLIDES - Drugs to Treat Bacterial MARROW BIOPSY 5 Infections TRAY/STERNAL-ILIAC NEEDLE 16G KIT Azithromycin AZITHROMYCIN PACK QL(2 ea per fill NAROPIN SOLN (Use 5 4 Ropivacaine HCl) OR 1 GM retail) P-CARE X KIT 5 RX/OTC azithromycin solr iv 500 mg 2 azithromycin susr or 100 READYSHARP 5 2 BUPIVACAINE KIT mg/5ml, 200 mg/5ml azithromycin tabs or 250 QL(6 ea per fill READYSHARP 5 RX/OTC 2 LIDOCAINE KIT mg retail) azithromycin tabs or 500 2 QL(2 ea daily) ropivacaine hcl soln 2 mg ROPIVACAINE azithromycin tabs or 600 2 QL(1 ea daily) HYDROCHLORIDE SOLN 5 mg EP 0.5 % ZITHROMAX PACK OR 1 4 QL(2 ea per fill ROPIVACAINE GM retail) HYDROCHLORIDE SOLN 4 ZITHROMAX SOLR IV 500 5 IJ 5 MG/ML MG (Use Azithromycin) ROPIVACAINE ZITHROMAX SUSR OR HYDROCHLORIDE/SODIU 5 100 MG/5ML, 200 MG/5ML 5 M CHLORIDE SOLN (Use Azithromycin) TURKEL PARACENTESIS RX/OTC ZITHROMAX TABS OR 5 QL(6 ea per fill PROCEDURE 5 250 MG (Use Azithromycin) retail) TRAY/8FRENCH KIT ZITHROMAX TABS OR 5 QL(2 ea daily) TURKEL RX/OTC 500 MG (Use Azithromycin) PNEUMOTHORAX 5 ZITHROMAX TABS OR 5 QL(1 ea daily) PROCEDURE 600 MG (Use Azithromycin) TRAY/8FRENCH KIT ZITHROMAX TRI-PAK 5 QL(2 ea daily) XYLOCAINE SOLN (Use TABS (Use Azithromycin) Lidocaine HCl (Local 5 Anesth.)) ZITHROMAX Z-PAK TABS 5 QL(6 ea per fill (Use Azithromycin) retail) XYLOCAINE-MPF SOLN (Use Lidocaine HCl (Local 5 ZMAX SUSR 5 Anesth.)) Clarithromycin ZINGO JTAJ 5 BIAXIN SUSR 250 Local Anesthetics - Esters MG/5ML (Use 5 Clarithromycin)

Updated August 1, 2018

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BIAXIN TABS 250 MG, 500 5 QL(28 ea per ALLEVYN THIN PADS 3 RX/OTC MG (Use Clarithromycin) fill retail) AMD FOAM DRESSING RX/OTC CLARITHROMYCIN SUSR 4 3 125 MG/5ML, 250 MG/5ML 4"X4" PADS AMD FOAM RX/OTC clarithromycin susr 125 2 mg/5ml, 250 mg/5ml DRESSING/TOPSHEET 3 4"X4" PADS clarithromycin tabs 250 mg, 2 QL(28 ea per 500 mg fill retail) BAND-AID GAUZE PADS 3 RX/OTC QL(14 ea per LARGE4" X 4" PADS clarithromycin tb24 500 mg 2 fill retail) BAND-AID GAUZE PADS 3 MEDIUM 3" X 3" PADS Erythromycins BAND-AID GAUZE PADS 3 RX/OTC E.E.S. 400 TABS 4 SMALL2" X 2" PADS BAND-AID MIRASORB RX/OTC E.E.S. GRANULES SUSR 3 (Use Erythromycin 5 GAUZE SPONGES Ethylsuccinate) LARGE 4" X 4" PADS BIATAIN ADHESIVE RX/OTC ERY-TAB TBEC 4 FOAM DRESSING 4"X4" 3 PADS ERYPED 200 SUSR (Use Erythromycin 5 BIATAIN FOAM 3 RX/OTC Ethylsuccinate) DRESSING 4"X4" PADS BIOGUARD GAUZE RX/OTC ERYPED 400 SUSR 5 SPONGE 2"X2" 8 PLY 3 PADS ERYTHROCIN 5 LACTOBIONATE SOLR BIOGUARD GAUZE RX/OTC SPONGES 4"X4" 12 PLY 3 ERYTHROCIN STEARATE 4 TABS PADS BORDERED GAUZE 3 RX/OTC erythromycin base cpep 2 PADS CARRASMART FOAM 3 RX/OTC erythromycin base tabs 2 PADS erythromycin CARRASMART PADS XX 3 RX/OTC ethylsuccinate susr 200 2 mg/5ml COPA ISLAND RX/OTC ERYTHROMYCIN BORDERED FOAM 3 ETHYLSUCCINATE TABS 4 DRESSING 4"X4" PADS 400 MG COPA PLUS RX/OTC HYDROPHILIC FOAM 3 PCE TBEC 5 DRESSING 4"X4" PADS Fidaxomicin COVRSITE COVER 3 RX/OTC DRESSING PADS DIFICID TABS 4 COVRSITE PLUS RX/OTC COMPOSITE DRESSING 3 MEDICAL DEVICES AND SUPPLIES PADS Bandages-Dressings-Tape CUREX ALL-PURPOSE RX/OTC SPONGES 4"X4" 4 PLY 3 ALLEVYN PLUS CAVITY 3 RX/OTC PADS PADS XX Updated August 1, 2018

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY ALL PURPOSE RX/OTC CURITY GAUZE SPONGE 3 SPONGES 2"X2" 4PLY 3 3"X3" 12 PLY PADS PADS CURITY GAUZE SPONGE 3 RX/OTC CURITY ALL PURPOSE 3 RX/OTC 4"X4" 12 PLY PADS SPONGES 2"X2" PADS CURITY GAUZE SPONGE 3 RX/OTC CURITY ALL PURPOSE 4"X4" 16 PLY PADS SPONGES 3"X3" 4PLY 3 CURITY GAUZE SPONGE 3 RX/OTC PADS 4"X4" 8 PLY PADS CURITY ALL PURPOSE RX/OTC 3 CURITY GAUZE SPONGE 3 RX/OTC SPONGES 4 PLY PADS 4"X4"16 PLY PADS CURITY ALL PURPOSE RX/OTC CURITY GAUZE RX/OTC SPONGES 4"X4" 4PLY 3 SPONGES 4"X4" 12 PLY 3 PADS PADS CURITY ALL PURPOSE RX/OTC CURITY GAUZE RX/OTC SPONGES 4"X4" 3 SPONGES 4"X4" 8 PLY 3 4PLY/SOFT POUCH PADS PADS CURITY ALL PURPOSE RX/OTC 3 CURITY NON-ADHERENT 3 SPONGES 4"X4" PADS STRIPS 3"X3" PADS CURITY AMD RX/OTC CURITY RX/OTC ANTIMICROBIALGAUZE 3 SPONGES/CELLULOSEFI 3 SPONGES 2"X2" 8 PLY LLED/2"X2" PADS PADS CURITY RX/OTC CURITY AMD RX/OTC SPONGES/CELLULOSEFI 3 ANTIMICROBIALGAUZE 3 LLED/4"X4" PADS SPONGES 4"X4" 12 PLY PADS CVS GAUZE PAD 3"X3" 3 PADS CURITY COVER SPONGE 3 RX/OTC 4"X4" PADS CVS GAUZE PADS 2"X2" 3 RX/OTC 12-PLY PADS CURITY COVER 3 SPONGES 3"X3" PADS CVS GAUZE PADS 4"X4" 3 RX/OTC 12-PLY PADS CURITY COVER 3 RX/OTC SPONGES 4"X4" PADS CVS GAUZE PADS RX/OTC STERILE 4"X4" 12-PLY 3 CURITY DRESSING RX/OTC PADS SPONGES 4"X4" 6 PLY 3 PADS DERMACEA DRAIN 3 RX/OTC SPONGES 4"X4" PADS CURITY GAUZE PADS 3 RX/OTC 2"X2" 12 PLY PADS DERMACEA GAUZE RX/OTC SPONGE 2"X2" 12 PLY 3 CURITY GAUZE PADS 3 RX/OTC PADS 2"X2" PADS DERMACEA GAUZE RX/OTC CURITY GAUZE PADS 3 SPONGE 2"X2" 8 PLY 3 3"X3" PADS PADS CURITY GAUZE PADS 3 RX/OTC DERMACEA GAUZE 4"X4" 12 PLY PADS SPONGE 3"X3" 12 PLY 3 CURITY GAUZE SPONGE 3 RX/OTC PADS 2"X2" 8 PLY PADS DERMACEA GAUZE 3 CURITY GAUZE SPONGE 3 RX/OTC SPONGE 3"X3" 8 PLY 2"X2"12 PLY PADS PADS Updated August 1, 2018

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA GAUZE RX/OTC DERMACEA X-RAY RX/OTC SPONGE 4"X4" 12 PLY 3 SPONGES 4"X4" 16 PLY 3 PADS PADS DERMACEA GAUZE RX/OTC DERMALEVIN ADHESIVE RX/OTC SPONGE 4"X4" 16 PLY 3 FOAMDRESSING 4"X4" 3 PADS PADS DERMACEA GAUZE RX/OTC DRYMAX EXTRA PADS 3 RX/OTC SPONGE 4"X4" 8 PLY 3 PADS EQL GAUZE PADS 3 RX/OTC 2"X2"/SMALL PADS DERMACEA I.V. DRAIN 3 RX/OTC SPONGES 2"X2" PADS EQL GAUZE PADS 3 RX/OTC 4"X4"/LARGE PADS DERMACEA I.V. DRAIN 3 RX/OTC SPONGES 4"X4" PADS EQL GAUZE STERILE 3 PADS 3"X3" PADS DERMACEA I.V. 3 RX/OTC SPONGES 2"X2" PADS EXCILON AMD RX/OTC DERMACEA NON-WOVEN RX/OTC ANTIMICROBIALDRAIN 3 SPONGES 2"X2" 4 PLY 3 SPONGES 4"X4" 6 PLY PADS PADS DERMACEA NON-WOVEN EXCILON AMD RX/OTC SPONGES 3"X3" 4 PLY 3 ANTIMICROBIALNON- 3 PADS WOVEN SPONGES 4"X4" DERMACEA NON-WOVEN RX/OTC 6 PLY PADS SPONGES 4"X4" 4 PLY 3 EXCILON DRAIN 3 RX/OTC PADS SPONGE 4"X4" PADS DERMACEA NON-WOVEN RX/OTC EXCILON DRAIN RX/OTC SPONGES 4"X4" 6 PLY 3 SPONGES 4"X4" 6 PLY 3 PADS PADS DERMACEA TYPE VII RX/OTC EXCILON I.V. SPONGES 3 RX/OTC GAUZE 2"X2" 12 PLY 3 2"X2" 6 PLY PADS PADS FLEXZAN 4 X 4 PADS 3 RX/OTC DERMACEA TYPE VII 3 RX/OTC GAUZE 2"X2" 8 PLY PADS GAUZE DRESSING 4"X4" 3 RX/OTC DERMACEA TYPE VII PADS GAUZE 3"X3" 12 PLY 3 GAUZE PADS 2"X2" PADS 3 RX/OTC PADS DERMACEA TYPE VII GAUZE PADS 3"X3" PADS 3 GAUZE 3"X3" 12PLY 3 PADS GAUZE PADS 4"X4" 12 3 RX/OTC DERMACEA TYPE VII RX/OTC PLY PADS GAUZE 4"X4" 12 PLY 3 GAUZE PADS 4"X4" PADS 3 RX/OTC PADS DERMACEA TYPE VII RX/OTC GAUZE SPONGE TYPE RX/OTC GAUZE 4"X4" 16 PLY 3 VII MEDI-PAK 2"X2" 8PLY 3 PADS PADS GAUZE SPONGES 4"X4" RX/OTC DERMACEA TYPE VII 3 RX/OTC 3 GAUZE 4"X4" 8 PLY PADS 12 PLY PADS

Updated August 1, 2018

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP STERILE PADS 3 NU GAUZE 4PLY 4"X4" 3 RX/OTC 3"X3" PADS PADS HM STERILE PADS 2"X2" 3 RX/OTC NU GAUZE GENERAL- RX/OTC PADS USE SPONGES 4"X4" 4 3 PLY MISC HM STERILE PADS PADS 3 RX/OTC OPTIFOAM PADS 3 RX/OTC HYDROCELL ADHESIVE 3 RX/OTC DRESSING 4"X4" PADS POLYMEM DRESSING/3" 3 X 3" PADS HYDROCELL DRESSING 3 RX/OTC 4"X4" PADS POLYMEM DRESSING/4" 3 RX/OTC X 4" PADS J & J GAUZE 2"X2" 8 PLY 3 RX/OTC PADS QC ALL PURPOSE 3 RX/OTC DRESSINGS4"X4" PADS J & J GAUZE 4"X4" 12 PLY 3 RX/OTC PADS QC BORDER ISLAND 3 RX/OTC GAUZE PAD 2"X2" PADS J & J GAUZE 4"X4" 8 PLY 3 RX/OTC PADS QC STERILE PADS PADS 3 J & J GAUZE SPONGES 3 RX/OTC 12-PLY 4" X 4" MISC QC STERILE PADS PADS 3 RX/OTC J & J GAUZE SPONGES 3 RX/OTC 16-PLY 4" X 4" MISC RA ALL PURPOSE 3 RX/OTC DRESSINGS4"X4" PADS J & J GAUZE SPONGES 3 RX/OTC 8-PLY4" X 4" MISC RA DRESSING SPONGES 3 RX/OTC 4"X4" PADS KENDALL HYDROPHILIC RX/OTC FOAMDRESSING 2"X2" 3 RA GAUZE SPONGES 3 RX/OTC PADS 4"X4" PADS KENDALL HYDROPHILIC RA STERILE PADS 2"X2" 3 RX/OTC FOAMDRESSING 3"X3" 3 PADS PADS RA STERILE PADS 3"X3" 3 KENDALL HYDROPHILIC RX/OTC PADS FOAMDRESSING 4"X4" 3 RA STERILE PADS 4"X4" 3 RX/OTC PADS PADS KENDALL HYDROPHILIC RX/OTC RAY-TEC X-RAY RX/OTC FOAMPLUS DRESSING 3 DETECTABLESPONGES 3 2"X2" PADS 4" X 4" 16 PLY MISC KENDALL HYDROPHILIC RESTORE CONTACT RX/OTC FOAMPLUS DRESSING 3 LAYER/NON-ADHERENT 3 3"X3" PADS 2"X2" PADS RESTORE FOAM RX/OTC KERLIX SPONGES 4" X 4" 3 RX/OTC 12 PLY PADS DRESSING BORDERED 3 4"X4" PADS KERLIX SPONGES 4" X 4" 3 RX/OTC 16 PLY PADS RESTORE FOAM RX/OTC DRESSING NON- 3 MIRASORB SPONGES 2" 3 RX/OTC X 2" MISC BORDERED 4"X4" PADS RESTORE ODOR RX/OTC MIRASORB SPONGES 4" 3 RX/OTC X 4" MISC ABSORBING DRESSING 3 4"X4" PADS

Updated August 1, 2018

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESTORE TRIO CAYA DPRH 5 ABSORBENT DRESSING 3 3"X3" PADS FC FEMALE CONDOM 6 MISC SM GAUZE PADS 2"X2" 3 RX/OTC PADS FC2 FEMALE CONDOM 6 MISC SM GAUZE PADS 3"X3" 3 PADS WIDE-SEAL SILICONE DIAPHRAGM KIT 60 5 SM GAUZE PADS 4"X4" 3 RX/OTC PADS DPRH WIDE-SEAL SILICONE SM STERILE PADS 2"X2" 3 RX/OTC PADS DIAPHRAGM KIT 65 5 RX/OTC DPRH SM STERILE PADS PADS 3 WIDE-SEAL SILICONE RX/OTC DIAPHRAGM KIT 70 5 SOF-WICK 4"X4" PADS 3 DPRH WIDE-SEAL SILICONE STERILE GAUZE PADS 3 RX/OTC 2"X2" PADS DIAPHRAGM KIT 75 5 DPRH STERILE GAUZE PADS 3 3"X3" PADS WIDE-SEAL SILICONE DIAPHRAGM KIT 80 5 STERILE PADS 2"X2" 3 RX/OTC PADS DPRH WIDE-SEAL SILICONE STERILE PADS 3"X3" 3 PADS DIAPHRAGM KIT 85 5 DPRH STERILE PADS 4"X4" 3 RX/OTC PADS WIDE-SEAL SILICONE DIAPHRAGM KIT 90 5 SURGICAL GAUZE 3 RX/OTC DPRH SPONGE PADS WIDE-SEAL SILICONE TEGADERM FOAM 3 RX/OTC DIAPHRAGM KIT 95 5 DRESSING 2"X2" PADS DPRH TEGADERM FOAM 3 RX/OTC DRESSING 4"X4" PADS Diabetic Supplies THERAGAUZE PADS 3 RX/OTC ACCU-CHEK AVIVA SOLN 3 ACCU-CHEK COMPACT TOPPER DRESSING 3 RX/OTC SPONGES 4"X4" MISC PLUS CLEAR CONTROL 3 SOLUTION (2 LEVELS) VERSIVA XC 3" X 3" SOLN FOAM 3 DRESSING/HYDROFIBER ACCU-CHEK GUIDE TECHNOLOGY PADS CONTROL 3 LEVEL1/LEVEL2 LIQD VERSIVA XC 4" X 4" RX/OTC ACCU-CHEK SMARTVIEW FOAM 3 3 DRESSING/HYDROFIBER CONTROL LIQD TECHNOLOGY PADS ACCUTREND GLUCOSE 3 VISTEC X-RAY RX/OTC CONTROL SOLN DETECTABLE SPONGES 3 ACURA CONTROL 3 4"X4" 16 PLY PADS SOLUTION HIGH SOLN Contraceptives Updated August 1, 2018

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACURA CONTROL 3 AT LAST CONTROL 3 SOLUTION LOW SOLN SOLUTION SOLN ACURA CONTROL BAYER BREEZE 2 HIGH 3 SOLUTION NORMAL 3 CONTROL LIQD SOLN BAYER BREEZE 2 LOW 3 ADVANCE INTUITION CONTROL LIQD CONTROL SOLUTION 3 BAYER BREEZE 2 3 LIQD NORMAL CONTROL LIQD ADVANCE MICRO-DRAW BAYER CONTOUR HIGH 3 CONTROL LEVEL 1-2 3 CONTROL LIQD LIQD BAYER CONTOUR LOW 3 ADVANCE MICRO-DRAW 3 CONTROL LIQD NORMAL CONTROL LIQD BAYER CONTOUR 3 ADVOCATE CONTROL 3 NORMAL CONTROL LIQD SOLUTIONHIGH LIQD BLOOD GLUCOSE 3 ADVOCATE CONTROL 3 METERS SOLUTIONLOW LIQD CARESENS CONTROL A 3 ADVOCATE REDI-CODE+ SOLUTION SOLN CONTROL SOLUTION 3 HIGH SOLN CLEVER CHOICE GLUCOSE CONTROL 3 ADVOCATE REDI-CODE+ HIGH LIQD CONTROL SOLUTION 3 LOW SOLN CLEVER CHOICE GLUCOSE CONTROL 3 AGAMATRIX CONTROL 3 LOW LIQD HIGH SOLN CONTOUR NEXT 3 AGAMATRIX CONTROL 3 CONTROL LEVEL 1 SOLN NORMAL SOLN CONTOUR NEXT 3 AGAMATRIX CONTROL 3 CONTROL LEVEL 2 SOLN NORMAL& HIGH SOLN CONTROL SOLUTION 3 ASSURE 3 CONTROL 3 NORMAL SOLN LEVEL 1/2 LIQD COOL CONTROL 3 ASSURE 4 CONTROL 3 SOLUTION A SOLN LEVEL 1/2 LIQD COOL CONTROL 3 ASSURE DOSE NORMAL 3 SOLUTION B SOLN CONTROL SOLN DIATRUE GLUCOSE ASSURE DOSE CONTROL SOLUTION 3 NORMAL/HIGH CONTROL 3 LEVEL 1 SOLN SOLN DIATRUE GLUCOSE ASSURE II CONTROL 3 CONTROL SOLUTION 3 LEVEL 1 LIQD LEVEL 2 SOLN ASSURE II CONTROL 3 DIATRUE GLUCOSE LEVEL 1/2 LIQD CONTROL SOLUTION 3 ASSURE PRISM LEVEL 3 SOLN CONTROL LEVEL 1/2 3 DUO-CARE CONTROL 3 SOLN SOLUTION LIQD ASSURE PRO CONTROL 3 LEVEL1/2 LIQD Updated August 1, 2018

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY PLUS II CONTROL 3 EASYMAX 15 LEVEL 1 SOLUTION HIGH SOLN GLUCOSE CONTROL 3 SOLUTION SOLN EASY PLUS II CONTROL 3 SOLUTION LOW SOLN EASYMAX 15 LEVEL 2 GLUCOSE CONTROL 3 EASY STEP CONTROL 3 SOLUTION HIGH SOLN SOLUTION SOLN EASYMAX CONTROL EASY STEP CONTROL 3 3 SOLUTION LOW SOLN SOLUTIONHIGH SOLN EASY STEP CONTROL EASYMAX CONTROL 3 SOLUTION NORMAL 3 SOLUTIONLOW SOLN SOLN EASYMAX CONTROL SOLUTIONNORMAL 3 EASY TALK CONTROL 3 SOLUTION HIGH SOLN SOLN EASYMAX GLUCOSE EASY TALK CONTROL 3 SOLUTION LOW SOLN CONTROL SOLUTION 3 NORMAL/LOW SOLN EASY TALK CONTROL SOLUTION NORMAL 3 ELEMENT COMPACT SOLN CONTROL SOLUTION 3 LEVEL 2 SOLN EASY TOUCH CONTROL SOLUTION/HIGH & LOW 3 ELEMENT COMPACT SOLN CONTROL SOLUTION 3 LEVEL 3 SOLN EASY TOUCH ELEMENT HIGH HEALTHPRO CONTROL 3 3 SOLUTION/HIGH & LOW CONTROL LIQD SOLN ELEMENT LOW 3 EASY TRAK GLUCOSE CONTROL LIQD CONTROLSOLUTION 3 ELEMENT NORMAL 3 HIGH SOLN CONTROL LIQD EASY TRAK GLUCOSE EMBRACE CONTROL 3 CONTROLSOLUTION 3 SOLUTIONLOW SOLN LOW SOLN EMBRACE EVO EASY TRAK GLUCOSE GLUCOSE CONTROL 3 CONTROLSOLUTION 3 SOLUTION LEVEL 1 LIQD NORMAL SOLN EMBRACE EVO EASYGLUCO CONTROL 3 GLUCOSE CONTROL 3 SOLUTION HIGH SOLN SOLUTION LEVEL 2 LIQD EASYGLUCO CONTROL 3 EMBRACE GLUCOSE SOLUTION LOW SOLN CONTROL SOLUTION 3 EASYGLUCO CONTROL HIGH LIQD SOLUTION NORMAL 3 EMBRACE PRO SOLN GLUCOSE CONTROL 3 EASYGLUCO PLUS SOLUTION LIQD CONTROL SOLUTION 3 EVENCARE CONTROL 3 LEVEL 1 SOLN SOLUTION LIQD EASYMAX 15 GLUCOSE CONTROL SOLUTION 3 LEVEL 1/LEVEL 2 SOLN

Updated August 1, 2018

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVENCARE G2 GLUCOSE GE100 CONTROL CONTROL 3 SOLUTION NORMAL 3 SOLUTION/LOW-HIGH SOLN SOLN GLUCOCARD 01 EVENCARE G3 GLUCOSE CONTROL SOLUTION 3 CONTROL 3 NORMAL/HIGH LIQD SOLUTION/LOW-HIGH GLUCOCARD 01 SOLN CONTROL 3 EVENCARE MINI SOLUTION/NORMAL GLUCOSE CONTROL 3 SOLN SOLUTION NORMAL GLUCOCARD SOLN EXPRESSION CONTROL 3 EVOLUTION CONTROL SOLUTION LEVEL 1 SOLUTION NORMAL 3 SOLN SOLN GLUCOCARD SHINE FIFTY50 CONTROL 3 CONTROL SOLUTION 3 SOLUTION2.0 SOLN LEVEL 1 SOLN FORA CONTROL 3 GLUCOCARD X-METER SOLUTION HIGH SOLN CONTROLSOLUTION/NO 3 RMAL SOLN FORA CONTROL 3 SOLUTION LOW SOLN GLUCOCOM HIGH 3 FORA CONTROL CONTROL LIQD SOLUTION NORMAL 3 GLUCOCOM NORMAL 3 SOLN CONTROL LIQD FORACARE GDH GLUCOSE CONTROL 3 CONTROL SOLUTION 3 NORMAL SOLN HIGH SOLN GLUCOSE CONTROL 3 FORACARE GDH SOLUTION SOLN CONTROL SOLUTION 3 GNP EASY TOUCH LOW SOLN CONTROL SOLUTION 3 FORACARE GDH HIGH/LOW SOLN CONTROL SOLUTION 3 IN TOUCH GLUCOSE NORMAL SOLN CONTROLSOLUTION 3 FORTISCARE CONTROL 3 SOLN SOLUTIONS HIGH SOLN INFINITY CONTROL 3 FORTISCARE CONTROL 3 SOLUTION HIGH SOLN SOLUTIONS LOW SOLN INFINITY CONTROL 3 FORTISCARE CONTROL SOLUTION LOW SOLN SOLUTIONS NORMAL 3 INFINITY CONTROL SOLN SOLUTION NORMAL 3 FREESTYLE CONTROL SOLN SOLUTION HIGH/LOW 3 INFINITY VOICE LEVEL 2 3 LIQD LIQD FREESTYLE CONTROL 3 3 QL(1 ea per SOLUTION LIQD LANCET DEVICES 180 days) 3 QL(6.67 ea LANCETS daily)

Updated August 1, 2018

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIBERTY CONTROL 3 NOVA MAX PLUS SOLUTION HIGH SOLN GLU/KET CONTROL 3 LIBERTY CONTROL SOLUTION-MID LIQD SOLUTIONNORMAL 3 ON CALL EXPRESS SOLN GLUCOSE CONTROL 3 SOLUTION SOLN LIBERTY GLUCOSE 3 CONTROL LEVEL 1 SOLN ON CALL PLUS GLUCOSE CONTROL 3 LIBERTY GLUCOSE 3 CONTROL LEVEL 2 SOLN LEVEL 1/2 SOLN ON CALL VIVID LIBERTY GLUCOSE 3 CONTROL MID SOLN GLUCOSE CONTROL 3 LEVEL 1/2 SOLN LIBERTY GLUCOSE 3 CONTROL NORMAL LIQD ONETOUCH ULTRA 3 CONTROL SOLN MAXIMA CONTROL 3 SOLUTION SOLN ONETOUCH VERIO CONTROL SOLUTION 3 MAXIMA CONTROL HIGH SOLN SOLUTION/NORMAL 3 SOLN ONETOUCH VERIO MID CONTROL SOLUTION 3 MEDISENSE GLUCOSE SOLN KETONECONTROL 3 SOLUTION 1-LOW,1- OPTUMRX GLUCOSE MED,1 HIGH LIQD CONTROL LEVEL 1/2 3 SOLN MEDISENSE GLUCOSE POCKETCHEM EZ KETONECONTROL 3 3 SOLUTION 1-NORMAL CONTROL LEVEL 1 SOLN LIQD PRECISION GLUCOSE 3 MEDISENSE HIGH/LOW CONTROL LIQD CONTROL SOLUTION 3 PRECISION GLUCOSE LIQD CONTROLSOLUTION MEDISENSE (TRI- 3 LEVEL/HI/LO/NORMAL) HIGH/MID/LOW 3 CONTROL SOLUTION SOLN LIQD PRECISION GLUCOSE MEDISENSE MID KETONECONTROL 3 CONTROL SOLUTION 3 SOLUTION 1-LOW, 1- LIQD HIGH LIQD MICRODOT CONTROL PRECISION SOLUTIONHIGH/LOW 3 GLUCOSE/KETONECONT 3 SOLN ROL SOLUTIONS 1-HI 1- LO LIQD MYGLUCOHEALTH PRODIGY CONTROL CONTROL 3 3 LOW/NORMAL/HIGH SOLUTIONHIGH SOLN SOLN PRODIGY CONTROL 3 SOLUTIONLOW SOLN NEUTEK 2TEK CONTROL 3 SOLUTIONS SOLN QUICKTEK CONTROL 3 SOLUTION LIQD NEXGEN NORMAL 3 CONTROL LIQD

Updated August 1, 2018

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QUINTET GLUCOSE TRUE METRIX CONTROL CONTROL/HIGH/NORMAL 3 SOLUTION LEVEL 3 3 SOLN SOLN REFUAH PLUS GLUCOSE TRUECONTROL CONTROL SOLUTION 3 GLUCOSE CONTROL 3 SOLN LEVEL 0 LIQD RIGHTEST GC300 HIGH 3 TRUECONTROL CONTROL LIQD GLUCOSE CONTROL 3 LEVEL 1 LIQD RIGHTEST GC300 3 NORMAL CONTROL LIQD TRUETEST GLUCOSE 3 CONTROLLEVEL 1 LIQD SMARTEST CONTROL 3 SOLUTIONMEDIUM SOLN TRUETEST GLUCOSE 3 SOLARTEK GLUCOSE CONTROLLEVEL 2 LIQD CONTROLSOLUTIONS 3 TRUETEST GLUCOSE 3 LIQD CONTROLLEVEL 3 LIQD SOLUS V2 CONTROL 3 ULTRATRAK PRO HIGH SOLN CONTROL SOLUTION 2 3 LEVELS SOLN SOLUS V2 CONTROL 3 LOW SOLN ULTRATRAK PRO SUPREME II HIGH/LOW NORMAL CONTROL 3 CONTROL SOLUTION 3 SOLN LIQD ULTRATRAK ULTIMATE CONTROL SOLUTION 2 3 SURESTEP GLUCOSE 3 CONTROL SOLN LEVELS SOLN SURESTEP GLUCOSE UNISTRIP CONTROL 3 CONTROLSOLUTION 3 SOLUTIONHIGH SOLN SOLN UNISTRIP CONTROL 3 SURESTEP PRO HIGH SOLUTIONLOW SOLN GLUCOSECONTROL 3 VERASENS GLUCOSE 3 LIQD CONTROLLEVEL 1 LIQD SURESTEP PRO LOW VICTORY CONTROL 3 GLUCOSECONTROL 3 LEVEL 1/2 SOLN LIQD Misc. Devices SURESTEP PRO NORMAL GLUCOSE 3 ALCOH-GLOVE 3 RX/OTC CONTROL LIQD CONTOURED WIPE PADS 3 RX/OTC TAI DOC CONTROL SOLN 3 ALCOHOL PADS PADS ALCOHOL PREP PADS 3 RX/OTC TELCARE GLUCOSE PADS CONTROL SOLUTION 3 LEVEL 1/2 SOLN ALCOHOL PREPS PADS 3 RX/OTC TRUE METRIX CONTROL SOLUTION LEVEL 1 3 ALCOHOL SWABS PADS 3 RX/OTC SOLN ALCOHOL SWABSTICK 3 RX/OTC TRUE METRIX CONTROL PADS SOLUTION LEVEL 2 3 SOLN ALCOHOL WIPES PADS 3 RX/OTC

Updated August 1, 2018

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APLICARE ALCOHOL RX/OTC 3 RA ALCOHOL SWABS 3 RX/OTC SWABSTICK PADS PADS BD SWABS SINGLE USE 3 RX/OTC REALITY SWABS PADS 3 RX/OTC BUTTERFLY PADS RELION ALCOHOL RX/OTC BD SWABS SINGLE USE 3 RX/OTC 3 PADS SWABS PADS SAPS CARE ALCOHOL RX/OTC CARETOUCH ALCOHOL 3 RX/OTC 3 PREP PADS PADS PREP PADS PADS CURITY ALCOHOL RX/OTC SAPS HEALTH ALCOHOL 3 RX/OTC PREPS/MEDIUM 2 PLY 3 PREPPADS PADS PADS SB ALCOHOL PREP 3 RX/OTC PADS PADS CURITY ALCOHOL 3 RX/OTC SWABS PADS SHOPKO ALCOHOL 3 RX/OTC SWABS PADS CVS ALCOHOL PREP 3 RX/OTC PADS PADS SM ALCOHOL PREP 3 RX/OTC PADS PADS CVS ALCOHOL PREP 3 RX/OTC SWABS PADS SURE COMFORT RX/OTC RX/OTC ALCOHOL PREP PADS 3 CVS PREP PADS PADS 3 PADS XX EASY TOUCH ALCOHOL RX/OTC SURE-PREP ALCOHOL 3 RX/OTC PREP PADS/MEDIUM 3 PREP PADS PADS PADS TGT ALCOHOL SWABS 3 RX/OTC EQL ALCOHOL SWABS 3 RX/OTC PADS PADS ULTICARE ALCOHOL 3 RX/OTC FIFTY50 ALCOHOL PREP 3 RX/OTC SWABS PADS PADS PADS ULTILET ALCOHOL 3 RX/OTC GLOBAL ALCOHOL PREP 3 RX/OTC SWABS PADS EASEPADS PADS ULTRA-CARE ALCOHOL 3 RX/OTC GNP ALCOHOL SWABS 3 RX/OTC PREP PADS PADS PADS WEBCOL ALCOHOL RX/OTC H-E-B INCONTROL 3 RX/OTC PREP LARGE 1 PLY 3 ALCOHOL PADS PADS PADS HEALTHWISE ALCOHOL 3 RX/OTC WEBCOL ALCOHOL RX/OTC PREP PADS PADS PREP LARGE 2 PLY 3 PADS HM STERILE ALCOHOL 3 RX/OTC PREP PADS PADS WEBCOL ALCOHOL RX/OTC MEIJER ALCOHOL RX/OTC PREP MEDIUM 2 PLY 3 SWABS EXTRA-THICK 3 PADS PADS Parenteral Therapy Supplies PHARMACIST CHOICE RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily) ALCOHOLPREP PADS 3 NEEDLES 30G X 3/16" 3 PADS MISC PRO COMFORT RX/OTC 3 5 PA; RX/OTC; ALCOHOL PADS PADS AUTOJECT 2 MISC SP QC ALCOHOL SWABS RX/OTC 3 BD AUTOSHIELD DUO 3 QL(5 ea daily) PADS 30G X 3/16" MISC

Updated August 1, 2018

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORNWALL METAL PA; RX/OTC; VANISHPOINT INSULIN PIPETTINGHOLDER (FOR 5 SP SYRINGE/1ML/30G X 5 1240S) MISC 3/16" MISC CORNWALL METAL PA; RX/OTC; MIGRAINE PRODUCTS - Drugs to Treat Migraine PIPETTINGHOLDER (FOR 5 SP Headaches 1250S) MISC Migraine Combinations CORNWALL METAL PA; RX/OTC; PIPETTINGHOLDER (FOR 5 SP CAFERGOT TABS (Use 5 1260S) MISC Ergotamine w/ Caffeine) CORNWALL METAL PA; RX/OTC; ergotamine w/ caffeine tabs 2 PIPETTINGHOLDER (FOR 5 SP 1270S) MISC MIGERGOT SUPP 4 HUMATROPEN FOR 5 PA; RX/OTC; 12MG DEVI SP MIGRAINE PACK THPK 5 HUMATROPEN FOR 5 PA; RX/OTC; 24MG DEVI SP MIGRANOW THPK 5 HUMATROPEN FOR 6MG PA; RX/OTC; 5 sumatriptan-naproxen 2 QL(0.3 ea DEVI SP sodium tabs daily) INJECT-EASE PA; RX/OTC; TREXIMET TABS 10MG- 4 QL(0.3 ea AUTOMATIC INJECTOR 5 SP 60MG daily) MISC TREXIMET TABS 85MG- QL(0.3 ea INJECT-EASE MISC 5 PA; RX/OTC; 500MG (Use Sumatriptan- 5 daily) SP Naproxen Sodium) INSULIN SYRINGES AND 3 QL(5 ea daily); PEN NEEDLES RX/OTC Migraine Products - NSAIDs CAMBIA PACK 5 J-TIP KIT W/VIAL 5 PA; SP ADAPTERS KIT Migraine Products NORDIPEN 5 INJECTION 5 PA; RX/OTC; DEVICE MISC SP D.H.E. 45 SOLN (Use Dihydroergotamine 5 NORDIPEN DELIVERY 5 PA; RX/OTC; SYSTEM MISC SP Mesylate) dihydroergotamine OMNITROPE PEN 10 5 PA; RX/OTC; 2 INJECTION DEVICE MISC SP mesylate soln ij 1 mg/ml DIHYDROERGOTAMINE QL(0.2667 ml OMNITROPE PEN 5 5 PA; RX/OTC; INJECTION DEVICE MISC SP MESYLATE SOLN NA 4 4 daily) MG/ML PEN NEEDLES 30GX5MM 3 QL(5 ea daily) MISC ERGOMAR SUBL 5 PLASTIC ADAPTER FOR PA; RX/OTC; 5 QL(0.2667 ml BUSHINJECTOR B-D 5 SP MIGRANAL SOLN daily) PLASTIPAK MISC Serotonin Agonists PLASTIC ADAPTER FOR 5 PA; SP BUSHINJECTOR MISC QL(0.4 ea almotriptan malate tabs 2 daily); AL; At VANISHPOINT INSULIN 12.5 mg SYRINGE/0.5ML/30G X 5 least 12 yrs old 3/16" MISC QL(0.2 ea almotriptan malate tabs 2 daily); AL; At 6.25 mg least 12 yrs old

Updated August 1, 2018

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.3 ea QL(0.3 ea AMERGE TABS (Use 5 2 ) daily); AL; At naratriptan hcl tabs daily); AL; At Naratriptan HCl least 18 yrs old least 18 yrs old QL(0.4 ea ONZETRA XSAIL EXHP 5 AXERT TABS 12.5 MG 5 daily); AL; At (Use Almotriptan Malate) least 12 yrs old RELPAX TABS 20 MG QL(0.2 ea QL(0.2 ea (Use Eletriptan 5 daily); AL; At AXERT TABS 6.25 MG 5 daily); AL; At Hydrobromide) least 18 yrs old (Use Almotriptan Malate) least 12 yrs old RELPAX TABS 40 MG QL(0.4 ea QL(0.2 ea (Use Eletriptan 5 daily); AL; At eletriptan hydrobromide 2 daily); AL; At Hydrobromide) least 18 yrs old tabs 20 mg least 18 yrs old QL(0.6 ea rizatriptan benzoate tabs 2 daily); AL; At QL(0.4 ea 10 mg eletriptan hydrobromide 2 daily); AL; At least 6 yrs old tabs 40 mg least 18 yrs old QL(0.4 ea rizatriptan benzoate tabs 5 2 daily); AL; At QL(0.4 ea mg FROVA TABS (Use 5 least 6 yrs old Frovatriptan Succinate) daily); AL; At least 18 yrs old QL(0.6 ea rizatriptan benzoate tbdp 2 daily); AL; At QL(0.4 ea 10 mg frovatriptan succinate tabs 2 daily); AL; At least 6 yrs old least 18 yrs old QL(0.4 ea rizatriptan benzoate tbdp 5 2 daily); AL; At IMITREX SOLN NA 5 QL(0.2 ea mg MG/ACT, 20 MG/ACT (Use 5 daily); AL; At least 6 yrs old Sumatriptan) least 18 yrs old QL(0.2 ea IMITREX SOLN SC 6 QL(0.134 ml sumatriptan soln 2 daily); AL; At MG/0.5ML (Use 5 daily) least 18 yrs old Sumatriptan Succinate) sumatriptan succinate soaj 2 QL(0.134 ml IMITREX STATDOSE QL(0.134 ml sc 4 mg/0.5ml, 6 mg/0.5ml daily) REFILL SOCT (Use 5 daily) sumatriptan succinate soct 2 QL(0.134 ml Sumatriptan Succinate) sc 4 mg/0.5ml, 6 mg/0.5ml daily) IMITREX STATDOSE QL(0.134 ml sumatriptan succinate soln 2 QL(0.134 ml SYSTEM SOAJ (Use 5 daily) sc 6 mg/0.5ml daily) Sumatriptan Succinate) SUMATRIPTAN IMITREX TABS OR 25 MG, QL(0.3 ea SUCCINATE SOSY SC 6 4 50 MG, 100 MG (Use 5 daily) MG/0.5ML Sumatriptan Succinate) sumatriptan succinate tabs 2 QL(0.3 ea QL(0.6 ea or 25 mg, 50 mg, 100 mg daily) MAXALT TABS 10 MG 5 daily); AL; At (Use Rizatriptan Benzoate) SUMAVEL DOSEPRO 5 least 6 yrs old SOTJ QL(0.4 ea ZEMBRACE SYMTOUCH MAXALT TABS 5 MG (Use 5 5 ) daily); AL; At SOAJ Rizatriptan Benzoate least 6 yrs old QL(0.2 ea MAXALT-MLT TBDP 10 QL(0.6 ea zolmitriptan tabs 2 daily); AL; At MG (Use Rizatriptan 5 daily); AL; At least 12 yrs old Benzoate) least 6 yrs old QL(0.2 ea QL(0.4 ea zolmitriptan tbdp 2 daily); AL; At MAXALT-MLT TBDP 5 MG 5 ) daily); AL; At least 12 yrs old (Use Rizatriptan Benzoate least 6 yrs old Updated August 1, 2018

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.2 ea Electrolyte Mixtures ZOMIG SOLN NA 5 MG, 4 daily); AL; At 2.5 MG DEXTROSE 10%/NACL 4 least 12 yrs old 0.45% SOLN QL(0.2 ea ZOMIG TABS OR 5 MG, 5 daily); AL; At DEXTROSE 2.5 MG (Use Zolmitriptan) 5%/ELECTROLYTE #48 5 least 12 yrs old VIAFLEX SOLN QL(0.2 ea ZOMIG ZMT TBDP (Use 5 DEXTROSE 10%/NACL 5 ) daily); AL; At Zolmitriptan least 12 yrs old 0.2% SOLN DEXTROSE 10%/NACL 5 MINERALS & ELECTROLYTES 0.225% SOLN DEXTROSE 2.5%/NACL 4 Bicarbonates 0.45% SOLN NEUT SOLN 5 DEXTROSE 5%/NACL 4 0.225% SOLN SODIUM ACETATE SOLN 4 2 MEQ/ML DEXTROSE 5%/NACL 5 0.3% SOLN sodium acetate soln 4 2 meq/ml dextrose in lactated ringers 2 soln sodium bicarbonate soln iv 2 4.2 %, 8.4 % dextrose w/ sodium 2 chloride soln SODIUM BICARBONATE 4 SOLN IV 7.5 % ELLIOTTS B SOLN 5

SODIUM LACTATE SOLN 5 HYPERLYTE-CR SOLN 4 Calcium IONOSOL-B/DEXTROSE 5 CALCIFOL WAFR 5 5% SOLN IONOSOL-MB/DEXTROSE 5 calcium chloride (dihydrate) 2 5% SOLN soln ISOLYTE-P/DEXTROSE 5 calcium gluconate soln iv 2 5% SOLN 10 % CALCIUM ISOLYTE-S PH 7.4 SOLN 5 GLUCONATE/DEXTROSE 5 SOLN 1GM/50ML-5%, 5%- ISOLYTE-S SOLN 5 4GM/250ML KCL 0.15%/D5W/NACL 5 CALCIUM 0.225% SOLN GLUCONATE/SODIUMCH KCL 0.3%/D5W/NACL 5 LORIDE SOLN 0.9%- 5 0.9% SOLN 1GM/100ML, 0.9%- 2GM/100ML, 0.9%- lactated ringer's soln 2 2GM/50ML CALCIUM NORMOSOL -R SOLN 5 GLUCONATE/SODIUMCH 5 NORMOSOL-M IN D5W 5 LORIDE SOSY 0.9%- SOLN 2GM/50ML NORMOSOL-R IN D5W 5 CALCIUM-FOLIC ACID 5 SOLN PLUS D WAFR

Updated August 1, 2018

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORMOSOL-R SOLN 5 LURIDE SOLN (Use 5 Sodium Fluoride) parenteral electrolytes conc 2 sodium fluoride chew 0.25 mg, 0.5 mg, 1 mg, 1.1 mg, 6 parenteral electrolytes soln 2 2.2 mg sodium fluoride soln 0.125 6 PLASMA-LYTE A SOLN 5 mg/drop, 0.5 mg/ml SODIUM FLUORIDE TABS 6 PLASMA-LYTE-148 SOLN 5 0.5 MG, 1 MG Iodine Products PLASMA-LYTE-56/D5W 5 SOLN IODINE STRONG SOLN 4 potassium chloride in OR dextrose & sodium chloride 2 soln IODOPEN SOLN 5 potassium chloride in 2 Magnesium dextrose soln POTASSIUM MAGNEBIND 400 TABS 5 CHLORIDE/DEXTROSE 4 MAGNESIUM SULFATE IN SOLN D5W SOLN 1GM/50ML- 4 POTASSIUM 5%, 2GM/100ML-5% CHLORIDE/DEXTROSE/L 5 MAGNESIUM SULFATE IN ACTATED RINGERS D5W SOLN 5%- SOLN 1GM/100ML (Use 5 POTASSIUM Magnesium Sulfate in CHLORIDE/LIDOCAINE 5 Dextrose) HYDROCHLORIDE SOLN magnesium sulfate in 2 POTASSIUM dextrose soln CHLORIDE/LIDOCAINE 5 MAGNESIUM HYDROCHLORIDE/DEXT SULFATE/DEXTROSE 4 ROSE SOLN SOLN 1GM/50ML-5%, POTASSIUM 2GM/100ML-5% CHLORIDE/LIDOCAINE 5 MAGNESIUM HYDROCHLORIDE/SODIU SULFATE/DEXTROSE 5 M CHLORIDE SOLN SOLN 5%-2GM/50ML, 5%- ringer's soln 2 3GM/50ML MAGNESIUM Fluoride SULFATE/SODIUMCHLOR 5 IDE SOLN 40GM/L-0.9%, FLORIVA LIQD 6 0.25MG/ML-400UNIT/ML 2GM/50ML-0.9% FLUOR-A-DAY CHEW 6 Manganese MANGANESE SULFATE 4 FLUORABON SOLN 6 PV SOLN MANGANESE TRACE 4 FLURA-DROPS SOLN 6 METAL SOLN Phosphate LOZI-FLUR LOZG 6

Updated August 1, 2018

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLYCOPHOS SOLN 5 POTASSIUM CHLORIDE 4 ER TBCR K-PHOS NEUTRAL TABS QL(8 ea daily) potassium chloride (Use Pot Phosphate microencapsulated crystals 2 Monobasic w/ Sod 5 er tbcr Phosphate Dibasic & potassium chloride pack or 2 Monobasic) 20 meq K-PHOS TABS 5 potassium chloride soln iv 0.4 meq/ml, 2 meq/ml, 20 pot phosphate monobasic QL(8 ea daily) meq/50ml, 10 meq/100ml, 2 w/ sod phosphate dibasic & 2 20 meq/100ml, 40 monobasic tabs meq/100ml POTASSIUM POTASSIUM CHLORIDE 4 PHOSPHATE/SODIUM 5 SOLN IV 10 MEQ/50ML CHLORIDE SOLN potassium chloride soln or 2 potassium phosphates soln 2 10 %, 20 % potassium chloride tbcr or 8 POTASSIUM 4 2 PHOSPHATES SOLN meq, 10 meq Sodium SODIUM PHOSPHATE 5 SOLN sodium chloride flush soln 2 SODIUM PHOSPHATE/SODIUM 5 SODIUM CHLORIDE 4 CHLORIDE SOLN SOLN IJ 0.9 % sodium phosphates sodium chloride soln ij 0.9 2 (sodium phosphate dibasic 2 %, 2.5 meq/ml & monobasic) soln sodium chloride soln iv Potassium 0.45 %, 0.9 %, 3 %, 5 %, 4 2 meq/ml EFFER-K TBEF 5 Trace Minerals K-TAB TBCR 10 MEQ (Use 5 CHROMIUM CHLORIDE 4 Potassium Chloride) SOLN K-TAB TBCR 8 MEQ, 20 4 COPPER TRACE METAL 4 MEQ SOLN KLOR-CON M15 TBCR 5 MULTITRACE-4 5 NEONATAL SOLN KLOR-CON/25 PACK 5 MULTITRACE-4 5 PEDIATRIC SOLN MICRO-K CPCR (Use 5 Potassium Chloride) MULTITRACE-4 SOLN 5 potassium acetate soln 2 MULTITRACE-5 SOLN 5 potassium bicarb & 2 SELENIUM SOLN IV 40 4 chloride tbef MCG/ML potassium bicarbonate tbef 2 THE LIQUILIFT TRACE 5 KIT KIT potassium chloride cpcr or 2 8 meq, 10 meq Updated August 1, 2018

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRACE ELEMENTS 5 ATGAM INJ 5 4/PEDIATRIC SOLN QL(3 ea daily) trace minerals (cr-cu-mn- 2 AZASAN TABS 5 se-zn) soln AZATHIOPRINE SOLR IJ trace minerals (cr-cu-mn- 2 5 zn) soln 100 MG Zinc azathioprine tabs or 50 mg 2 GALZIN CAPS 5 CELLCEPT CAPS (Use 5 Mycophenolate Mofetil) ZINC GLUCONATE SOLN 5 CELLCEPT PA IV 10 MG/10ML INTRAVENOUS SOLR 5 zinc sulfate caps or 220 mg 2 (Use Mycophenolate Mofetil HCl) ZINC SULFATE SOLN IV 1 4 CELLCEPT SUSR (Use 5 MG/ML, 5 MG/ML Mycophenolate Mofetil) ZINC TRACE METAL 4 CELLCEPT TABS (Use 5 SOLN Mycophenolate Mofetil) MISCELLANEOUS THERAPEUTIC CLASSES cyclosporine caps 2 Chelating Agents cyclosporine modified (for 2 microemulsion) caps CUPRIMINE CAPS 5 cyclosporine modified (for 2 DEPEN TITRATABS TABS 5 microemulsion) soln CYCLOSPORINE 4 SYPRINE CAPS (Use 5 PA; SP MODIFIED CAPS Trientine HCl) CYCLOSPORINE PA; SP trientine hcl caps 2 MODIFIED CAPS (Use 5 Cyclosporine Modified (For Enzymes Microemulsion)) AMPHADASE SOLN 5 cyclosporine soln 2 PA HYLENEX SOLN 5 ENVARSUS XR TB24 5

IMURAN TABS (Use 5 VITRASE SOLN 5 Azathioprine) PA; SP XIAFLEX SOLR 5 mycophenolate mofetil 2 caps Immunomodulators mycophenolate mofetil hcl 2 PA solr REVLIMID CAPS 5 PA; SP mycophenolate mofetil susr 2 THALOMID CAPS 5 PA; SP mycophenolate mofetil tabs 2 Immunosuppressive Agents mycophenolate sodium 2 PA ASTAGRAF XL CP24 5 tbec MYFORTIC TBEC (Use 5 PA Mycophenolate Sodium) Updated August 1, 2018

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEORAL CAPS (Use SYLVANT SOLR 5 Cyclosporine Modified (For 5 Microemulsion)) Misc Natural Products NEORAL SOLN (Use RX/OTC Cyclosporine Modified (For 5 AURUM LIQD 4 Microemulsion)) BLACK CHERRY 4 RX/OTC NULOJIX SOLR 5 PA; SP CONCENTRATE LIQD BODY CHOICE HOODIA RX/OTC PROGRAF CAPS OR 0.5 WEIGHTLOSS/HIGH 4 MG, 1 MG, 5 MG (Use 5 FIBER LIQD Tacrolimus) CHELIDONIUM 4 RX/OTC PROGRAF SOLN IV 5 5 PA COMPOUND LIQD MG/ML CRAMP RELEAF LIQD 4 RX/OTC RAPAMUNE SOLN 1 5 MG/ML RX/OTC RAPAMUNE TABS 0.5 CRAN-B-OTC LIQD 4 MG, 1 MG, 2 MG (Use 5 CRANBLADDER RELEAF 4 RX/OTC Sirolimus) LIQD SANDIMMUNE CAPS OR RX/OTC 25 MG, 100 MG (Use 4 DEEP HEALTH LIQD 4 Cyclosporine) DEEP SLEEP LIQD 4 RX/OTC SANDIMMUNE SOLN IV 50 MG/ML (Use 4 RX/OTC Cyclosporine) EARLY ALERT LIQD 4 ECHINACEA COMPOUND RX/OTC SANDIMMUNE SOLN OR 5 4 100 MG/ML LIQD SIMULECT SOLR 5 ECZEMA & PSORIASIS 4 RX/OTC SPRAY LIQD sirolimus tabs 2 ESSIAC TONIC LIQD 4 RX/OTC tacrolimus caps 2 HERBAPROFEN LIQD 4 RX/OTC

THYMOGLOBULIN SOLR 5 HIMALAYAN GOJI LIQD 4 RX/OTC PA ZORTRESS TABS 5 JOINT LUBE LIQD 4 RX/OTC

Irrigation Solutions LOVIRAL LIQD 4 RX/OTC irrigation solutions, 2 physiological soln LUNG TONIC LIQD 4 RX/OTC lactated ringer's (irrigation) 2 RX/OTC soln LYDIA PINKHAM LIQD 4 ringer's irrigation soln 2 LYMPHATONIC LIQD 4 RX/OTC water for irrigation, sterile 2 RX/OTC soln MENOPAUTONIC LIQD 4 Lymphatic Agents MOUTH TONIC LIQD 4 RX/OTC

Updated August 1, 2018

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NF FORMULAS CALCIUM RX/OTC PROSTIN VR PEDIATRIC 5 MAGNESIUM/BOTANICAL 4 SOLN (Use Alprostadil) S LIQD Sclerosing Agents 4 RX/OTC PHYTOCILLIN LIQD ASCLERA SOLN 5 4 RX/OTC RESPIRATONIC LIQD ETHAMOLIN SOLN 5 SINGERS SAVING RX/OTC SOTRADECOL SOLN 5 GRACE SOOTHING 4 THROAT SPRAY EXTRA STRENGTH LIQD VARITHENA FOAM 5 SINGERS SAVING RX/OTC GRACE SOOTHING 4 Systemic Lupus Erythematosus Agents THROAT SPRAY LIQD BENLYSTA SOAJ SC 200 PA; QL(30 SINGERS SAVING RX/OTC 5 day(s) limit); MG/ML SP GRACE SOOTHING 4 THROAT SPRAY BENLYSTA SOLR IV 120 5 PA; SP PROFESSIONAL LIQD MG, 400 MG PA; QL(30 SPATONE IRON PLUS 4 RX/OTC BENLYSTA SOSY SC 200 LIQD 5 day(s) limit); MG/ML SP STRESS RELEAF LIQD 4 RX/OTC MOUTH/THROAT/DENTAL AGENTS SWAMP ROOT LIQD 4 RX/OTC Anesthetics Topical Oral Peritoneal Dialysis Solutions benzocaine (dental) aero 2 RX/OTC 20 % DIANEAL PD-2/1.5% 5 DEXTROSE SOLN FIRST-MOUTHWASH BLM 5 SUSP ULTRABAG/DIANEAL PD- 5 2/1.5% DEXTROSE SOLN HURRICAINE AERO (Use 5 RX/OTC Potassium Removing Agents Benzocaine (Dental)) KAYEXALATE POWD (Use QL(454 gm per lidocaine hcl (mouth-throat) 2 QL(100 ml per Sodium Polystyrene 5 fill retail) soln fill retail) Sulfonate) LIDOCAINE HCL SOLN 4 MT 4 % sodium polystyrene 2 QL(454 gm per sulfonate powd or fill retail) Anti-infectives - Throat sodium polystyrene clotrimazole lozg 2 sulfonate susp or 15 2 gm/60ml clotrimazole troc 2 sodium polystyrene sulfonate susp re 30 2 FIRST-BXN MOUTHWASH 5 gm/120ml, 50 gm/200ml SUSP VELTASSA PACK 5 FIRST-DUKES 5 MOUTHWASH SUSP Prostaglandins FIRST-MARYS 5 MOUTHWASH SUSP alprostadil soln 2 nystatin (mouth-throat) 2 QL(120 ml per susp fill retail) Updated August 1, 2018

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORAVIG TABS 5 MUGARD LIQD 4

Antiseptics - Mouth/Throat NEUTRASAL PACK 5 chlorhexidine gluconate 2 (mouth-throat) soln NUMOISYN LIQD 5 RX/OTC

DEBACTEROL SOLN 5 NUMOISYN LOZG (Use 5 RX/OTC Artificial Saliva) PERIDEX SOLN (Use Chlorhexidine Gluconate 5 ORAFATE PSTE 5 (Mouth-Throat)) ORAL RELIEF SPRAY RX/OTC Periodontal Products FOR DRYMOUTH & 5 DISCOMFORT SOLN ARESTIN MISC 5 pilocarpine hcl (oral) tabs 5 2 QL(6 ea daily) Steroids - Mouth/Throat mg pilocarpine hcl (oral) tabs triamcinolone acetonide 2 QL(5 gm per fill 2 (mouth) pste retail) 7.5 mg Throat Products - Misc. PROTHELIAL PSTE 5

AQUORAL AERS 5 RA DRY MOUTH SOLN 5 RX/OTC AQUORAL SOLN 5 RX/OTC SALAGEN TABS 5 MG QL(6 ea daily) (Use Pilocarpine HCl 5 artificial saliva lozg 2 RX/OTC (Oral)) BIOTENE DRY MOUTH RX/OTC SALAGEN TABS 7.5 MG MOISTURIZING SPRAY 5 (Use Pilocarpine HCl 5 SOLN (Oral)) BOCASAL PACK 5 SALIVAMAX PACK 5

CAPHOSOL SOLN 5 RX/OTC SALIVATE RX PACK 5 cevimeline hcl caps 2 MULTIVITAMINS B-Complex Vitamins CVS DRY MOUTH SPRAY 5 RX/OTC SOLN b-complex vitamins inj ij 2mg/ml-100mg/ml-2mg/ml- 2 EPISIL LIQD 4 100mg/ml-2mg/ml b-complex vitamins soln ij EQL DRY MOUTH ORAL 5 RX/OTC RINSE SOLN 2mg/ml-2%-100mg/ml- 2 2mg/ml-100mg/ml-2mg/ml EVOXAC CAPS (Use 5 Cevimeline HCl) GELCLAIR GEL 5

MOI-STIR SOLN 5 RX/OTC

MOUTHKOTE SOLN 5 RX/OTC

Updated August 1, 2018

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits b-complex vitamins tabs or b-complex w/ c & folic acid RX/OTC 0.1mg-20mg-2mg-5mcg- tabs 15mg-100mg-15mg- 3mg-1mg, 10mg-10mg- 18mg-5mcg-0.5mg-4mg- 2mg-1.5mg-0.2mg, 10mg- 500mg, 18mg-5mg-45mg- 14mg-25mcg-7mg-4.5mg, 10mg-10mcg-400mcg- 15mg-2mg-5mg-2mcg- 5mg-250mg, 15mg-50mg- 2mg-2mg, 3mg-10mg- 10.2mg-10mg-6mcg- 20mg-3mg-6mcg-2mg, 400mcg-5mg-300mg, 3mg-20mg-3mg-10mg- 15mg-50mg-10.2mg-10mg- 6mcg-2mg, 83mg-3mg- 2 400mcg-300mcg-5mg- 20mg-2mg-5mcg-1mg, 300mg, 25mg-5mg-10mg- 100mg-50mg-40mg-10mg- 250mcg-5mg-400mcg- 20mg-5mg-4.6mg-1mcg- 300mcg-5mg-120mg, 5mg- 5mg-1mg, 3mg-3mg-20mg- 25mg-20mg-15mcg- 20mg-3mg-3mg-10mg- 100mg-400mcg-30mcg- 10mg-6mcg-6mcg-2mg- 2mg-150mg, 5mg-25mg- 2mg, 30mg-50mg-50mg- 50mg-5mg-37.5mcg- 50mg-50mg-50mg-50mcg- 200mcg-15mcg-5mg- 50mg-100mcg-50mcg- 150mg, 50mg-50mg-50mg- 50mg 50mg-50mcg-400mcg- 2 50mcg-50mg-500mg, B-Complex w/ C 50mg-50mg-50mg-50mg- VITAJECT INJ 5 50mcg-50mg-400mcg- 50mcg-500mg, 100mg- B-Complex w/ Folic Acid 5.5mg-25mg-20mg-15mcg- b-complex w/ c & folic acid QL(1 ea daily); 400mcg-30mcg-2mg- caps 1.5mg-5mg-20mg- RX/OTC 150mg, 25mg-5.5mg- 25mg-20mg-100mcg- 1.7mg-6mcg-1mg-150mcg- 2 10mg-100mg, 5mg-1.7mg- 400mcg-1000mcg-5mg- 6mcg-20mg-1.5mg-1mg- 60mg, 30unit-10mg- 150mcg-10mg-100mg 100mg-10mg-20mg- 12mcg-400mcg-45mcg- b-complex w/ c & folic acid QL(1 ea daily) 5mg-500mg, 25mg-100mg- tabs 1.5mg-10mg-20mg- 5.5mg-25mg-20mg- 1.7mg-6mcg-1mg-300mcg- 100mcg-400mcg-1000mcg- 10mg-60mg, 6mcg-1.5mg- 5mg-60mg, 30unit-100mg- 10mg-20mg-1.7mg-1mg- 10mg-1mg-20mg-1mg- 300mcg-10mg-100mg, 2 1mg-10mg-12mcg- 1.5mg-1.7mg-10mg- 400mcg-45mcg-5mg- 0.01mcg-20mg-1mg- 500mg 300mcg-10mg-60mg, 20mg-1.7mg-10mg- BIOTALAN CLEAR LIQD 5 RX/OTC 0.006mg-1.5mg-1mg- 0.3mg-10mg-100mg DIALYVITE 3000 TABS 5 b-complex w/ c & folic acid tabs 10mg-20mg-1.5mg- DIALYVITE 5000 TABS 5 1mg-1.5mg-5mg-300mcg- 2 50mg-60mg, 20mg-1.5mg- DIALYVITE/ZINC TABS 5 10mg-1mg-1.5mg-5mg- 300mcg-50mg-60mg FOLBEE PLUS CZ TABS 4

Updated August 1, 2018

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MILCO-B-FORTE TABS RX/OTC bioflavonoid products tabs RX/OTC (Use B-Complex w/ C & 5 500mg, 1000mg, 25mg- Folic Acid) 1000mg, 300mg-200mg, 550mg-500mg, 900mg- NEPHPLEX RX TABS 5 100mg, 100mg-100mg- NEPHRO-VITE RX TABS QL(1 ea daily) 50mg, 100mg-50mg- (Use B-Complex w/ C & 5 100mg, 100mg-50mg- Folic Acid) 500mg, 18mg-30mg- 1000mg, 200mg-50mg- NEPHROCAPS CAPS QL(1 ea daily); 500mg, 200mg-55mg- (Use B-Complex w/ C & 5 RX/OTC 500mg, 500mg-50mg- Folic Acid) 500mg, 100mg-100mg- NUTRIVIT LIQD 5 500mg, 200mg-110mg- 2 1000mg, 200mg-10mg- RENATABS TABS 5 10mg-500mg, 150mg- 250mg-500mg-250mg, 200mg-65mg-10mg-10mg- RENATABS WITH IRON 5 MISC 500mg, 20mg-100mg- 110mg-20mg-1000mg, SM B-COMPLEX/VITAMIN 4 RX/OTC C TABS 1mg-10mg-100mg-25mg- 50mg-500mg, 2mg-20mg- SUPERVITE LIQD 5 RX/OTC 200mg-50mg-100mg- 1000mg, 25mg-50mg- VITAL-D RX TABS 5 25mg-25mg-25mg-40mg- 500mg B-Complex w/ Minerals CEMILL PLUS TABS 5 RX/OTC b-complex w/ minerals liqd 2 ESTER-C TABS 200MG- 5 RX/OTC Bioflavonoid Products 60MG-500MG NAT-RUL C-COMPLEX RX/OTC ADRENAL C FORMULA 5 RX/OTC 5 TABS TABS PERIDIN-C TABS (Use RX/OTC ADVANCED C PLUS 5 RX/OTC 5 TABS Bioflavonoid Products) Iron w/ Vitamins GERITOL COMPLETE RX/OTC TABS (Use Iron w/ 5 Vitamins) iron w/ vitamins tabs 2mg- RX/OTC 100mg-4mg-60mg-4.8mg- 3mcg-10mg-1mg-150mg, 2 2mg-100mg-4mg-60mg- 4.8mg-3mcg-10mg-31mg- 150mg VITAFOL TABS (Use Iron 5 RX/OTC w/ Vitamins) Multiple Vitamins & Fluoride-Folic Acid MULTIVITAMIN WITH 5 FLUORIDE CHEW

Updated August 1, 2018

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Multiple Vitamins w/ Calcium AQUADEKS CAPS RX/OTC 18167UNIT-10MG-10MG- ADVANCED AM/PM MISC 5 75MCG-80MG-1.5MG- 10MG-12MG-75MG-10MG- 4 Multiple Vitamins w/ Minerals & Calcium-Folic 700MCG-1.7MG-12MCG- FOLGARD OS TABS 5 800UNIT-200MCG- 150UNIT-100MCG-1.9MG TL G-FOL OS TABS 5 BACMIN TABS 4 RX/OTC Multiple Vitamins w/ Minerals & Fluoride-Iron-Folic BARIATRIC RX/OTC MULTIVITAMINS/IRON 4 QUFLORA FE CHEW 5 CAPS Multiple Vitamins w/ Minerals BASIC AM TABS 4 RX/OTC RX/OTC ABDEK CAPS 4 BASIC PM TABS 4 RX/OTC RX/OTC ACTIVITE EC TABS 5 BIO-35 GLUTEN-FREE 4 RX/OTC CAPS ACTIVNUTRIENTS CAPS 4 RX/OTC BIO-35 IRON FREE CAPS 4 RX/OTC ADVANCED DIABETIC RX/OTC MULTIVITAMIN FORMULA 4 BIOCAL CAPS 4 RX/OTC TABS BIOSUPP LIQD 4 RX/OTC ALIVE ENERGY 50+ TABS 4 RX/OTC BIOTECT PLUS CAPS 4 RX/OTC ALIVE MENS ENERGY 4 RX/OTC TABS RX/OTC ALIVE ONCE DAILY RX/OTC BIOTECT PLUS LIQD 4 WOMENS 50+ ULTRA 4 BURIED TREASURE RX/OTC POTENCY TABS ACTIVE 55PLUS SENIOR 4 ALIVE ONCE DAILY RX/OTC COMPLEX LIQD WOMENS ULTRA 4 RX/OTC POTENCY TABS CAL-DAY 1000 TABS 4 ALIVE WOMENS 50+ 4 RX/OTC CELEBRATE MULTI- RX/OTC TABS COMPLETE18 CAPS 46.666MCG-0.666MG- ALIVE WOMENS ENERGY 4 RX/OTC TABS 5MG-0.666MG- 66.666MCG-25MCG- ANTIOXIDANT FORTE 4 RX/OTC TABS 50MCG-33.333MG-2MG- 4 6MG-6.666MG-13.333MG- AP-ZEL TABS 4 RX/OTC 13.333MCG-1.133MG- 1666.666UNIT- APATATE FORTE LIQD 4 RX/OTC 166.666MCG-1000UNIT- 266.666MCG-10UNIT- 200MCG-1.333MG-30MG

Updated August 1, 2018

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEBRATE MULTI- RX/OTC CENTRUM LIQD RX/OTC COMPLETE36 CAPS 150MCG/15ML- 46.666MCG-1MG-10MG- 3MG/15ML-25MCG/15ML- 0.666MG-66.666MCG- 25MCG/15ML-2MG/15ML- 25MCG-166.666MCG- 9MG/15ML-20MG/15ML- 50MCG-33.333MG-4MG- 4 1.7MG/15ML-10MG/15ML- 12MG-6.666MG- 1300UNIT/15ML- 13.333MG-40MCG-4MG- 6MCG/15ML- 3333.333UNIT-1000UNIT- 400UNIT/15ML- 200MCG-20UNIT- 1.1MG/15ML- 200MCG-1.333MG-60MG 30UNIT/15ML- CELEBRATE MULTI- RX/OTC 300MCG/15ML- COMPLETE45 CAPS 2MG/15ML-60MG/15ML, 46.666MCG-10MG- 2500UNIT/15ML- 5 0.666MG-66.666MCG- 150MCG/15ML- 25MCG-333.333MCG- 3MG/15ML-25MCG/15ML- 1MG-50MCG-33.333MG- 4 25MCG/15ML- 4MG-15MG-6.666MG- 2.5MG/15ML-9MG/15ML- 13.333MG-40MCG-4MG- 30UNIT/15ML- 3333.333UNIT-1000UNIT- 400UNIT/15ML- 266.666MCG-20UNIT- 20MG/15ML-1.7MG/15ML- 200MCG-1.33MG-60MG 10MG/15ML-6MCG/15ML- 1.5MG/15ML- CELEBRATE MULTI- RX/OTC 300MCG/15ML- COMPLETE60 CAPS 2MG/15ML-60MG/15ML 46.666MCG-10MG- (Use Multiple Vitamins w/ 0.666MG-66.666MCG- Minerals) 25MCG-333.333MCG- 1MG-50MCG-33.333MG- 4 CENTRUM MEN TABS 4 RX/OTC 4MG-20MG-6.666MG- 13.333MG-40MCG-4MG- CENTRUM SILVER RX/OTC 3333.333UNIT-1000UNIT- 50+MEN TABS (Use 5 266.666MCG-20UNIT- Multiple Vitamins w/ 200MCG-1.333MG-60MG Minerals) CENTRUM SILVER RX/OTC CELLULAR SECURITY 4 RX/OTC CAPS 50+WOMEN TABS (Use 5 Multiple Vitamins w/ CENTRAVITES 50 PLUS 4 RX/OTC TABS Minerals) CENTRUM SILVER RX/OTC CENTRAVITES ADULTS 4 RX/OTC TABS ADULT 50+ TABS (Use 5 Multiple Vitamins w/ CENTRUM ADULTS TABS RX/OTC Minerals) (Use Multiple Vitamins w/ 5 Minerals) CENTRUM CARDIO TABS 4 RX/OTC

Updated August 1, 2018

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM SILVER TABS RX/OTC CENTRUM ULTRA 4 RX/OTC 45MCG-2MG-72MG- WOMENS TABS 10MCG-55MCG-2.3MG- CENTRUM WOMEN TABS RX/OTC 5MCG-0.5MG-20MG- (Use Multiple Vitamins w/ 5 50UNIT-150MCG-45MCG- Minerals) 220MG-80MG-50MG- 150MCG-11MG-1.5MG- CEROVITE ADVANCED 4 RX/OTC 10MG-2500UNIT-20MG- FORMULA LIQD 30MCG-1.7MG-25MCG- CERTAVITE RX/OTC 500UNIT-400MCG- SENIOR/ANTIOXIDANT 4 30MCG-3MG-60MG, 2MG- NUTRIENTS TABS 72MG-10MCG-20MCG- 5 CHOICEFUL RX/OTC 150MCG-2MG-5MCG- MULTIVITAMIN CAPS 48MG-150MCG-75MCG- 15MG-1MG-8MG-18MG- 200MG-150MCG-80MG- 700MCG-1.5MG- 4 100MG-45UNIT-2MG- 14000UNIT-5MCG- 15MG-1.5MG-300MCG- 1000UNIT-180MCG- 10MG-3500UNIT- 170UNIT-80MCG-1.9MG- 250MCG-20MG-10MCG- 30MG 1.7MG-25MCG-400MCG- CLINICAL NUTRIENTS 45- 4 RX/OTC 30MCG-3MG-60MG- PLUS WOMEN TABS 400UNIT (Use Multiple Vitamins w/ Minerals) CLINICAL NUTRIENTS 50- 4 RX/OTC PLUS MEN TABS CENTRUM SILVER 4 RX/OTC ULTRA MENS TABS CLINICAL NUTRIENTS 4 RX/OTC ANTIOXIDANT CAPS CENTRUM SILVER 4 RX/OTC ULTRA WOMENS TABS CLINICAL NUTRIENTS RX/OTC FOR FEMALE TEENS 4 CENTRUM SPECIALIST 4 RX/OTC TABS HEART TABS CLINICAL NUTRIENTS 4 RX/OTC CENTRUM SPECIALIST 4 RX/OTC FOR MALE TEENS TABS IMMUNE SUPPORT TABS CLINICAL NUTRIENTS 4 RX/OTC CENTRUM SPECIALIST 4 RX/OTC FOR MEN TABS VISION TABS CLINICAL NUTRIENTS 4 RX/OTC CENTRUM TABS 35MCG- RX/OTC FOR WOMEN TABS 2MG-72MG-10MCG- 55MCG-75MCG-2.3MG- CONCEPTIONXR 10MCG-5MCG-0.5MG- MOTILITY SUPPORT 4 20MG-150MCG-45MCG- FORMULA MISC 80MG-200MG-30UNIT- CORVITE TABS (Use 11MG-50MG-1.5MG- 5 Multiple Vitamins w/ 5 18MG-10MG-3500UNIT- Minerals & Folic Acid) 20MG-25MCG-1.7MG- CVS DIABETES HEALTH 4 6MCG-400UNIT-400MCG- SUPPORT MISC 30MCG-2MG-60MG (Use CVS ONE DAILY MENS 4 RX/OTC Multiple Vitamins w/ 50+ ADVANCED TABS Minerals) CENTRUM ULTRA MENS RX/OTC TABS (Use Multiple 5 Vitamins w/ Minerals)

Updated August 1, 2018

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS SPECTRAVITE RX/OTC DIABETES SUPPORT 4 ADULT 50+ TABS 45MCG- PACK MISC 2MG-72MG-10MCG- DIALYVITE SUPREME D 5 55MCG-2.3MG-5MCG- TABS 0.5MG-20MG-50UNIT- 150MCG-45MCG-220MG- ENDUR-VM TBCR 4 150MCG-80MG-11MG- 4 50MG-1.5MG-300MCG- ENDUR-VM WITH IRON 4 10MG-2500UNIT- TBCR 250MCG-20MG-30MCG- EQ COMPLETE RX/OTC 1.7MG-25MCG-500UNIT- MULTIVITAMINADULTS 4 400MCG-30MCG-3MG- UNDER 50 TABS 60MG EQ ONE DAILY MENS 50+ 4 RX/OTC TABS CVS SPECTRAVITE 4 RX/OTC ULTRA MEN50+ TABS EQ ONE DAILY MENS 4 RX/OTC CVS SPECTRAVITE RX/OTC HEALTH TABS ULTRA MENS HEALTH 4 EQ ONE DAILY WOMENS 4 RX/OTC SENIOR TABS 50+ TABS CVS SPECTRAVITE RX/OTC EQ ONE DAILY WOMENS 4 RX/OTC ULTRA MENS HEALTH 4 HEALTH TABS TABS EQL CENTURY MATURE 4 RX/OTC CVS SPECTRAVITE 4 RX/OTC ADULTS50+ TABS ULTRA WOMEN TABS EQL CENTURY MENS 4 RX/OTC CVS SPECTRAVITE RX/OTC TABS ULTRA WOMENS 4 EQL CENTURY WOMENS 4 RX/OTC HEALTH SENIOR TABS TABS CVS SPECTRAVITE RX/OTC EQL ONE DAILY MENS 4 RX/OTC ULTRA WOMENS 4 TABS HEALTH TABS EYE HEALTH CAPS 4 RX/OTC DAILY HEART HEALTH 4 SUPPORT MISC FITNESS TABS FOR MEN 4 RX/OTC DAILY PAK MAXIMUM AM/PM/LYCOPENE TABS MULTIVITAMIN/ASIAN 4 GINSENG EXTRACT FITNESS TABS FOR RX/OTC MISC WOMEN 4 AM/PM/LYCOPENE TABS DECUBI-VITE CAPS 4 RX/OTC FORTAVIT CAPS 4 RX/OTC DEKAS PLUS CAPS RX/OTC 75MCG-10MG-150UNIT- FORTAVIT LIQD 4 RX/OTC 10MG-12MG-75MG-10MG- 1000MCG-1.7MG- 4 FOSFREE TABS (Use RX/OTC 18167UNIT-12MCG- Multiple Vitamins w/ 5 3000UNIT-1.5MG- Minerals) 200MCG-100MCG-1.9MG FREEDAVITE TABS 4 RX/OTC DERMAVITE TABS 4 RX/OTC GERI-FREEDA SENIOR 4 RX/OTC FORMULA TABS DIABETES HEALTH PACK 4 MISC HAIR-VITES TABS 4 RX/OTC

Updated August 1, 2018

163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HAIR/SKIN/NAILS CAPS RX/OTC MEGA MULTI FOR 4 RX/OTC 2500UNIT-0.9MG-11MG- 4 WOMEN TABS 2500MCG-100MG MEGA MULTIVITAMIN 4 RX/OTC HM COMPLETE 50+ 4 RX/OTC FOR MEN TABS MENS ULTIMATE TABS MEGA MULTIVITAMIN 4 RX/OTC HM COMPLETE 50+ RX/OTC FOR WOMEN TABS WOMENS ULTIMATE 4 MEGAVITE FRUITS & 4 RX/OTC TABS VEGGIES TABS RX/OTC HM COMPLETE TABS 4 MEGAVITE GOLDEN 4 RX/OTC YEARS 55+ TABS HM HAIR/SKIN/NAILS RX/OTC 4 MENS 50+ ADVANCED 4 RX/OTC TABS CAPS HM ONE DAILY MENS 4 RX/OTC MENS 50+ MULTI RX/OTC TABS VITAMIN &MINERAL 4 HM ONE DAILY WOMENS 4 RX/OTC FORMULA TABS TABS MENS MULTI VITAMIN & RX/OTC HYALEX TABS 4 RX/OTC MINERAL FORMULA 4 TABS ICAPS AREDS FORMULA 4 RX/OTC TABS MENS PACK MISC 4 RX/OTC ICAPS PLUS TABS 4 MH MACULAR HEALTH 4 MISC K-PAX IMMUNE RX/OTC MULTI-BETIC DIABETES 4 RX/OTC SUPPORT FORMULA 4 TABS DOUBLE STRENGTH CAPS MULTI-VITAMIN 4 RX/OTC MONOCAPS TABS K-PAX IMMUNE RX/OTC multiple vitamins w/ SUPPORT FORMULA 4 2 PROFESSIONAL minerals & folic acid tabs STRENGTH TABS K-PAX IMMUNE RX/OTC SUPPORT FORMULA 4 SINGLE STRENGTH CAPS KP MENS DAILY PACK 4 MISC KP WOMENS DAILY 4 PACK MISC LIFE PACK MENS MISC 4

LIFE PACK WOMENS 4 MISC M2 B-60 TBCR 4

MACULAR VITAMIN 4 RX/OTC BENEFIT TABS

Updated August 1, 2018

164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ RX/OTC 1000unit-273.333unit- minerals caps 0.667mg- 20unit-26.667mg, 70mg- 10unit-83.333mg-50mcg- 4mg-80mg-50unit-10mg- 66.667mg-133.333mg- 10mg-25mg-5mg-8000unit- 2000unit-3.333mg- 10mcg-1mg-2mg-150mg, 1.667mg-33.333mg-3mg- 8000unit-70mg-4mg-80mg- 20mg-5mg-33.333mg- 50unit-10mg-10mg-25mg- 166.667mg-0.567mg- 5mg-10mcg-1mg-2mg- 2mcg-0.5mg-6.667mg- 150mg, 25mg-20mg- 133.333mcg-200mcg- 12500unit-7.5mg-200unit- 0.667mg-20mg, 25mg- 100mcg-1mg-40mg-25mg- 100unit-45mg-500mg, 1.75mg-5mg-250mg, 50mcg-7.5mg-400unit- 10mg-7.5mg-1mg-200unit- 500mg, 200unit-1mg- 25mcg-20mg-10mg-1mg- 40mg-3mg-250mg, 25mcg- 5mg-5mg-500unit-100mcg- 5000unit-100unit-200mg, 10mg-250mg, 613.5mg- 22mg-2mg-15mg-6mg- 250mg-175mg-0.75mg- 30unit-60mg, 22mg-30unit- 135mg-0.85mg-1500mcg- 2mg-15mg-6mg-60mg, 200unit-215mg-150mcg- 25mcg-10000unit-125unit- 0.5mg-30mg, 50mg-2mg- 200mg, 50mcg-25000unit- 15unit-2500unit-25mcg- 400unit-500mg, 200unit- 25mg-25mg-50mg-3mg- 0.8mg-34.8mg-5mg- 12mcg-500unit-3mg- 226mg, 200unit-1mg- 800mcg-25mcg-6mg- 10mg-1mg-5mg-250mg, 250mg, 15mg-16000unit- 1mg-200unit-12.5mg-1mg- 2 1.5mg-12mg-20mg- 5mg-250mg, 200mg- 800mcg-1.7mg-6mcg- 14320unit-0.8mg-34.8mg- 1000unit-200mcg-200unit- 226mg, 200unit-14320unit- 100mcg-1.9mg-100mg, 0.8mg-34.8mg-226mg, 280mg-34mcg-1mg-7mg- 12500unit-200unit-7.5mg- 0.9mg-2.3mg-10unit-2mg- 1mg-40mg-250mg, 45mg-600mcg-10mg- 12500unit-200unit-7.5mg- 1.3mg-2.4mcg-1.3mg- 1mg-40mg-3mg-250mg, 16mg-1.2mg-240mcg, 15mcg-1.5mg-200unit- 105mcg-120mcg-2mg- 10000unit-1mg-7.5mg- 45unit-100mg-2mg-15mg- 250mg, 250mg-160mg- 120mg-1.2mg-600mcg- 1mg-90mg-9mg-1mg-5mg- 210mg-5mg-3500unit- 30unit-150mg, 166.667mg- 16mg-20mcg-1.7mg- 133.333mg-6.667mg- 18mcg-400unit-400mcg- 16.667unit-3.333mg- 30mcg-3mg-90mg, 40mcg- 33.333mg, 25mg-20mg- 120mcg-4mg-50unit- 200unit-100mcg-1mg- 150mcg-45mcg-100mg- 40mg-25mg-1.75mg-5mg- 2500unit-2mg-15mg-40mg- 250mg, 18mg-90mg- 1.5mg-10mg-20mg-40mcg- 30mcg-70mcg-15mg- 1.7mg-18mcg-1000unit- 400unit-300mcg-20mg- 400mcg-30mcg-4mg-60mg, 25mg-10mg, 375mg- 70mcg-120mcg-4mg- 0.5mg-300mg-3.75mg- 150mcg-75mcg-200mg- 5mcg-68.75unit-100mcg- 2500unit-2mg-15mg- 0.5mg-25mg, 491.667mg- 100mg-1.5mg-10mg-20mg- 88.333mg-1mg-5mg- 80mcg-1.7mg-25mcg- Updated August 1, 2018

165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1000unit-400mcg-60unit- 56.7mcg-5.7mg-19mcg- 30mcg-6mg-60mg, 70mcg- 75.7mg-5.7mcg-3.7mg- 120mcg-4mg-60unit- 75.7mg-1mg-15mg-1.3mg- 150mcg-75mcg-200mg- 7.7mg-4.7mcg-141.7unit- 2500unit-2mg-15mg- 0.33mg-11.3unit-56.7mcg- 100mg-1.5mg-10mg-20mg- 2.3mg-113.3mg, 15mg- 80mcg-1.7mg-25mcg- 2mg-200mcg-200mcg- 1000unit-400mcg-30mcg- 150mcg-150mcg-25mg- 6mg-60mg, 70mcg- 5mg-7.2mg-5000unit-5mg- 120mcg-4mg-60unit- 100unit-25mg-25mg-50mg- 150mcg-75mcg-2500unit- 100mg-25mg-25mg-25mg- 2mg-15mg-100mg-1.5mg- 100mcg-400unit-400mcg- 200mg-10mg-20mg- 300mcg-25mg-150mg, 80mcg-1.7mg-25mcg- 2.6mg-10mcg-100mg- 1000unit-400mcg-30mcg- 150mcg-130mg-15mg- 6mg-60mg, 20mcg- 2mg-10mcg-37.5mg- 120mcg-4mg-50unit- 10mcg-100mg-27mg- 150mcg-45mcg-100mg- 5000unit-30unit-400unit- 2500unit-2mg-15mg-40mg- 1500unit-1.7mg-10mg- 1.5mg-18mg-10mg-20mg- 6mcg-1.5mg-20mg-0.4mg- 40mcg-1.7mg-6mcg- 30mcg-2mg-60mg, 1000unit-400mcg-30mcg- 4.167mcg-8.333mg-20mg- 2mg-60mg, 20mcg- 1mg-10mg-0.333mg-10mg- 120mcg-4mg-50unit- 2.5mg-1.667mg-3.333mg- 150mcg-45mcg-100mg- 5mg-8.333mg-1.667mg- 2500unit-2mg-15mg-40mg- 1666.667unit-2.667mcg- 1.5mg-18mg-10mg-20mg- 666.667unit-133.333mcg- 40mcg-1.7mg-6mcg- 10unit-1666.667mcg- 1000unit-600mcg-30mcg- 1.667mg-30mg, 5mg- 2mg-60mg, 20mcg- 70mcg-25mg-1mg-35mg- 120mcg-4mg-50unit- 5mg-5mg-1mg-7.5mg- 150mcg-45mcg-2500unit- 75mcg-100mcg-10mg- 2mg-15mg-40mg-1.5mg- 10000unit-25mg-25unit- 100mg-18mg-10mg-20mg- 150mcg-50mg-15mg- 40mcg-1.7mg-6mcg- 25mg-25mg-25mcg-50mg- 1000unit-600mcg-30mcg- 100mg-250mcg-150mcg- 2mg-60mg, 2973unit- 25mg-100mcg-400unit- 14mcg-42.3mg-42.3mcg- 400mcg-30mcg-25mg- 4.3mg-14mcg-56.7mg- 150mg, 75mcg-2mg- 4.3mcg-2.7mg-56.7mg- 552mcg-2mg-10mcg-6mg- 1mg-11.3mg-1mg-5.7mg- 70mcg-120mcg-10mcg- 3.3mcg-106.3unit-255mcg- 5mcg-33unit-150mcg- 8.3unit-42.3mcg-1.7mg- 150mcg-16mg-2mg-15mg- 85mg, 70mcg-1mg- 4mg-3mg-234mcg- 120mcg-150mcg-75mcg- 100mcg-10mg-21mg- 5000unit-2mg-120mg- 18mg-20mg-2500unit- 40mg-15mg-1.5mg- 9.5mg-20mg-20mcg- 500mcg-30mg-2mg-20mg- 1.7mg-15mcg-1000unit- 100mcg-1.7mg-10mg- 600mcg-30mcg-4mg-72mg, 6mcg-2000unit-200mcg- 90mcg-4mg-552mcg-2mg- 30unit-30mcg-2mg, 10mcg-6mg-105mcg- 3964unit-19mcg-56.7mg- 180mcg-10mcg-5mcg- Updated August 1, 2018

166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 33unit-150mcg-150mcg- multiple vitamins w/ RX/OTC 16mg-2mg-22.5mg-4mg- minerals liqd 1000mg/15ml- 4.5mg-234mcg-100mcg- 2mg/15ml-15mg/15ml- 10mg-21mg-20mg- 15mcg/15ml-10mg/15ml- 2500unit-9.5mg-20mg- 50mg/15ml-15mg/15ml- 20mcg-3.4mg-25mcg- 50mg/15ml-5000unit/15ml- 1000unit-400mcg-30mcg- 50mcg/15ml-50mg/15ml- 6mg-72mg, 10mg- 800mcg/15ml- 23.333mcg-1mg-10mg- 150mcg/15ml-50mg/15ml, 5mg-25mcg-40mcg-10mg- 1.7mg/15ml-25mcg/15ml- 0.667mg-50mcg- 2mg/15ml-30unit/15ml- 133.333mg-10unit-10mg- 150mcg/15ml-25mcg/15ml- 33.333mg-15mg-6.667mg- 3mg/15ml-9mg/15ml- 3333.333unit-16.667mg- 10mg/15ml-20mg/15ml- 3.333mg-3.333mg- 6mcg/15ml-1.5mg/15ml- 1.133mg-33.333mcg- 300mcg/15ml-2mg/15ml- 1000unit-4mg- 60mg/15ml, 7.5mg/5ml- 266.667mcg-200mcg- 2500unit/5ml-750mcg/5ml- 1.333mg-40mg, 25mcg/5ml-5mg/5ml- 833.33unit-16.67mg- 2.5unit/5ml-75mg/5ml- 33.33mcg-66.67unit- 100unit/5ml-12.5mg/5ml- 33.33mcg-66.67mg-2.5mg- 10mg/5ml-5mcg/5ml- 3.33mcg-200mcg- 7.5mg/5ml-200mcg/5ml- 33.33mcg-0.25mg-16.5mg- 25mcg/5ml-225mg/5ml- 8.33mcg-1.67mg-66.67mg- 250mg/5ml, 250mcg/15ml- 2.5mg-2500unit-12.5mg- 2mg/15ml-150mcg/15ml- 2 8.33mg-30mg-12.5mg- 25mcg/15ml-3mg/15ml- 12.5mg-6.33mg-16.67mg- 30unit/15ml-9mg/15ml- 12.5mcg-33.33unit- 20mg/15ml-1.7mg/15ml- 6.67mg-66.67mcg-50mcg- 10mg/15ml-6mcg/15ml- 12.5mg-4.17mg-166.67mg, 400unit/15ml-1.5mg/15ml- 33.3mg-20mg-6.7mg- 300mcg/15ml-2mg/15ml- 20mg-33.3mcg-166.7mcg- 60mg/15ml, 37mg/15ml- 0.33mg-83.3mg-6.7mg- 112.5mcg/15ml- 16.7mcg-33.3mg-33.3mcg- 75mg/15ml-15mg/15ml- 0.33mg-16.5mg-1.67mcg- 15mg/15ml-45mg/15ml- 20.8mcg-33.3mg-0.83mg- 2.55mg/15ml- 66.7unit-33.3mcg-25mg- 5250unit/15ml- 33.3mg-4mg-0.5mg-3.3mg- 18mcg/15ml-600unit/15ml- 0.67mg-8.3mg-1.67mg- 2.25mg/15ml- 83.3mg-41.7mg-16.7mcg- 300mcg/15ml-45unit/15ml- 1.67mg-833.3unit-66.7unit- 150mcg/15ml-3mg/15ml- 3.3mg-133.3mcg-50mcg- 90mg/15ml, 25mcg/15ml- 16.7mg-83.3mg 2mg/15ml-150mcg/15ml- 25mcg/15ml-3mg/15ml- 9mg/15ml-1.7mg/15ml- 10mg/15ml-20mg/15ml- 1300unit/15ml-6mcg/15ml- 400unit/15ml-1.5mg/15ml- 30unit/15ml-300mcg/15ml- 2mg/15ml-60mg/15ml, 25mcg/15ml-2mg/15ml- Updated August 1, 2018

167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 150mcg/15ml-25mcg/15ml- multiple vitamins w/ RX/OTC 3mg/15ml-9mg/15ml- minerals tabs 0.6mg-10mg- 20mg/15ml-1.7mg/15ml- 50mg-10mg-897mcg- 10mg/15ml-1300unit/15ml- 73mg-54mg-25unit- 6mcg/15ml-400unit/15ml- 150mcg-0.5mg-20mg-5mg- 2mg/15ml-1.5mg/15ml- 10mg-3.3mg-15mg-10mg- 30unit/15ml-300mcg/15ml- 10mg-25mg-5mg-2500unit- 60mg/15ml, 2mg/15ml- 25mcg-50unit-7.2mg- 30unit/15ml-150mcg/15ml- 7.5mg-25mcg-25mcg- 25mcg/15ml-25mcg/15ml- 6.5mg-3.5mg-50mg, 3mg/15ml-400unit/15ml- 0.6mg-10mg-10mg- 9mg/15ml-1.7mg/15ml- 897mcg-58mg-25unit- 20mg/15ml-10mg/15ml- 150mcg-125mg-0.6mg- 2500unit/15ml-6mcg/15ml- 20mg-5mg-10mg-3.3mg- 1.5mg/15ml-300mcg/15ml- 15mg-10mg-10mg-25mg- 2mg/15ml-60mg/15ml, 5mg-2500unit-25mcg- 25mcg/15ml-2mg/15ml- 50unit-7.2mg-7.5mg- 30unit/15ml-150mcg/15ml- 25mcg-25mcg-6.5mg- 25mcg/15ml-3mg/15ml- 3.5mg-50mg, 0.5mg- 9mg/15ml-20mg/15ml- 25000unit-30mg-0.15mg- 1.7mg/15ml-10mg/15ml- 6mg-25mg-7mg-100unit- 1300unit/15ml-6mcg/15ml- 1000unit-30mg-5mg-10mg- 1000unit/15ml-2mg/15ml- 50mg-10mg-30mg-80mg- 1.5mg/15ml-300mcg/15ml- 30mg-80mg-80mg-80mg- 60mg/15ml, 2500unit/15ml- 80mg-80mg-80mcg-80mg- 150mcg/15ml-3mg/15ml- 400mcg-80mcg-80mg- 2 25mcg/15ml-25mcg/15ml- 250mg, 0.2mg-35mcg- 2.5mg/15ml-9mg/15ml- 150mcg-30mg-2mg-50unit- 30unit/15ml-400unit/15ml- 15mg-7.5mg-10mg-30mg- 20mg/15ml-1.7mg/15ml- 100mg-30mg-5000unit- 10mg/15ml-6mcg/15ml- 30mcg-30mg-400mcg- 1.5mg/15ml-300mcg/15ml- 30mcg-30mg-300mg- 2mg/15ml-60mg/15ml 400unit, 0.5mg-1mg-50mg- 50mg-100mg-7.5mg- 30unit-0.75mg-2500unit- 250mcg-10mg-0.85mg- 100unit-50mg-25mg- 100mcg-1250mcg-50mg- 60mg, 0.5mg-0.375mg- 1.5mg-80mg-15unit- 75mcg-100mg-2.5mg- 7.5mg-5mg-5000unit- 15mg-2.5mg-1mcg- 400unit-400mcg-1mg- 60mg, 0.5mg-0.37mg- 1.5mg-80mg-15unit- 75mcg-100mg-2.5mg- 2.5mg-5000unit-15mg- 2.5mg-5mg-1mcg-400unit- 400mcg-1mg-60mg, 0.05mg-50mcg-60unit- 20mcg-3mg-15mg-50mg- Updated August 1, 2018

168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 20mg-10mg-100mg-20mg- 166.667mg, 25mcg-3mg- 25mg-50mcg-1mg-0.15mg- 2mg-500mg-30unit-2mg- 25mg-500mg-400unit, 10mg-2mg-10mg-10mg, 0.5mg-15mg-155mcg- 16.667mcg-133.333unit- 9.5mg-15unit-150mg- 53.333mg-8333.333unit- 9.5mg-22mg-12.5mcg- 166.667mg, 40mcg- 99mg-12.5mg-1mg- 6000unit-50unit-5mg-2mg- 222mcg-99mg-122mg- 40mg-40mg-3mg-5mg- 22mcg, 0.12mg-3.75mg- 200mg, 12.5mg-1.5mg- 5unit-15mg-10mg-3.33mg- 10mg-20mg-1.7mg-6mcg- 0.33mcg-1.67mg, 2mg- 800mcg-300mcg-10mg- 12mg-8mg-500mcg, 60mg, 30unit-10mg-18mg- 30unit-2mg-15mg-6mg- 20mg-100mg-10mg- 60mg, 10000unit-25mcg- 12mcg-400mcg-45mcg- 200unit-200mg, 100mcg- 5mg-500mg, 69mg-30unit- 200unit-5000unit-250mg, 10mg-20mg-100mg-10mg- 200unit-1mg-40mg-1mg- 12mcg-400mcg-45mcg- 5mg-250mg, 50mcg- 5mg-500mg, 30unit- 100unit-10000unit-400unit, 5000unit-1.7mg-10mg- 17mcg-53mg-133unit- 6mcg-1.5mg-20mg-0.4mg- 8333unit-167mg, 40mcg- 2mg-60mg-400unit, 5000unit-30mg-2mg-40mg- 150mcg-5mg-15mg-2mg- 60mg, 100unit-7160unit- 30mg-100mg-125mg- 0.4mg-17.4mg-113mg, 500mg-6mcg-35mg- 40mcg-2mg-30unit- 400mcg-100mcg, 23.9mg- 1000unit-40mg-60mg, 30unit-3mg-10mg-20mg- 40mcg-2mg-30unit- 100mg-10mg-12mcg- 5000unit-40mg-60mg, 400mcg-45mcg-5mg- 40mcg-30unit-5000unit- 500mg, 46mg-60mg-3mg- 2mg-40mg-60mg, 40mcg- 24mg-20mg-20mg-5mg- 5000unit-2mg-40mg- 20mcg-100mg-400mcg- 30unit-60mg, 40mcg- 100mcg-20mg-500mg, 5000unit-30unit-2mg- 150mcg-15mg-2mg-5mg- 40mg-60mg, 5000unit- 18mg-30mg-65mg-125mg- 30unit-40mcg-2mg-40mg- 100mg-6mcg-35mg- 60mg, 5000unit-40mcg- 400mcg-300mcg, 15mg- 40mg-2mg-30unit-60mg, 30unit-20mg-10mg-4mg- 7160unit-0.4mg-17.4mg- 20mg-100mg-10mg- 100unit-113mg, 7160unit- 12mcg-400mcg-45mcg- 100unit-0.4mg-17.4mg- 5mg-300mg, 77mg-24mg- 113mg, 55mcg-60unit- 30unit-3mg-10mg-20mg- 1000unit-2mg-40mg- 100mg-10mg-12mcg- 200mg, 5000unit-30unit- 400mcg-45mcg-5mg- 40mcg-2mg-40mg-2mg- 500mg, 15mcg-2500unit- 60mg, 40mcg-30unit- 500mg-7.5mg-1mg-50mg- 44mg-5000unit-2mg-40mg- 18mg-15unit-200unit-6mcg- 60mg, 55mcg-2mg-60unit- 0.4mg-90mg, 18mg-0.8mg- 1000unit-40mg-2mg- 1.3mg-7mg-50unit-25mg- 200mg, 55mcg-60unit- 100mg-10mg-25mg- 1000unit-2mg-40mg-2mg- 25mcg-10mg-0.4mg- 200mg, 16.667mcg-53mg- 300mg, 25mcg-30mg- 133.333unit-8333.333unit- 60mg-30unit-5mg-100mg- Updated August 1, 2018

169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 50mg-50mg-25mcg-50mg- 32mg-50mcg-5mg-100mg- 400mcg-50mg-600mg, 3.6mg, 60mg-5000unit- 30unit-1.5mg-45mg- 50mcg-12mg-1.5mg-75mg- 10mcg-3000unit-20mg- 13.5mg-25mg-15mg- 1.7mg-6mcg-400unit- 1.3mg-200mg-1.25mg- 0.4mg-2mg-60mg, 30unit- 30unit-500mg, 30unit- 45mg-1.5mg-10mg- 15mg-50mg-1.5mg-450mg- 3000unit-20mg-1.7mg- 18mg-5mg-2500unit- 6mcg-400unit-400mcg- 1.7mg-6mcg-400unit- 2mg-60mg, 5000unit- 10mg-400mcg-2mg-60mg, 5000unit-40mcg-40mcg- 30unit-15mg-50mg-1.5mg- 40mg-40mg-2mg-2mg- 450mg-18mg-5mg- 30unit-30unit-60mg-60mg, 2500unit-10mg-1.7mg- 15unit-20mg-30mg-1.5mg- 6mcg-400unit-400mcg- 20mg-1.5mg-2500unit- 2mg-60mg, 5000unit- 50mcg-400unit-400mcg- 125mg-18mg-150mcg- 5mg-30mg, 22.5mg-27mg- 160mg-100mg-15mg- 45unit-400unit-2mg- 400unit-1.7mg-6mcg- 5000unit-30mg-2.6mg- 1.2mg-20mg-0.4mg-2mg- 9mcg-0.4mg-20.6mg- 60mg, 16.6mcg-16.66mg- 90mg, 30unit-1.5mg-75mg- 16.6mcg-66unit-5mg- 18mg-10mg-5000unit- 8333unit-33.3unit- 20mg-1.7mg-6mcg- 16.66mcg-8.33mg- 400unit-400mcg-2mg- 133.33mcg-8.3mg-166mg, 60mg, 70mcg-30unit- 1mg-1.5mg-15mg-5.5unit- 15mg-1.5mg-20mg-1.7mg- 0.15mg-1mg-5mg-10mg- 10mg-6mcg-2000unit- 10mg-10000unit-30mg- 800mcg-300mcg-10mg- 5mg-3mcg-400unit-1.7mg- 80mg, 5000unit-450mg- 100mg, 30unit-450mg- 15mg-27mg-30unit-1.5mg- 15mg-27mg-2500unit- 1.7mg-10mg-6mcg-20mg- 2500unit-20mg-1.7mg- 0.4mg-2mg-60mg-400unit, 10mg-6mcg-1.5mg- 10unit-150mcg-125mg- 400mcg-2mg-60mg- 1mg-5mg-400unit- 400unit, 1mg-1.5mg- 5000unit-20mg-1.7mg- 5.5unit-0.15mg-1mg-5mg- 3mcg-1.5mg-100mcg-1mg- 15mg-15mg-10mg- 50mg, 30unit-15mg-1.5mg- 10000unit-100mg-10mg- 450mg-27mg-10mg- 7.5mcg-400unit-2mg- 5000unit-20mg-1.7mg- 150mg, 50mcg-10mg- 6mcg-400unit-400mcg- 60mg-100unit-125mg- 2mg-60mg, 3mg-30mg- 33mg-25mg-5000unit- 23.9mg-30unit-70mg- 50mg-25mg-25mg-200unit- 25mg-10mg-20mg-100mg- 1mg-300mcg-25mg- 10mg-12mcg-400mcg- 500mg, 50mcg-10mg- 45mcg-5mg-500mg, 80mg-125mg-200unit- 5000unit-450mg-15mg- 33mg-25mg-5000unit- 27mg-30unit-400unit- 50mg-25mg-25mg-25mg- 1.5mg-1.7mg-10mg-6mcg- 1mg-100unit-300mcg- 20mg-400mcg-2mg-60mg, 500mg, 1400unit-0.67mg- 25mcg-50mcg-200mg- 5unit-140unit-41.7mg- 10.5mg-25mcg-500mcg- 3.3mg-66.7mg-11.7mg- 50mcg-500mcg-2.4mg- 100mg-33.3mg-3.3mg- Updated August 1, 2018

170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 50mcg-0.33mg-3.3mg, 100mg-20mg-25mg- 10000unit-150mcg-1.5mg- 50mcg-1000mcg-200mcg- 2mg-1mg-65mg-12mg- 25mg-500mg, 10000unit- 15unit-100mg-10mg-20mg- 57mg-0.15mg-125mg-5mg- 5mcg-10mg-0.4mg-5mg- 2mg-2mg-40mg-15mg- 120mg-400unit, 30unit- 100unit-400unit-25mg- 0.1mg-5mg-3mg-22.5mg- 10mg-25mg-15mcg-10mg- 50mg-20mg-27mg- 400mcg-25mcg-10mg- 5000unit-100mg-20mg- 250mg, 20mcg-5250unit- 25mg-50mcg-0.8mg- 120mcg-2mg-2mg-15mg- 0.15mg-25mg-500mg, 1.5mg-450mg-27mg-10mg- 5000unit-5mcg-10mg- 20mg-25mcg-1.7mg-6mcg- 150mcg-19mg-3.75mg- 400unit-400mcg-30unit- 5mcg-1mg-10mg-4.5mg- 30mcg-2mg-60mg, 2.5mg-1mg-1mcg-400unit- 10000unit-0.125mg- 1mg-20mg-2mg-50mg, 150mcg-0.161mg-15mg- 7mg-5mg-30unit-200mg- 2mg-1.25mg-100mg-24mg- 60mg-15mg-50mg-1.5mg- 30unit-400unit-100mg- 5mg-2500unit-10mg-1mg- 10mg-20mg-6mcg-10mg- 1.7mg-6mcg-1000unit- 0.4mg-5mg-250mg, 1mg- 400mcg-300mcg-2mg, 150mcg-125unit-125mcg- 5mcg-5mcg-1mg-15.8mg- 35mg-35mg-10mg-25mg- 11.6mg-4.5mg-150mcg- 125mcg-35mg-400mcg- 3.75mg-10mg-1mg- 35mg-3.4mg-5mg-70mcg- 5000unit-20mg-2.5mg- 400unit-1.25mg-75mcg- 1mcg-400unit-2mg-1mg- 35mg-500mg, 20mcg- 50mg, 5mg-200mcg- 120mcg-2mg-2mg-30unit- 30unit-200mg-60mg-15mg- 15mg-50mg-5mg-450mg- 50mg-1.5mg-5mg- 15mg-5mg-10mg-25mcg- 2500unit-10mg-1mg- 1.7mg-2500unit-5mcg- 1.7mg-6mcg-1000unit- 500unit-400mcg-30mcg- 400mcg-300mcg-2mg, 2mg-60mg, 20mcg- 1mg-5mg-45mg-150mcg- 120mcg-2mg-2mg-30unit- 60mg-15mg-2mg-16mg- 450mg-50mg-15mg-18mg- 1.5mg-5000unit-1.7mg- 5mg-2500unit-10mg- 10mg-6mcg-400unit-20mg- 25mcg-1.7mg-6mcg- 400mcg-30unit-2mg-60mg, 800unit-1.5mg-0.4mg- 25mcg-5mg-2mg-5mg- 30mcg-2mg-60mg, 75mcg-150mg-30unit- 6.25mcg-72.5mg-50mg- 150mg-2mg-22.5mg- 30unit-100mg-2.5mg- 100mg-30mg-5mg-10mg- 0.5mg-7.5mg-0.75mg- 18mg-5000unit-10mg- 2500unit-250mcg-10mg- 10mg-400unit, 12.5mcg- 0.85mg-500unit-50mg- 2.5mg-1mg-2.5mg- 100mcg-1500mcg-60mg, 37.5mcg-75mg-15unit- 120mcg-2mg-2500unit- 2500unit-1mg-11.25mg- 2mg-30unit-20mcg-50mg- 50mg-15mg-2.5mg-10mg- 15mg-1.5mg-450mg-18mg- 9mg-10mg-10mg-200unit- 5mg-25mcg-1.7mg-6mcg- 300mcg, 200mcg-5mg- 400unit-10mg-400mcg- 50mcg-66mg-2.5mg- 30mcg-2mg-60mg, 20mcg- 50unit-400unit-20mg- 2mg-120mcg-2mg-30unit- 50mg-20mg-5000unit- 15mg-50mg-1.5mg-450mg- Updated August 1, 2018

171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 18mg-5mg-2500unit-10mg- 800unit-400mcg-300mcg- 25mcg-1.7mg-6mcg- 3mg-120mg, 70mcg- 800unit-400mcg-30mcg- 200mcg-2mg-2mg-30unit- 2mg-60mg, 20mcg- 50mg-15mg-1.9mg-200mg- 120mcg-2mg-2mg-30unit- 18mg-12.5mg-2500unit- 15mg-50mg-1.5mg-450mg- 25mg-80mcg-2.1mg- 18mg-5mg-2500unit-10mg- 7.5mcg-400unit-400mcg- 25mcg-1.7mg-6mcg- 2.5mg-10mg-60mg, 1000unit-400mcg-30mcg- 110mcg-120mcg-2mg- 2mg-60mg, 20mcg- 210mg-22.5unit-2mg- 120mcg-2mg-2mg-30unit- 15mg-120mg-1.2mg- 50mg-15mg-1.5mg-450mg- 300mcg-5mg-3500unit- 18mg-5mg-2500unit-10mg- 16mg-20mcg-1.7mg- 25mcg-1.7mg-6mcg- 18mcg-700unit-400mcg- 1000unit-400mcg-30mcg- 30mcg-3mg-60mg, 2mg-60mg, 70mcg-2mg- 110mcg-120mcg-2mg- 150mcg-2mg-30unit- 22.5unit-2mg-15mg- 2500unit-15mg-50mg- 120mg-1.2mg-300mcg- 1.9mg-300mg-18mg- 210mg-5mg-3500unit- 12.5mg-25mg-80mcg- 16mg-20mcg-1.7mg- 2.1mg-7.5mcg-400unit- 18mcg-700unit-400mcg- 400mcg-2.5mg-60mg, 30mcg-3mg-60mg, 20mcg-120mcg-2mg-2mg- 120mcg-20mcg-22.5unit- 22.5unit-15mg-50mg- 2mg-2mg-150mcg-15mg- 1.5mg-500mg-18mg-5mg- 1.5mg-500mg-18mg-10mg- 2500unit-10mg-25mcg- 2500unit-20mg-25mcg- 1.7mg-6mcg-1000unit- 1.7mg-6mcg-1000unit- 400mcg-30mcg-2mg- 400mcg-300mcg-2mg- 60mg, 20mcg-120mcg- 60mg, 20mcg-120mcg- 2mg-2mg-22.5unit-15mg- 2mg-150mcg-500mg- 50mg-1.5mg-500mg-18mg- 22.5unit-2mg-15mg-1.5mg- 5mg-2500unit-25mcg- 18mg-10mg-2500unit- 1.7mg-6mcg-1000unit- 20mg-25mcg-1.7mg-6mcg- 10mg-400mcg-30mcg- 1000unit-400mcg-300mcg- 2mg-60mg, 20mcg- 2mg-60mg, 20mcg- 120mcg-2mg-2mg- 120mcg-2mg-22.5unit- 22.5unit-15mg-50mg- 150mcg-20mg-2mg-15mg- 1.6mg-500mg-18mg-5mg- 1.5mg-500mg-18mg-10mg- 2500unit-10mg-25mcg- 2500unit-25mcg-1.7mg- 1.7mg-6mcg-1000unit- 6mcg-1000unit-400mcg- 400mcg-30mcg-2mg- 300mcg-2mg-60mg, 60mg, 20mcg-120mcg- 20mcg-120mcg-2mg-2mg- 2mg-2mg-22.5unit-500mg- 22.5unit-150mcg-15mg- 15mg-50mg-1.5mg-18mg- 1.5mg-500mg-18mg-10mg- 5mg-2500unit-10mg- 2500unit-20mg-25mcg- 25mcg-1.7mg-6mcg- 1.7mg-6mcg-1000unit- 1000unit-400mcg-30mcg- 400mcg-300mcg-2mg- 2mg-60mg, 20mcg- 60mg, 20mcg-120mcg- 120mcg-2mg-2mg-30unit- 2mg-2mg-22.5unit- 300mg-50mg-15mg-2.3mg- 150mcg-500mg-15mg- 18mg-10mg-2500unit- 1.5mg-18mg-10mg- 30mg-25mcg-2.6mg-9mcg- 2500unit-20mg-25mcg- Updated August 1, 2018

172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1.7mg-6mcg-1000unit- 210mg-16mg-3500unit- 400mcg-300mcg-2mg- 18mg-20mcg-1.7mg- 60mg, 10mg-70mcg- 18mcg-700unit-400mcg- 20mcg-120mcg-2mg- 75mcg-3mg-60mg, 18mcg- 33unit-100mg-2mg-15mg- 20mcg-2mg-105mcg- 120mg-1.1mg-240mg-5mg- 99mg-2mg-120mcg-45unit- 3000unit-14mg-1.7mg- 400unit-15mg-120mg- 18mcg-400unit-400mcg- 1.2mg-0.6mg-210mg- 30mcg-3mg-75mg, 32mg- 3500unit-1.7mg-5mg-3mg- 70mcg-200mcg-2mg-2mg- 16mg-400mcg-30mcg- 30unit-300mg-50mg- 90mg, 105mcg-120mcg- 2500unit-15mg-1.9mg- 2mg-45unit-100mg-120mg- 18mg-12.5mg-25mg- 2mg-15mg-1.2mg-0.6mg- 80mcg-2.125mg-7.5mcg- 210mg-5mg-3500unit- 400unit-400mcg-2.5mg- 16mg-20mcg-1.7mg- 60mg, 32mg-70mcg- 18mcg-400mcg-30mcg- 200mcg-2mg-30unit- 3mg-90mg-400unit, 300mg-2500unit-2mg- 105mcg-120mcg-2mg- 15mg-50mg-1.9mg-18mg- 45unit-210mg-99mg-2mg- 12.5mg-25mg-80mcg- 15mg-120mg-1.2mg- 2.125mg-7.5mcg-400unit- 600mcg-5mg-3500unit- 400mcg-2.5mg-60mg, 16mg-20mcg-1.7mg- 32mg-70mcg-80mcg- 18mcg-400mcg-30mcg- 200mcg-2mg-2mg-30unit- 3mg-90mg-400unit, 2500unit-15mg-50mg- 105mcg-120mcg-2mg- 1.9mg-300mg-18mg- 45unit-99mg-210mg- 12.5mg-25mg-2.125mg- 120mg-2mg-15mg-1.2mg- 7.5mcg-400unit-400mcg- 600mcg-5mg-3500unit- 2.5mg-60mg, 50mg-30mg- 16mg-20mcg-1.7mg- 150mcg-1.35mg-75mg- 18mcg-400unit-400mcg- 30unit-100mg-1.1mg- 30mcg-3mg-90mg, 100mg-15mg-10mg-6.5mg- 105mcg-2mg-45unit-99mg- 5mg-10mg-5000unit- 120mcg-2mg-15mg- 12mcg-400unit-5mg-20mg- 120mg-1.2mg-600mcg- 400mcg-2mg-150mg, 210mg-5mg-3500unit- 110mcg-120mcg-2mg- 16mg-20mcg-1.7mg- 210mg-140mg-22.5unit- 18mcg-400unit-400mcg- 2mg-15mg-1.35mg- 30mcg-3mg-90mg, 300mcg-16mg-3500unit- 110mcg-120mcg-2mg- 18mg-20mcg-1.7mg- 2mg-22.5unit-15mg- 18mcg-700unit-400mcg- 140mg-1.35mg-300mcg- 75mcg-3mg-60mg, 210mg-16mcg-3500unit- 110mcg-120mcg-2mg- 18mg-20mcg-1.7mg- 22.5unit-2mg-15mg- 18mcg-700unit-400mcg- 140mg-1.35mg-300mcg- 75mcg-3mg-60mg, 180mg- 210mg-16mg-3500unit- 20mcg-120mcg-2mg- 18mg-20mcg-1.7mg- 30unit-300mg-2mg-15mg- 18mcg-700unit-400mcg- 50mg-2.4mg-18mg-5mg- 75mcg-3mg-60mg, 2500unit-10mg-25mcg- 110mcg-120mcg-2mg- 2.7mg-9.5mcg-800unit- 2mg-22.5unit-15mg- 400mcg-30mcg-3.2mg- 140mg-1.35mg-300mcg- 60mg, 105mcg-120mcg- Updated August 1, 2018

173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2mg-45unit-100mg-2mg- 8.3mg-1.7mcg-1.7mg- 15mg-120mg-1.2mg- 2.5mg-66.7mcg-8.3mcg- 600mcg-210mg-5mg- 83mg-83mg, 110mcg- 1500unit-18mg-20mcg- 120mcg-2mg-22.5unit- 1.7mg-18mcg-400unit- 100mg-2mg-15mg-120mg- 400mcg-30mcg-3mg- 1.2mg-300mcg-210mg- 90mg, 105mcg-120mcg- 5mg-3500unit-16mg- 2mg-45unit-100mg-2mg- 20mcg-1.7mg-18mcg- 15mg-120mg-1.2mg- 700unit-400mcg-30mcg- 600mcg-210mg-5mg- 3mg-60mg, 110mcg- 3500unit-16mg-20mcg- 120mcg-2mg-22.5unit- 1.7mg-18mcg-400unit- 210mg-100mg-2mg-15mg- 400mcg-30mcg-3mg- 120mg-1.2mg-300mcg- 90mg, 105mcg-20mcg- 5mg-3500unit-16mg- 120mcg-2mg-45unit- 20mcg-1.7mg-18mcg- 100mg-2mg-15mg-120mg- 700unit-400mcg-30mcg- 1.2mg-600mcg-210mg- 3mg-60mg, 20mcg- 5mg-3500unit-16mg- 120mcg-150mcg-75mcg- 1.7mg-18mcg-400unit- 10mcg-2mg-250mcg-2mg- 400mcg-30mcg-3mg- 15mg-100mg-5mg-100mg- 90mg, 10mcg-15mcg-5mg- 10mg-20mg-100mg-5mg- 2mg-15mg-30unit-150mcg- 3500unit-30mcg-400mcg- 15mcg-10mg-40mg- 30unit-30mcg-5mg-100mg, 100mg-3mg-27mg-10mg- 70mcg-2500unit-50unit- 30mg-3.4mg-5500unit- 4mg-75mcg-150mcg- 9mcg-400unit-400mcg- 162mg-2mg-120mcg- 15mcg-3mg-120mg, 20mg-15mg-100mg-1.5mg- 10mcg-5mg-2mg-15mg- 80mcg-1.7mg-10mg- 30unit-150mcg-15mcg- 18mcg-1000unit-400mcg- 10mg-40mg-15mcg- 30mcg-4mg-180mg, 100mg-3mg-27mg-10mg- 70mcg-2500unit-60unit- 30mg-3.4mg-5500unit- 4mg-75mcg-150mcg- 9mcg-400unit-400mcg- 200mg-2mg-120mcg- 15mcg-3mg-120mg, 100mg-20mg-15mg-1.5mg- 200mcg-70mcg-5mg- 80mcg-1.7mg-10mg- 150mcg-75mcg-50unit- 25mcg-1000unit-400mcg- 2mg-15mg-150mg-3mg- 30mcg-6mg-180mg, 8mg- 100mg-20mg-5000unit- 30unit-10mcg-150mcg- 25mg-10mcg-3.4mg- 40mg-15mg-2mg-15mcg- 30mcg-500unit-500mcg- 8mg-15mcg-2mg-60mg- 666mcg-4mg-100mg, 9mg-10mg-5000unit-20mg- 10mcg-20mcg-120mcg- 1.7mg-6mcg-400unit- 2mg-10mcg-5mcg-2mg- 1.5mg-400mcg-30mcg- 109mg-30unit-150mcg- 2mg-90mg, 105mcg- 75mcg-150mcg-2mg- 2500unit-60unit-4mg- 300mcg-10mg-18mg- 75mcg-150mcg-162mg- 3500unit-250mcg-10mg- 2mg-120mcg-100mg- 10mg-25mcg-400unit, 20mg-15mg-1.5mg-80mcg- 833unit-41.7mg-1.7mg- 1.7mg-10mg-25mcg- 83mcg-250mcg-28.3mg- 1000unit-400mcg-30mcg- 5unit-33unit-5mg-5mg- 6mg-180mg, 5000unit- 16.7mg-16.7mg-2.5mg- 10mcg-31mg-150mcg- Updated August 1, 2018

174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 40mg-15mg-2mg-15mcg- 2500unit-10mg-25mcg- 10mg-15mcg-5mg-100mg- 2.7mg-9.5mcg-600unit- 27mg-30unit-400unit-3mg- 400mcg-30mcg-3.2mg- 3.4mg-10mg-9mcg-20mg- 120mg-60mg, 50mg- 400mcg-30mcg-3mg- 20mcg-120mcg-2mg-2mg- 90mg, 10mcg-10mcg- 22.5unit-15mg-50mg- 2.5mg-2mg-15mg-100mg- 2.4mg-300mg-18mg-5mg- 30unit-150mcg-40mg- 2500unit-10mg-25mcg- 130mg-10mcg-100mg- 2.7mg-9.5mcg-800unit- 1.5mg-10mg-5000unit- 400mcg-30mcg-3.2mg- 20mg-1.7mg-6mcg- 120mg-60mg, 7.5mg- 400mcg-30mcg-2mg- 10mcg-150mcg-41mg- 60mg-400unit, 27mcg- 15mg-2mg-15mcg-7.5mg- 180mcg-4.2mg-30unit- 15mcg-5mg-100mg-27mg- 150mcg-90mcg-2.2mg- 30unit-400unit-5500unit- 24mg-50mg-4.5mg-500mg- 30mg-3.4mg-10mg-9mcg- 10mg-3500unit-20mg- 3mg-0.4mg-15mcg-3mg- 20mcg-3.4mg-25mcg- 120mg, 105mcg-200mcg- 1000unit-400mcg-30mcg- 2mg-154mg-45unit-75mcg- 6mg-120mg, 27mcg- 99mg-200mg-2500unit- 180mcg-4.2mg-30unit- 2mg-22.5mg-100mg- 150mcg-90mcg-50mg- 2.2mg-15mg-25mg-25mcg- 2.2mg-24mg-4.5mg- 2.5mg-9mcg-400unit- 500mg-15mg-3500unit- 400mcg-450mcg-3mg- 20mg-20mcg-3.4mg- 90mg, 120mg-20mcg- 25mcg-1000unit-400mcg- 100mcg-33unit-150mcg- 30mcg-6mg-120mg, 90mcg-4mg-2mg-22.5mg- 70mcg-120mcg-4mg-2mg- 50mg-4.5mg-405mg-15mg- 50unit-150mcg-75mcg- 2500unit-20mg-20mcg- 100mg-15mg-1.5mg- 3.4mg-25mcg-800unit- 162mg-18mg-10mg- 400mcg-30mcg-6mg-60mg, 2500unit-20mg-80mcg- 120mg-20mcg-180mcg- 1.7mg-6mcg-1000unit- 4mg-2mg-33unit-150mcg- 400mcg-30mg-2mg- 90mcg-22.5mg-50mg- 180mg, 10mcg-15mcg- 4.5mg-405mg-15mg- 5mg-31mg-30unit-150mcg- 2500unit-20mg-20mcg- 15mcg-7.5mg-40mg-2mg- 3.4mg-25mcg-800unit- 15mg-100mg-3mg-18mg- 400mcg-30mcg-6mg-60mg, 10mg-5500unit-30mg- 120mg-20mcg-2500unit- 3.4mg-9mcg-400unit- 4mg-180mcg-2mg-33unit- 400mcg-15mcg-3mg- 150mcg-90mcg-22.5mg- 120mg, 50mg-20mcg- 50mg-4.5mg-405mg-15mg- 120mcg-2mg-22.5unit- 20mg-20mcg-3.4mg- 300mg-50mg-2mg-15mg- 25mcg-800unit-400mcg- 2.4mg-18mg-5mg- 30mcg-6mg-60mg, 120mg- 2500unit-10mg-25mcg- 20mcg-4mg-180mcg-2mg- 2.7mg-9.5mcg-800unit- 33unit-150mcg-90mcg- 400mcg-30mcg-3.2mg- 50mg-22.5mg-4.5mg- 120mg-60mg, 50mg- 405mg-15mg-2500unit- 20mcg-120mcg-2mg-2mg- 20mg-20mcg-3.4mg- 22.5unit-15mg-50mg- 25mcg-800unit-400mcg- 2.4mg-300mg-18mg-5mg- 30mcg-6mg-60mg, 120mg- Updated August 1, 2018

175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 20mcg-2500unit-180mcg- 40mg-15mg-2mg-15mcg- 33unit-150mcg-90mcg- 7.5mg-15mcg-5mg-100mg- 4mg-2mg-22.5mg-50mg- 27mg-30unit-400unit- 4.5mg-405mg-15mcg- 3.4mg-10mg-9mcg-3mg- 20mg-20mcg-3.4mg- 20mg-0.04mg-30mcg-3mg- 25mcg-800unit-400mcg- 90mg, 117mcg-180mcg- 30mcg-6mg-60mg, 4.2mg-2.2mg-30unit- 833.33unit-0.03mg- 150mcg-90mcg-24mg- 8.33mg-1mg-0.33mg- 110mg-4.5mg-370mcg- 0.33mg-11.33mg-3.33mg- 120mg-15mg-3500unit- 4.67unit-66.67unit-10mg- 20mg-20mcg-3.4mg- 43.55mg-0.67mg-2.5mg- 25mcg-700unit-400mcg- 1.67mg-3.33mg-0.03mg- 30mcg-6mg-120mg, 2mg- 1.33mg-33.33mg, 10mg- 72mg-20mcg-150mcg- 0.5mg-10mg-17.5mcg- 5mcg-48mg-75mcg- 75mcg-120mg-1mg-30unit- 200mg-10mcg-150mcg- 60mg-35mg-7.5mg-9mg- 150mcg-80mg-2mg- 10mg-100mg-10mg-10mg- 100mg-300mcg-10mg- 5000unit-10mcg-10mg- 20mg-10mcg-1.7mg- 400mcg-30mcg-10mg- 25mcg-400unit-1.5mg- 200mg-400unit, 100mcg- 400mcg-30mcg-3mg, 50mcg-25mcg-2.5mg- 34mg-105mcg-180mcg- 7.5mg-75mcg-50mg- 4mg-2mg-33unit-150mcg- 30unit-100mg-50mg- 90mcg-40mg-22.5mg- 1.5mg-100mg-10mg- 100mg-4.5mg-120mg- 250mcg-20mg-1.7mg- 15mg-2500unit-20mg- 2500unit-5mcg-200unit- 20mcg-3.4mg-25mcg- 200mcg-75mcg-2.5mg- 400unit-400mcg-30mcg- 60mg, 120mg-20mcg- 6mg-120mg, 117mcg- 180mcg-4mg-2mg- 180mcg-4.2mg-2.2mg- 22.5unit-150mcg-90mcg- 150mcg-90mcg-110mg- 500mg-22.5mg-50mg- 24mg-4.5mg-370mcg- 4.5mg-15mg-2500unit- 120mg-15mg-3500unit- 20mg-20mcg-3.4mg- 20mg-20mcg-3.4mg- 25mcg-1000unit-400mcg- 25mcg-700unit-400mcg- 30mcg-6mg-60mg, 120mg- 25.5unit-30mcg-6mg- 27mcg-4.2mg-180mcg- 120mg, 117mcg-180mcg- 30unit-150mcg-90mcg- 4.2mg-2.2mg-25.5unit- 500mg-50mg-2.2mg-24mg- 150mcg-90mcg-110mg- 4.5mg-15mg-3500unit- 24mg-4.5mg-370mcg- 20mg-20mcg-3.4mg- 120mg-15mg-3500unit- 25mcg-1000unit-400mcg- 20mg-20mcg-3.4mg- 30mcg-6mg-120mg, 25mcg-700unit-400mcg- 7.5mg-10mcg-15mcg-5mg- 30mcg-6mg-120mg, 31mg-30unit-150mcg- 117mcg-180mcg-4.2mg- 15mcg-44mg-7.5mg-2mg- 2.2mg-25.5unit-150mcg- 15mg-100mg-18mg-10mg- 90mcg-24mg-110mg- 5500unit-30mg-3.4mg- 4.5mg-370mcg-120mg- 9mcg-400unit-3mg- 15mg-3500unit-20mg- 400mcg-15mcg-3mg- 20mcg-3.4mg-25mcg- 120mg, 7.5mg-5000unit- 700unit-400mcg-30mcg- 10mcg-31mcg-150mcg- 6mg-120mg, 117mcg- Updated August 1, 2018

176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 180mcg-4.2mg-25.5unit- 6mcg-1.5mg-20mg- 150mcg-90mcg-110mg- 400mcg-30mcg-2mg-60mg, 2.2mg-24mg-4.5mg- 35mcg-1mg-1mg-60mcg- 370mcg-120mg-15mg- 7mg-25unit-75mcg- 3500unit-20mg-20mcg- 37.5mcg-100mg-50mg- 3.4mg-25mcg-700unit- 500unit-11.5mg-0.75mg- 400mcg-30mcg-6mg- 150mcg-1mg-5mg-5mg- 120mg, 117mcg-180mcg- 10mg-15mcg-0.85mg- 4.2mg-25.5unit-150mcg- 3mcg-200unit-200mcg- 90mcg-120mg-110mg- 15mcg-1mg-75mg, 7.5mg- 2.2mg-24mg-4.5mg- 10mcg-31mg-150mcg- 370mcg-15mg-3500unit- 40mg-15mg-2mg-15mcg- 20mg-20mcg-3.4mg- 7.5mg-15mcg-5mg-100mg- 25mcg-700unit-400mcg- 27mg-1250unit-30unit- 30mcg-6mg-120mg, 5mg- 400unit-5000unit-30mg- 0.5mg-250mcg-1.5mg- 3.4mg-10mg-9mcg-3mg- 50mg-750mcg-50mg- 0.4mg-35mcg-3mg-90mg, 15unit-100mg-60mg- 7.5mg-10mcg-31mg- 7.5mg-5mg-0.75mg- 150mcg-40mg-15mg-2mg- 6.75mg-2500unit-5mg- 15mcg-7.5mg-15mcg-5mg- 10mg-0.85mg-100unit- 100mg-27mg-2500unit- 50mg-25mg-100mcg- 30unit-400unit-2500unit- 1500mcg-100mg, 20mg-3.4mg-10mg-9mcg- 3333.3unit-0.66mg-25mg- 3mg-0.4mg-30mcg-3mg- 115mg-5mg-0.033mg- 90mg, 7.5mg-21mcg- 15mg-10mg-0.33mg- 26mcg-3.5mg-2mg-31mg- 25mcg-26.6mg-20unit- 30unit-150mcg-32mcg- 133.3unit-16.6mg-5mg- 7.5mg-15mg-100mg-3mg- 5mg-5mcg-15mg-10mg- 40mg-18mg-10mg- 0.025mg-5mcg-5mg-10mg- 5000unit-20mg-28mcg- 66.6mg, 34mg-105mcg- 3.4mg-9mcg-400unit- 180mcg-4mg-60unit- 400mcg-30mcg-3mg-90mg, 150mcg-90mcg-37.5mg- 7.5mg-5mg-10mcg-2mg- 100mg-2mg-22.5mg- 31mg-30unit-150mcg- 4.5mg-120mg-15mg- 15mg-40mg-15mcg-7.5mg- 5000unit-20mg-20mcg- 15mcg-1250unit-100mg- 3.4mg-30mcg-400unit- 3mg-27mg-5000unit-30mg- 400mcg-30mcg-6mg- 3.4mg-10mg-9mcg-0.4mg- 120mg, 120mg-110mcg- 35mcg-3mg-90mg-400unit, 180mcg-4mg-2mg- 32mcg-72mg-18mcg- 22.5unit-150mcg-90mcg- 1.8mg-0.5mg-20mg-35unit- 120mg-22.5mg-100mg- 150mcg-50mcg-80mg- 4.5mg-300mg-15mg- 200mg-8mg-100mg-1.1mg- 2500unit-20mg-20mcg- 18mg-15mg-3500unit- 3.4mg-25mcg-700unit- 14mg-50mcg-1.1mg-6mcg- 400mcg-30mcg-6mg- 800unit-400mcg-40mcg- 60mg, 34mg-10mcg- 2mg-75mg, 120mg- 100mg-150mcg-130mg- 105mcg-180mcg-4mg- 15mg-2mg-10mcg-37.5mg- 2mg-33unit-150mcg- 10mcg-2.5mg-100mg- 90mcg-40mg-100mg- 18mg-30unit-400unit- 22.5mg-4.5mg-600mcg- 5000unit-1.7mg-10mg- 120mg-15mg-2500unit- Updated August 1, 2018

177 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 20mg-20mcg-3.4mg- 10mcg-2mg-60unit- 25mcg-400unit-400mcg- 250mcg-2mg-15mg- 30mcg-6mg-120mg, 100mg-10mg-100mg- 120mg-105mcg-180mcg- 18mg-10mg-25mg-100mg- 4mg-2mg-33unit-150mcg- 100mcg-10mg-3000unit- 90mcg-40mg-22.5mg- 25mcg-2000unit-400mcg- 100mg-4.5mg-600mcg- 30mcg-6mg-100mg, 30mg- 120mg-15mg-2500unit- 2mg-72mg-10mcg-20mcg- 20mg-20mcg-3.4mg- 120mcg-10mcg-5mcg-2mg- 25mcg-400unit-400mcg- 109mg-30unit-150mcg- 30mcg-6mg-120mg, 0.75mcg-150mcg-80mg- 120mg-105mcg-2500unit- 2mg-300mcg-10mg-18mg- 180mcg-33unit-150mcg- 3500unit-250mcg-10mg- 90mcg-40mg-4mg-2mg- 10mg-25mcg-400unit- 22.5mg-100mg-4.5mg- 400mcg, 150mcg-120mcg- 600mcg-120mg-15mg- 70mcg-2mg-2mg-30unit- 20mg-20mcg-3.4mg- 150mcg-75mcg-15mg- 25mcg-400unit-400mcg- 50mg-4.5mg-700mcg- 30mcg-6mg-120mg, 500mg-18mg-15mg- 120mg-105mcg-4mg- 3500unit-100mcg-20mg- 180mcg-2mg-33unit- 60mcg-5.1mg-18mcg- 150mcg-90mcg-40mg- 1000unit-400mcg-300mcg- 22.5mg-100mg-4.5mg- 6mg-60mg, 16.7unit- 600mcg-120mg-15mg- 16.7mcg-12.5mcg-4.16mg- 2500unit-20mg-20mcg- 0.08mg-16.7mcg-7.9mg- 3.4mg-25mcg-400unit- 1.67mg-41.7mg-2.5mg- 400mcg-30mcg-6mg- 16.7unit-4.16mg-4.16mg- 120mg, 45mg-25mg-40mg- 52.08mg-4.16mg- 1mg-37.5mcg-100mcg- 2083.3unit-10.4mcg- 25mcg-35mcg-1mg- 4.16mg-33.3mcg-4.16mg- 75mcg-1mg-15unit-200mg- 250mg, 25mcg-300mcg- 7.5mg-0.75mg-125mg- 25mcg-25mcg-27mg-5mg- 5mg-10mg-0.85mg- 2mg-125mg-34unit- 2500unit-3mcg-200unit- 150mcg-162mg-30mg- 1mg-200mcg-150mcg- 5000unit-15mg-100mg- 30mg, 50mcg-1.75mg- 2.25mg-27mg-10mg-20mg- 5mg-0.5mg-1.5mg-25mcg- 25mcg-2.6mg-9mcg- 32mg-12.5mcg-200mg- 400unit-400mcg-45mcg- 0.75mg-3.75mg-75mg- 3mg-90mg, 25mg-120mcg- 1.25mg-11.25mcg-5mg- 25mg-70mcg-80mcg- 5mg-12.5mg-75mcg-5mg- 5000unit-2mg-50unit- 12.5mcg-200unit-5mg- 150mcg-75mcg-150mcg- 200mcg-6.25mg-30mg, 2mg-15mg-100mg-225mg- 15mg-25mg-1.5mg-50mg- 9mg-275mcg-20mg-1.7mg- 5mg-64mg-7.5unit-25mg- 10mg-12mcg-400unit- 1mg-3.75mg-5mg-130mg- 1.5mg-400mcg-30mcg- 4mg-5mg-7.5mg-12.5mg- 2mg-120mg, 60mcg-72mg- 15mg-5mg-2.5mg- 21mcg-4mg-0.5mg-20mg- 2500unit-4mcg-500unit- 60unit-150mcg-50mcg- 2.5mg-100mcg-2500mcg- 80mg-210mg-15mg-75mg- 2.5mg-30mg, 100mcg- 1.5mg-600mcg-10mg- 70mcg-150mcg-75mcg- 3500unit-300mcg-20mg- Updated August 1, 2018

178 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 60mcg-1.7mg-100mcg- 2.5mg-1.5mcg-100unit- 600unit-300mcg-30mcg- 0.5mg-100mcg-7.5mcg- 6mg-120mg, 35mg-2mg- 128mg, 32mcg-2mg-72mg- 72mg-10mcg-55mcg- 10mcg-18mcg-1.8mg- 75mcg-2.3mg-10mcg- 10mcg-5mcg-0.5mg-20mg- 5mcg-0.5mg-20mg-30unit- 35unit-150mcg-50mcg- 150mcg-45mcg-200mg- 80mg-100mg-8mg-1.1mg- 80mg-11mg-50mg-1.5mg- 200mg-18mg-15mg- 18mg-10mg-3500unit- 3500unit-14mg-50mcg- 20mg-25mcg-1.7mg- 1.1mg-6mcg-800unit- 400unit-30mcg-2mg-60mg, 400mcg-40mcg-2mg-75mg, 5000unit-5000unit-450mg- 72mg-10mcg-5000unit- 450mg-15mg-15mg-27mg- 20mcg-46mg-150mcg- 27mg-30unit-30unit- 200mg-15mg-10mcg-2mg- 400unit-400unit-1.7mg- 130mcg-150mcg-2mg- 1.7mg-10mg-10mg-6mcg- 60mg-5mcg-160mcg- 6mcg-20mg-20mg-1.5mg- 3.5mg-100mg-4mg-45unit- 1.5mg-400mcg-400mcg- 400unit-15mg-1.7mg- 2mg-2mg-60mg-60mg, 10mg-25mcg-3mg-20mg- 72mg-10mcg-6000unit- 400mcg-30mcg-60mg, 5mcg-25mcg-48mg- 72mg-10mcg-5000unit- 150mcg-200mg-15mg- 20mcg-48mg-150mcg- 10mcg-2mg-100mcg- 200mg-15mg-10mcg-2mg- 10mcg-80mg-25mcg- 130mcg-150mcg-2mg- 2.5mg-100mg-9mg-45unit- 80mg-5mcg-160mg-3.5mg- 400unit-1.5mg-20mg- 100mg-4mg-45unit- 1.7mg-10mg-25mcg- 400unit-20mg-1.7mg- 200mcg-30mcg-3mg- 10mg-25mcg-3mg-1.5mg- 60mg, 50mg-162mg- 400mcg-30mcg-60mg, 0.25mg-25000unit-15mg- 12.667mg-1mg-30mg- 24.3mg-0.1mg-53.5mg- 5unit-66.667mg-0.667mg- 50mg-6.15mg-2.2mg- 2.5mg-16.667mg- 7.2mg-12.5unit-400unit- 16.667mg-3.333mg-5mg- 25mg-5mg-15mg-12.5mg- 8.333mg-10mg-3.333mg- 50mg-250mg-150mg- 0.667mg-1666.667unit- 25mg-50mcg-25mg-0.4mg- 2.667mcg-333.333unit- 1mcg-15mg-150mg, 5mg- 1.667mg-66.667mcg-1mg- 90mg-10mcg-45mcg- 1.667mg-20mg, 2mg- 3500unit-2mg-10mcg- 72mg-10mcg-20mcg- 5mcg-30unit-150mcg- 150mcg-2mg-5mcg-48mg- 25mcg-2mg-100mcg- 45unit-150mcg-75mcg- 99mg-40mg-150mcg- 80mg-150mcg-2mg-15mg- 15mg-3mg-250mg-9mg- 100mg-1.5mg-200mg- 10mg-40mg-25mcg-3.4mg- 10mg-3500unit-250mcg- 12mcg-400unit-400mcg- 20mg-10mcg-1.7mg- 300mcg-4mg-60mg, 25mcg-400unit-400mcg- 10mcg-0.5mg-35mg- 30mcg-3mg-60mg, 52mcg- 107.5unit-37.5mcg-30mcg- 2mg-72mg-10mcg-50mcg- 18.75mcg-0.9mg-21.15mg- 22mcg-2.3mg-5mcg- 25mg-0.38mg-0.075mg- 0.5mg-20mg-150mcg- 83.25mg-0.83mg-2.5mg- 80mg-100mg-35unit-15mg- 1.67mg-2.5mg-6.25mcg- 1.1mg-300mg-8mg-5mg- Updated August 1, 2018

179 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3500unit-300mcg-14mg- 30unit-150mcg-25mcg- 50mcg-1.1mg-50mcg- 162mg-10mcg-40mg- 800unit-400mcg-30mcg- 400unit-2mg-15mg-100mg- 5mg-100mg, 72mg-10mcg- 1.5mg-18mg-10mg-20mg- 20mcg-150mcg-2mg- 25mcg-1.7mg-6mcg- 5mcg-48mg-45unit- 400mcg-30mcg-2mg-60mg, 150mcg-75mcg-80mg- 50mcg-2mg-10mcg-7.5mg- 200mg-150mcg-100mg- 70mcg-2mg-10mcg-5mcg- 2mg-2mg-15mg-1.5mg- 2mg-31mg-60unit-150mcg- 10mg-5000unit-250mcg- 75mcg-40mg-150mcg- 20mg-10mcg-1.7mg- 7.5mg-15mg-100mg-3mg- 25mcg-400unit-400mcg- 9mg-10mg-5000unit-20mg- 30mcg-3mg-60mg, 72mg- 28mcg-3.4mg-12mcg- 10mcg-5000unit-45unit- 400unit-400mcg-30mcg- 20mcg-48mg-150mcg- 6mg-90mg, 7.5mg-10mcg- 200mg-15mg-10mcg-2mg- 70mcg-50mcg-2mg-10mcg- 130mcg-150mcg-2mg- 5mcg-2mg-31mg-60unit- 80mg-5mcg-160mcg- 150mcg-75mcg-40mg- 3.5mg-100mg-4mg- 2mg-7.5mg-100mg- 400unit-1.5mg-20mg- 150mcg-15mg-3mg-9mg- 1.7mg-10mg-25mcg- 10mg-5000unit-20mg- 400mcg-30mcg-3mg- 28mcg-3.4mg-12mcg- 60mg, 72mg-2.5mg-5mcg- 400unit-400mcg-30mcg- 20mcg-48mg-45unit- 6mg-90mg, 7.5mg-10mcg- 150mcg-2mg-200mg- 70mcg-50mcg-2mg-10mcg- 10mcg-130mcg-150mcg- 5mcg-2mg-31mg-60unit- 80mg-160mcg-4mg-2mg- 150mcg-75mcg-40mg- 15mg-100mg-1.5mg- 2mg-7.5mg-150mcg-15mg- 5000unit-20mg-10mcg- 100mg-3mg-9mg-10mg- 1.7mg-10mg-25mcg- 5000unit-20mg-28mcg- 400mcg-30mcg-3mg- 3.4mg-12mcg-400unit- 60mg-400unit, 2mg-7.5mg- 400mcg-30mcg-6mg-90mg, 10mcg-70mcg-50mcg- 72mg-10mcg-20mcg- 2mg-10mcg-5mcg-31mg- 65mcg-3.5mg-10mcg-2mg- 60unit-150mcg-75mcg- 109mg-30unit-150mcg- 7.5mg-40mg-150mcg-2mg- 160mcg-2mg-80mg- 15mg-100mg-9mg-10mg- 100mg-150mcg-15mg- 5000unit-20mg-28mcg- 1.5mg-162mg-18mg-10mg- 3.4mg-12mcg-400unit- 2500unit-20mg-25mcg- 3mg-400mcg-30mcg-6mg- 1.7mg-6mcg-400unit- 90mg, 2mg-7.5mg-10mcg- 400mcg-30mcg-2mg-60mg, 70mcg-50mcg-2mg- 34mg-25mcg-6000unit- 10mcg-5mcg-40mg-31mg- 10mcg-15mcg-125mg- 60unit-150mcg-75mcg- 150mcg-162mg-15mg- 7.5mg-150mcg-2mg-15mg- 10mcg-2mg-15mcg-80mcg- 100mg-9mg-10mg- 37.5mg-5mcg-15mcg- 5000unit-20mg-28mcg- 2.5mg-100mg-18mg- 3.4mg-12mcg-400unit- 30unit-400unit-1.7mg- 3mg-400mcg-30mcg-6mg- 10mg-6mcg-1.5mg-20mg- 90mg, 36.3mg-10mcg- 400mcg-45mcg-2mg-60mg, 25mcg-5000unit-25mcg- 50mcg-2mg-72mg-10mcg- 2.5mg-10mcg-5mg-125mg- 19mcg-2.3mg-5mcg- Updated August 1, 2018

180 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 0.5mg-20mg-50unit- 10mg-25mg-15mg-25mg- 150mcg-45mcg-80mg- 200mcg-1mcg-100mg, 50mg-20mg-11mg-1.5mg- 35mcg-2mg-72mg-10mcg- 300mcg-220mg-10mg- 55mcg-2.3mg-10mcg- 2500unit-250mcg-30mcg- 5mcg-0.5mg-20mg-30unit- 1.7mg-25mcg-500unit- 150mcg-45mcg-200mg- 400mcg-30mcg-3mg- 75mcg-80mg-11mg-50mg- 60mg, 50mcg-2mg-72mg- 1.5mg-18mg-10mg- 19mcg-2.3mg-5mcg- 3500unit-20mg-25mcg- 0.5mg-20mg-50unit- 1.7mg-6mcg-400unit- 150mg-45mcg-80mg- 400mcg-30mcg-2mg-60mg, 10mcg-11mg-50mg-1.5mg- 35mcg-2mg-72mg-10mcg- 300mcg-220mg-10mg- 55mcg-2.3mg-10mcg- 2500unit-250mcg-20mg- 5mcg-0.5mg-20mg-30unit- 30mcg-1.7mg-25mcg- 150mcg-45mcg-200mg- 1000unit-400mcg-30mcg- 75mcg-80mg-50mg-11mg- 3mg-60mg, 21mcg-28mcg- 1.5mg-18mg-10mg- 5000unit-26mcg-3.5mg- 3500unit-20mg-25mcg- 2mg-31mg-30unit-150mcg- 1.7mg-6mcg-400unit- 32mcg-7.5mg-40mg- 400mcg-30mcg-2mg-60mg, 10mcg-150mcg-10mcg- 35mcg-2mg-72mg-10mcg- 2mg-7.5mg-5mcg-15mg- 55mcg-2.3mg-10mcg- 100mg-18mg-10mg-20mg- 5mcg-0.5mg-20mg-30unit- 3.4mg-9mcg-400unit-3mg- 150mcg-45mcg-200mg- 400mcg-30mcg-3mg- 80mg-50mg-75mcg-11mg- 90mg, 7.5mg-28mcg- 1.5mg-18mg-10mg- 5000unit-21mcg-31mg- 3500unit-20mg-25mcg- 150mcg-40mg-15mg- 1.7mg-6mcg-400unit- 10mcg-2mg-26mcg- 400mcg-30mcg-2mg-60mg, 150mcg-10mcg-2mg- 35mcg-2mg-72mg-10mcg- 7.5mg-5mcg-32mcg- 55mcg-2.3mg-10mcg- 3.5mg-100mg-18mg- 5mcg-0.5mg-20mg-30unit- 30unit-400unit-3.4mg- 150mcg-45mcg-80mg- 10mg-9mcg-3mg-20mg- 200mg-50mg-75mcg- 3mg-400mcg-30mcg- 11mg-1.5mg-18mg-10mg- 90mg, 7.5mg-28mcg- 3500unit-20mg-25mcg- 5000unit-21mcg-31mg- 1.7mg-6mcg-400unit- 150mcg-40mg-15mg- 400mcg-30mcg-2mg-60mg, 10mcg-2mg-26mcg- 35mcg-2mg-72mg-10mcg- 150mcg-10mcg-2mg- 55mcg-2.3mg-10mcg- 7.5mg-5mcg-32mcg- 5mcg-0.5mg-20mg-30unit- 3.5mg-100mg-18mg- 150mcg-45mcg-80mg- 30unit-400unit-3.4mg- 200mg-75mcg-11mg- 10mg-9mcg-3mg-20mg- 50mg-1.5mg-18mg-10mg- 400mcg-30mcg-3mg- 3500unit-20mg-25mcg- 90mg, 10mg-25mcg- 1.7mg-6mcg-400unit- 25mcg-4000unit-15mg- 400mcg-30mcg-2mg-60mg, 50mg-5mcg-50unit-100mg- 35mcg-2mg-72mg-10mcg- 15mg-0.25mg-1mg-10mg- 55mcg-2.3mg-10mcg- 5mg-15mg-1000unit-10mg- 5mcg-0.9mg-20mg-30unit- 100unit-10mg-10mcg-5mg- 150mcg-45mcg-200mg- 15mg-10mg-25mg-10mg- 75mcg-80mg-11mg-50mg- Updated August 1, 2018

181 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1.5mg-18mg-10mg- 30unit-150mcg-45mcg- 3500unit-20mg-25mcg- 80mg-200mg-2mg-50mg- 1.7mg-6mcg-400unit- 75mcg-11mg-1.5mg-18mg- 400mcg-30mcg-2mg- 10mg-3500unit-20mg- 60mg, 35mcg-2mg-72mg- 25mcg-1.7mg-6mcg- 10mcg-55mcg-75mcg- 400unit-400mcg-30mcg- 2.3mg-10mcg-5mcg- 2mg-60mg, 45mcg-2mg- 0.5mg-20mg-30unit- 10mcg-55mcg-2.3mg- 150mcg-45mcg-200mg- 5mcg-0.5mg-20mg-50unit- 80mg-11mg-50mg-1.5mg- 150mcg-45mcg-80mg- 18mg-10mg-3500unit- 220mg-150mcg-11mg- 20mg-25mcg-1.7mg-6mcg- 50mg-1.5mg-300mcg- 400unit-400mcg-30mcg- 10mg-2500unit-250mcg- 2mg-60mg, 35mcg-2mg- 20mg-30mcg-1.7mg- 72mg-10mcg-55mcg- 25mcg-500unit-400mcg- 75mcg-2.3mg-10mcg- 30mcg-3mg-60mg, 45mcg- 5mcg-0.5mg-20mg-30unit- 72mg-10mcg-55mcg- 150mcg-45mcg-80mg- 2.3mg-5mcg-0.9mg-50unit- 200mg-11mg-50mg-1.5mg- 45mcg-150mcg-220mg- 18mg-10mg-3500unit- 80mg-2mg-150mcg-11mg- 20mg-25mcg-1.7mg-6mcg- 50mg-1.5mg-300mcg- 400unit-400mcg-30mcg- 10mg-2500unit-250mcg- 2mg-60mg, 35mcg-2mg- 20mg-30mcg-1.7mg- 72mg-10mcg-55mcg- 25mcg-500unit-500mcg- 75mcg-2.3mg-10mcg- 30mcg-3mg-90mg, 5mcg-0.5mg-20mg-30unit- 200mcg-12mg-72mg- 150mcg-45mcg-80mg- 1.5mg-2.3mg-35mcg- 200mg-50mg-11mg-1.5mg- 110mg-50unit-150mcg- 18mg-10mg-3500unit- 2mg-80mg-220mg-10mcg- 20mg-25mcg-1.7mg-6mcg- 150mcg-5mcg-45mcg- 400unit-400mcg-30mcg- 50mg-1.5mg-10mg- 2mg-60mg, 35mcg-72mg- 2500unit-250mcg-20mg- 10mcg-55mcg-2.3mg- 30mcg-1.7mg-30mcg- 10mcg-5mcg-0.5mg-20mg- 600unit-500mcg-300mcg- 30unit-150mcg-45mcg- 3mg-90mg, 25mcg-72mg- 200mg-2mg-80mg-75mcg- 10mcg-55mcg-1.8mg- 11mg-50mg-1.5mg-18mg- 10mcg-5mcg-0.9mg-20mg- 10mg-3500unit-20mg- 35unit-150mcg-50mcg- 25mcg-1.7mg-6mcg- 80mg-500mg-2mg-100mg- 400unit-400mcg-30mcg- 150mcg-8mg-1.1mg-18mg- 2mg-60mg, 35mcg-72mg- 15mg-3500unit-14mg- 10mcg-55mcg-2.3mg- 50mcg-1.1mg-6mcg- 10mcg-5mcg-0.5mg-20mg- 800unit-400mcg-40mcg- 30unit-150mcg-45mcg- 2mg-75mg, 2mg-72mg- 200mg-80mg-2mg-75mcg- 10mcg-55mcg-25mcg- 11mg-50mg-1.5mg-18mg- 1.8mg-10mcg-5mcg-20mg- 10mg-3500unit-20mg- 150mcg-50mcg-80mg- 25mcg-1.7mg-6mcg- 150mcg-100mg-35unit- 400unit-400mcg-30mcg- 0.9mg-8mg-1.1mg-500mg- 2mg-60mg, 35mcg-72mg- 18mg-15mg-3500unit- 10mcg-55mcg-2.3mg- 14mg-50mcg-1.1mg-6mcg- 10mcg-5mcg-0.5mg-20mg- 800unit-400mcg-40mcg- Updated August 1, 2018

182 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2mg-75mg, 50mcg-2mg- 80mg-162mg-150mcg- 72mg-10mcg-50mcg- 15mg-100mg-1.5mg-18mg- 55mcg-150mcg-2.3mg- 10mg-2500unit-20mg- 5mcg-0.5mg-20mg-150mg- 25mcg-1.7mg-6mcg- 80mg-500mg-50mg-35unit- 400unit-400mcg-30mcg- 15mg-1.1mg-8mg-5mg- 2mg-60mg, 2mg-72mg- 3500unit-300mcg-14mg- 10mcg-20mcg-65mcg- 50mcg-1.1mg-50mcg- 3.5mg-5mcg-2mg-109mg- 800unit-400mcg-30mcg- 15mg-30unit-150mcg- 5mg-100mg, 600mcg- 160mcg-162mg-10mcg- 12mg-72mg-10mcg- 80mg-150mcg-100mg- 35mcg-1.5mg-2.3mg- 1.5mg-18mg-2500unit- 5mcg-110mg-50unit- 20mg-25mcg-1.7mg-10mg- 150mcg-45mcg-2mg- 6mcg-400unit-400mcg- 80mg-220mg-150mcg- 30mcg-2mg-60mg, 50mcg- 50mg-1.5mg-10mg- 2mg-72mg-10mcg-55mcg- 2500unit-250mcg-20mg- 2.3mg-5mcg-0.5mg-20mg- 30mcg-1.7mg-30mcg- 35unit-150mcg-50mcg- 600unit-500mcg-300mcg- 500mg-150mcg-80mg- 3mg-90mg, 72mg-25mcg- 15mg-50mg-1.1mg-8mg- 5000unit-20mcg-109mg- 5mg-3500unit-300mcg- 150mcg-162mg-15mg- 14mg-50mcg-1.1mg- 10mcg-2mg-65mcg- 50mcg-800unit-400mcg- 150mcg-10mcg-2mg- 30mcg-5mg-100mg, 80mg-5mcg-160mg-3.5mg- 50mcg-2mg-72mg-10mcg- 100mg-18mg-30unit- 55mcg-2.3mg-5mcg- 400unit-20mg-1.7mg- 0.5mg-20mg-35unit- 10mg-6mcg-2mg-1.5mg- 150mcg-50mcg-500mg- 400mcg-30mcg-60mg, 80mg-50mg-150mcg- 150mcg-65mcg-72mg- 15mg-1.1mg-8mg-5mg- 10mcg-20mcg-3.5mg- 3500unit-300mcg-14mg- 10mcg-5mcg-2mg-125mg- 50mcg-1.1mg-50mcg- 30unit-150mcg-160mcg- 800unit-400mcg-30mcg- 162mg-15mg-80mg-2mg- 5mg-100mg, 50mcg-2mg- 20mg-100mg-1.5mg-18mg- 72mg-10mcg-55mcg- 10mg-5000unit-25mcg- 2.3mg-5mcg-0.5mg-20mg- 1.7mg-6mcg-400unit- 35unit-150mcg-50mcg- 400mcg-30mcg-2mg- 80mg-500mg-50mg- 90mg, 150mcg-72mg- 150mcg-15mg-1.1mg-8mg- 10mcg-20mcg-65mcg- 5mg-3500unit-300mcg- 3.5mg-10mcg-5mcg- 14mg-50mcg-1.1mg- 109mg-30unit-150mcg- 50mcg-800unit-400mcg- 160mcg-80mg-162mg- 30mcg-5mg-100mg, 2mg-2mg-15mg-100mg- 50mcg-2mg-72mg-10mcg- 1.5mg-18mg-10mg- 55mcg-3500unit-2.3mg- 5000unit-20mg-25mcg- 5mcg-0.5mg-20mg-8mg- 1.7mg-6mcg-400unit- 150mcg-50mcg-500mg- 400mcg-30mcg-2mg- 80mg-150mcg-15mg- 60mg, 2mg-72mg-10mcg- 50mg-1.1mg-5mg-300mcg- 20mcg-3.5mg-65mcg- 14mg-50mcg-1.1mg- 10mcg-5mcg-2mg-109mg- 50mcg-800unit-400mcg- 30unit-150mcg-160mcg- 35unit-30mcg-5mg-100mg, Updated August 1, 2018

183 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 50mcg-72mg-10mcg- 100mg-1.5mg-300mcg- 55mcg-2.3mg-5mcg- 200mg-10mg-3500unit- 0.5mg-20mg-35unit- 250mcg-20mg-1.7mg- 150mcg-50mcg-80mg- 25mcg-400unit-400mcg- 500mg-2mg-50mg- 30mcg-3mg-60mg, 2mg- 150mcg-15mg-1.1mg-8mg- 72mg-10mcg-20mcg- 5mg-3500unit-300mcg- 150mcg-2mg-5mcg-48mg- 14mg-50mcg-1.1mg- 45unit-150mcg-75mcg- 50mcg-800unit-400mcg- 200mg-80mg-150mcg- 30mcg-5mg-100mg, 72mg- 2mg-15mg-100mg-1.5mg- 10mcg-20mcg-2mg- 300mcg-10mg-3500unit- 10mcg-5mcg-109mg- 250mcg-20mg-10mcg- 30unit-150mcg-75mcg- 1.7mg-25mcg-400unit- 162mg-120mg-150mcg- 400mcg-30mcg-3mg-60mg, 2mg-80mg-2mg-15mg- 2mg-72mg-10mcg-20mcg- 100mg-1.5mg-300mcg- 45unit-150mcg-2mg-5mcg- 3500unit-250mcg-20mg- 2mg-48mg-150mcg- 1.7mg-10mg-6mcg- 75mcg-80mg-200mg- 400unit-400mcg-30mcg- 150mcg-15mg-100mg- 2mg-60mg, 72mg-10mcg- 1.5mg-300mcg-10mg- 20mcg-65mcg-3.5mg- 3500unit-250mcg-20mg- 10mcg-5mcg-2mg-109mg- 10mcg-1.7mg-25mcg- 30unit-150mcg-160mcg- 400unit-400mcg-30mcg- 162mg-2mg-80mg- 3mg-60mg, 2mg-72mg- 150mcg-15mg-100mg- 10mcg-20mcg-65mcg- 1.5mg-18mg-10mg-20mg- 3.5mg-10mcg-5mcg-2mg- 25mcg-1.7mg-2500unit- 15mg-109mg-30unit- 6mcg-400unit-400mcg- 150mcg-160mcg-162mg- 30mcg-2mg-50mg, 72mg- 80mg-150mcg-100mg- 25mcg-5000unit-10mcg- 1.5mg-18mg-10mcg- 20mcg-109mg-30unit- 2500unit-20mg-25mcg- 150mcg-162mg-15mg- 1.7mg-6mcg-400unit- 10mcg-2mg-65mcg- 400mcg-30mcg-2mg-60mg, 150mcg-2mg-80mg-5mcg- 36.3mg-25mcg-10mcg- 160mcg-3.5mg-100mg- 25mcg-125mg-150mcg- 18mg-400unit-1.5mg- 162mg-15mg-10mcg-2mg- 20mg-1.7mg-10mg-6mcg- 25mcg-150mcg-10mcg- 400mcg-30mcg-2mg- 40mg-5mcg-25mcg-2.5mg- 60mg, 150mcg-50mcg- 100mg-18mg-30unit- 10mcg-72mg-55mcg- 400unit-5000unit-20mg- 35unit-2.3mg-20mg- 2mg-10mg-6mcg-1.7mg- 150mcg-50mcg-15mg- 400mcg-30mcg-3mg-60mg, 80mg-500mg-5mcg-50mg- 50mcg-2mg-72mg-10mcg- 0.5mg-15mg-1.1mg-8mg- 55mcg-2.3mg-5mcg- 3500unit-300mcg-14mg- 0.05mg-20mg-35unit- 50mcg-1.1mg-5mg-50mcg- 150mcg-50mcg-500mg- 800unit-400mcg-30mcg- 80mg-150mcg-15mg- 5mg-100mg, 2mg-72mg- 50mg-1.1mg-8mg-5mg- 10mcg-20mcg-10mcg- 3500unit-300mcg-14mg- 150mcg-2mg-5mcg-48mg- 50mcg-1.1mg-50mcg- 45unit-75mcg-150mcg- 800unit-400mcg-30mcg- 150mcg-80mg-2mg-15mg- 5mg-100mg, 72mg-10mcg- Updated August 1, 2018

184 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 20mcg-150mcg-2mg- 11mg-50mg-1.5mg- 5mcg-48mg-45unit- 300mcg-10mg-2500unit- 150mcg-75mcg-200mg- 250mcg-20mg-30mcg- 2mg-80mg-150mcg-2mg- 1.7mg-25mcg-500unit- 15mg-100mg-1.5mg- 400mcg-30mcg-3mg-60mg, 300mcg-10mg-3500unit- 2mg-7.5mg-10mcg-70mcg- 250mcg-20mg-10mcg- 120mcg-2mg-10mcg-5mcg- 1.7mg-25mcg-400unit- 31mg-60unit-150mcg- 400mcg-30mcg-3mg- 75mcg-40mg-150mcg- 60mg, 72mg-10mcg- 7.5mg-2mg-15mg-100mg- 20mcg-3500unit-150mcg- 9mg-10mg-5000unit- 2mg-5mcg-48mg-45unit- 250mcg-20mg-28mcg- 150mcg-75mcg-150mcg- 3.4mg-12mcg-400unit- 2mg-80mg-2mg-15mg- 3mg-400mcg-30mcg-6mg- 100mg-1.5mg-300mcg- 90mg, 2mg-72mg-10mcg- 200mg-10mg-250mcg- 55mcg-2.3mg-5mcg- 20mg-10mcg-1.7mg- 0.5mg-20mg-50unit- 25mcg-400unit-400mcg- 150mcg-45mcg-80mg- 30mcg-3mg-60mg, 72mg- 220mg-45mcg-50mg- 10mcg-3500unit-20mcg- 150mcg-11mg-1.5mg- 48mg-150mcg-200mg- 300mcg-10mg-2500unit- 15mg-10mcg-2mg- 250mcg-20mg-30mcg- 150mcg-150mcg-2mg- 1.7mg-25mcg-500unit- 80mg-5mcg-75mcg-2mg- 400mcg-30mcg-3mg-60mg, 100mg-45unit-400unit- 2mg-72mg-10mcg-55mcg- 300mcg-250mcg-1.7mg- 45mcg-2.3mg-5mcg- 10mg-25mcg-20mg-1.5mg- 0.5mg-20mg-150mcg- 400mcg-30mcg-3mg- 45mcg-80mg-50mg-50unit- 60mg, 72mg-20mcg- 150mcg-11mg-1.5mg- 3500unit-45unit-2mg- 300mcg-220mg-10mg- 48mg-150mcg-75mcg- 2500unit-250mcg-20mg- 80mg-200mg-10mcg-2mg- 30mcg-1.7mg-25mcg- 150mcg-150mcg-2mg- 500unit-400mcg-30mcg- 5mcg-15mg-100mg-1.5mg- 3mg-60mg, 2mg-72mg- 300mcg-10mg-250mcg- 10mcg-55mcg-45mcg- 20mg-10mcg-1.7mg- 2.3mg-5mcg-0.5mg-20mg- 25mcg-400unit-400mcg- 50unit-150mcg-45mcg- 30mcg-3mg-60mg, 80mg-50mg-150mcg- 36.3mg-25mcg-5000unit- 11mg-1.5mg-300mcg- 10mcg-5mcg-20mcg- 220mg-10mg-2500unit- 109mg-150mcg-162mg- 250mcg-20mg-30mcg- 15mg-10mcg-2mg-25mcg- 1.7mg-25mcg-500unit- 150mcg-2mcg-40mg- 400mcg-30mcg-3mg-60mg, 25mcg-2.5mg-100mg- 35mcg-2mg-72mg-10mcg- 18mg-30unit-400unit- 55mcg-75mcg-2.3mg- 1.5mg-20mg-1.7mg-10mg- 10mcg-5mcg-0.5mg-20mg- 6mcg-400mcg-30mcg- 30unit-150mcg-45mcg- 2mg-60mg, 45mg-2mg- 200mg-80mg-15mg-11mg- 72mg-10mcg-55mcg- 50mg-1.5mg-18mg-10mg- 2.3mg-5mcg-0.5mg-20mg- 3500unit-20mg-25mcg- 50unit-150mcg-45mcg- 1.7mg-6mcg-400unit- 220mg-150mcg-80mg- 400mcg-30mcg-2mg-60mg, Updated August 1, 2018

185 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 45mcg-2mg-72mg-10mcg- 11mg-1.5mg-300mcg- 55mcg-2.3mg-5mcg- 220mg-10mg-2500unit- 0.5mg-20mg-150mcg- 250mcg-20mg-30mcg- 45mcg-80mg-50mg-50unit- 1.7mg-25mcg-500unit- 150mcg-11mg-1.5mg- 400mcg-30mcg-3mg-60mg, 300mcg-220mg-10mg- 45mcg-2mg-72mg-10mcg- 2500unit-250mcg-20mg- 55mcg-2.3mg-5mcg- 30mcg-1.7mg-25mcg- 0.5mg-20mg-50unit- 500unit-400mcg-30mcg- 150mcg-45mcg-80mg- 3mg-60mg, 45mcg-2mg- 50mg-150mcg-11mg- 72mg-10mcg-55mcg- 1.5mg-300mcg-220mg- 2.3mg-5mcg-0.5mg-20mg- 10mg-250mcg-20mg- 50unit-150mcg-45mcg- 30mcg-1.7mg-2500unit- 220mg-150mcg-80mg- 25mcg-500unit-400mcg- 11mg-50mg-1.5mg- 30mcg-3mg-60mg, 45mcg- 300mcg-10mg-2500unit- 72mg-10mcg-55mcg- 250mcg-20mg-30mcg- 2.3mg-5mcg-0.5mg-20mg- 1.7mg-25mcg-500unit- 50unit-150mcg-45mcg- 400mcg-30mcg-3mg- 80mg-220mg-2mg- 60mg, 45mcg-2mg-72mg- 150mcg-11mg-50mg- 10mcg-55mcg-2.3mg- 1.5mg-300mcg-10mg- 5mcg-0.5mg-20mg-50unit- 2500unit-250mcg-20mg- 150mcg-45mcg-220mg- 30mcg-1.7mg-25mcg- 80mg-150mcg-11mg- 500unit-400mcg-30mcg- 50mg-1.5mg-300mcg- 3mg-60mg, 45mcg-72mg- 10mg-2500unit-250mcg- 10mcg-55mcg-2.3mg- 20mg-30mcg-1.7mg- 5mcg-0.5mg-20mg-50unit- 25mcg-500unit-400mcg- 150mcg-45mcg-80mg- 30mcg-3mg-60mg, 45mcg- 220mg-2mg-50mg- 2mg-72mg-10mcg-55mcg- 150mcg-11mg-1.5mg- 2.3mg-5mcg-0.5mg-20mg- 300mcg-10mg-2500unit- 50unit-150mcg-45mcg- 250mcg-20mg-30mcg- 80mg-220mg-150mcg- 1.7mg-25mcg-500unit- 11mg-50mg-1.5mg- 400mcg-30mcg-3mg-60mg, 300mcg-10mg-2500unit- 45mcg-72mg-10mcg- 250mcg-20mg-30mcg- 55mcg-2.3mg-5mcg- 1.7mg-25mcg-500unit- 0.5mg-20mg-50unit- 400mcg-30mcg-3mg- 45mcg-100mcg-80mg- 60mg, 45mcg-2mg-72mg- 2mg-150mcg-11mg-50mg- 10mcg-55mcg-2.3mg- 1.5mg-300mcg-220mg- 5mcg-0.5mg-20mg-50unit- 10mg-2500unit-250mcg- 150mcg-45mcg-80mg- 20mg-30mcg-1.7mg- 220mg-50mg-150mcg- 25mcg-500unit-400mcg- 11mg-1.5mg-300mcg- 30mcg-3mg-60mg, 10mg-2500unit-250mcg- 120mcg-50mg-4mg-72mg- 20mg-30mcg-1.7mg- 10mcg-70mcg-4mg-10mcg- 25mcg-500unit-400mcg- 5mcg-0.9mg-48mg-60unit- 30mcg-3mg-60mg, 45mcg- 150mcg-75mcg-80mg- 2mg-72mg-10mcg-55mcg- 100mg-40mg-60mcg- 2.3mg-5mcg-0.5mg-20mg- 11mg-4.5mg-18mg-12mg- 50unit-150mcg-45mcg- 3500unit-40mg-25mcg- 80mg-50mg-150mcg- 5.1mg-18mcg-400unit- Updated August 1, 2018

186 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 400mcg-50mcg-6mg- 150mcg-50mcg-250mg- 120mg, 120mcg-50mg- 80mg-150mcg-15mg- 72mg-10mcg-70mcg-4mg- 50mg-1.5mg-600mcg- 10mcg-5mcg-0.9mg-48mg- 10mg-3500unit-300mcg- 60unit-150mcg-75mcg- 20mg-60mcg-1.7mg- 100mg-80mg-4mg-60mcg- 100mcg-600unit-300mcg- 11mg-40mg-4.5mg-18mg- 30mcg-6mg-120mg, 12mg-3500unit-40mg- 60mcg-2mg-72mg-10mcg- 25mcg-5.1mg-18mcg- 100mcg-4mg-5mcg-0.7mg- 400unit-400mcg-50mcg- 20mg-60unit-150mcg- 6mg-120mg, 36mg-10mcg- 50mcg-80mg-250mg- 25mcg-25mcg-120mcg- 50mg-150mcg-15mg- 2mg-10mcg-5mcg-77mg- 1.5mg-600mcg-10mg- 50unit-150mcg-25mcg- 3500unit-300mcg-20mg- 100mg-2mg-40mg-100mg- 60mcg-1.7mg-100mcg- 20mg-150mcg-2mg-15mg- 600unit-300mcg-30mcg- 1.5mg-9mg-10mg- 6mg-120mg, 60mcg-72mg- 3000unit-250mcg-1.7mg- 10mcg-100mcg-4mg-5mcg- 6mcg-400unit-400mcg- 0.7mg-20mg-60unit- 30mcg-2mg-120mg, 150mcg-50mcg-80mg- 45mcg-2mg-72mg-10mcg- 250mg-2mg-50mg- 55mcg-2.3mg-5mcg- 150mcg-15mg-1.5mg- 0.9mg-110mg-50unit- 600mcg-10mg-3500unit- 150mcg-45mcg-220mg- 300mcg-20mg-60mcg- 150mcg-80mg-11mg- 1.7mg-100mcg-600unit- 50mg-1.5mg-300mcg- 300mcg-30mcg-6mg- 10mg-2500unit-250mcg- 120mg, 72mg-50unit- 20mg-30mcg-1.7mg- 55mcg-110mg-150mcg- 25mcg-500unit-500mcg- 220mg-11mg-10mcg- 30mcg-3mg-90mg, 45mcg- 0.9mg-45mcg-150mcg- 72mg-10mcg-55mcg- 2mg-80mg-5mcg-45mcg- 2.3mg-5mcg-0.9mg- 2.3mg-50mg-300mcg- 110mg-50unit-150mcg- 2500unit-250mcg-20mg- 220mg-80mg-45mcg- 30mcg-1.7mg-10mg- 50mg-2mg-150mcg-11mg- 25mcg-500unit-1.5mg- 1.5mg-300mcg-2500unit- 500mcg-30mcg-3mg-90mg, 250mcg-20mg-30mcg- 10mcg-20mcg-25mcg- 1.7mg-10mg-25mcg- 120mcg-2mg-10mcg-5mcg- 500unit-500mcg-30mcg- 72mg-2mg-108mg-30unit- 3mg-90mg, 45mcg-72mg- 75mcg-150mcg-162mg- 10mcg-55mcg-2.3mg- 150mcg-2mg-80mg-15mg- 5mcg-0.9mg-110mg- 100mg-1.5mg-18mg-10mg- 50unit-150mcg-45mcg- 5000unit-250mcg-20mg- 80mg-220mg-2mg-50mg- 1.7mg-6mcg-400unit- 150mcg-11mg-1.5mg- 400mcg-30mcg-2mg-60mg, 300mcg-10mg-2500unit- 150mcg-60mcg-10mcg- 250mcg-20mg-30mcg- 72mg-100mcg-60unit-4mg- 1.7mg-25mcg-500unit- 20mg-150mcg-50mcg- 500mcg-30mcg-3mg- 15mg-80mg-250mg-5mcg- 90mg, 60mcg-2mg-72mg- 50mg-0.7mg-15mg-1.5mg- 10mcg-100mcg-4mg- 600mcg-3500unit-300mcg- 5mcg-0.7mg-20mg-60unit- 20mg-60mcg-1.7mg-10mg- Updated August 1, 2018

187 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 100mcg-600unit-300mcg- 10mcg-100mcg-150mcg- 30mcg-6mg-120mg, 2.3mg-10mcg-5mcg- 1666.67unit-8.33mg- 0.9mg-20mg-45unit- 4.17mcg-50mg-37.5mcg- 150mcg-50mcg-210mg- 100mg-2.5mg-1.67mg- 80mg-11mg-100mg-1.2mg- 33.33mg-1mg-5unit- 600mcg-8mg-15mg- 33.33unit-8.33mg-4.17mg- 3500unit-16mg-60mcg- 8.33mg-10mg-8.33mg- 1.3mg-6mcg-600unit- 10mg-1.67mg-5mg- 200mcg-40mcg-2mg-90mg, 2.67mcg-1.67mg-25mg- 35mcg-72mg-10mcg- 66.67mcg-66.67mcg- 100mcg-2.3mg-10mcg- 1.67mg-20mg, 2mg-36mg- 5mcg-0.9mg-20mg-45unit- 250mg-25mcg-50unit-2mg- 150mcg-50mcg-80mg- 5mcg-77mg-25mcg- 210mg-2mg-100mg- 150mcg-10mcg-2mg- 150mcg-11mg-1.2mg- 120mcg-10mcg-40mg- 600mcg-8mg-15mg- 18mg-20mg-400unit- 3500unit-16mg-60mcg- 150mcg-15mg-100mg- 1.3mg-6mcg-600unit- 1.5mg-3000unit-250mcg- 200mcg-40mcg-2mg-90mg, 100mcg-1.7mg-10mg- 60mg-50mg-72mg-10mcg- 6mcg-400mcg-30mcg- 70mcg-4mg-10mcg-5mcg- 2mg-120mg, 60mcg- 48mg-60unit-150mcg- 10mcg-72mg-10mcg- 75mcg-80mg-120mcg- 100mcg-4mg-5mcg-0.7mg- 4mg-40mg-60mcg-2mg- 20mg-150mcg-50mcg- 15mg-4.5mg-100mg-18mg- 250mg-80mg-150mcg- 10mg-3500unit-40mg- 15mg-50mg-1.5mg- 25mcg-5.1mg-16mcg- 600mcg-10mg-300mcg- 400mcg-40mcg-6mg- 20mg-60mcg-1.7mg- 120mg-400unit, 25mg- 3500unit-100mcg-600unit- 50mg-50mcg-1mg- 300mcg-60unit-30mcg- 10000unit-5mg-100mcg- 6mg-120mg, 2mg-72mg- 7.5mg-18mg-75mcg-35mg- 10mcg-20mcg-65mcg- 25mg-1mg-10mg-25unit- 3.5mg-10mcg-5mcg- 400unit-150mcg-15mg- 109mg-30unit-150mcg- 5mg-6mg-25mg-25mcg- 160mcg-162mg-80mg- 50mg-100mg-250mcg- 150mcg-2mg-15mg- 150mcg-25mg-100mcg- 100mg-1.5mg-600mcg- 25mg-400mcg-30mcg- 18mg-10mg-2500unit- 25mg-150mg, 2mg-72mg- 20mg-25mcg-1.7mg-6mcg- 10mcg-55mcg-45mcg- 400mcg-30mcg-2mg- 2.3mg-5mcg-0.5mg-20mg- 60mg-400unit, 30unit- 20mg-150mcg-45mcg- 10mg-70mcg-5000unit- 80mg-50mg-50unit- 10mg-25mcg-100mcg- 150mcg-11mg-1.5mg- 100mg-30mg-25mcg-2mg- 300mcg-220mg-10mg- 200mcg-2.4mg-25mg- 2500unit-250mcg-20mg- 100mcg-6mg-100mg- 30mcg-1.7mg-25mcg- 5000unit-10mg-8mg-10mg- 500unit-400mcg-30mcg- 10mg-15mg-25mg-25mcg- 3mg-60mg, 36.3mg- 400unit-15mg-25mg- 10mcg-5000unit-25mcg- 400mcg-300mcg-25mg- 2.5mg-10mcg-5mcg- 100mg, 35mcg-2mg-72mg- 20mcg-109mg-30unit- Updated August 1, 2018

188 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 150mcg-25mcg-150mcg- 18mg-10mg-3500unit- 162mg-2mg-40mg-400unit- 250mcg-20mg-25mcg- 150mcg-2mg-15mg- 1.7mg-6mcg-400unit- 100mg-1.5mg-18mg-10mg- 400mcg-30mcg-2mg-60mg, 20mg-25mcg-1.7mg-6mcg- 2mg-72mg-10mcg-20mcg- 400mcg-30mcg-2mg- 120mcg-2mg-10mcg-5mcg- 60mg, 30unit-10mg- 109mg-30unit-150mcg- 70mcg-10000unit-10mg- 75mcg-162mg-80mg- 25mcg-52mg-100mcg- 150mcg-2mg-15mg- 100mg-30mg-25mcg-2mg- 100mg-1.5mg-300mcg- 500mcg-2.4mg-25mg- 18mg-10mg-3500unit- 100mcg-6mg-100mg- 250mcg-20mg-25mcg- 20mg-10mg-8mg-10mg- 1.7mg-6mcg-400mcg- 10mg-15mg-25mg-25mcg- 30mcg-2mg-60mg-400unit, 400unit-15mg-25mg- 2mg-72mg-10mcg-20mcg- 400mcg-300mcg-25mg- 25mcg-120mcg-2mg- 100mg, 7mg-10mcg- 10mcg-5mcg-109mg- 50mcg-25mcg-7.5mg- 30unit-75mcg-150mcg- 10mcg-5mcg-125mg- 150mcg-80mg-2mg-15mg- 30unit-50mcg-2mg- 100mg-1.5mg-300mcg- 150mcg-162mg-50mcg- 162mg-18mg-10mg- 150mcg-7.7mg-3mg-15mg- 3500unit-250mcg-20mg- 100mg-5mg-300mcg- 1.7mg-6mcg-400unit- 25mg-3500unit-275mcg- 400mcg-30mcg-2mg-60mg, 30mg-5mg-10mg-12mcg- 30unit-10mg-70mcg- 400unit-400mcg-40mcg- 5000unit-10mg-25mcg- 5mg-90mg, 400mg-16mcg- 100mcg-100mg-30mg- 1mg-29mg-5mcg-10mcg- 25mcg-2mg-200mcg- 60mcg-1mg-5mcg-2.5mcg- 2.4mg-25mg-100mcg-6mg- 0.35mg-40mg-15unit- 100mg-20mg-5000unit- 75mcg-37.5mcg-54mg- 10mg-8mg-10mg-10mg- 32mg-3.75mg-20mg- 15mg-25mg-25mcg- 0.75mg-3mg-5mg- 400unit-15mg-25mg- 1750unit-10mg-12.5mcg- 400mcg-300mcg-25mg- 0.85mg-100mcg-200unit- 100mg, 72mg-10mcg- 200mcg-15mcg-2.5mg- 20mcg-25mcg-2mg-10mcg- 30mg, 25mg-1mg-12.5mg- 5mcg-109mg-75mcg- 1mg-75mcg-50mcg-1mg- 150mcg-162mg-120mcg- 50mcg-1mg-25mcg-2.5mg- 2mg-80mg-100mg-30unit- 13.5mg-12.5mg-7.5mg- 150mcg-2mg-15mg-1.5mg- 100mg-40mg-250mg-5mg- 300mcg-18mg-10mg- 40mg-250mcg-40mg- 3500unit-250mcg-20mg- 10mcg-5mg-37.5mcg- 1.7mg-6mcg-400mcg- 40mg-5000unit-40mcg- 30mcg-2mg-60mg-400unit, 200unit-200mcg-50unit- 16.666mg-1mg-3.333mg- 40mcg-40mg-100mg, 2mg- 42.666mg-5unit-86.666mg- 10mcg-20mcg-120mcg- 0.666mg-2.5mg-16.666mg- 2mg-10mcg-5mcg-2mg- 3.333mg-3.333mg-5mg- 109mg-30unit-150mcg- 8.333mg-10mg-3.333mg- 75mcg-72mg-162mg- 1.666mg-1666.666unit- 150mcg-80mg-15mg- 2.666mcg-333.333unit- 100mg-1.5mg-300mcg- 1.666mg-66.666mcg- Updated August 1, 2018

189 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1666.666mcg-1.666mg- 30mcg-2mg-90mg, 35mcg- 20mg, 2mg-72mg-10mcg- 2mg-72mg-10mcg-55mcg- 55mcg-200mg-35mcg- 2.3mg-10mcg-5mcg- 2.3mg-10mcg-5mcg- 0.9mg-109mg-30unit- 0.9mg-109mg-30unit- 150mcg-45mcg-200mg- 150mcg-45mcg-80mg- 80mg-100mg-150mcg- 150mcg-11mg-100mg- 11mg-1.5mg-300mcg- 1.5mg-300mcg-18mg- 18mg-10mg-3500unit- 10mg-3500unit-250mcg- 250mcg-20mg-25mcg- 20mg-25mcg-1.7mg-6mcg- 1.7mg-6mcg-400unit- 400unit-500mcg-30mcg- 500mcg-30mcg-2mg-90mg, 2mg-90mg, 2mg-72mg- 35mcg-72mg-10mcg- 10mcg-55mcg-25mcg- 55mcg-2.3mg-10mcg- 35mcg-2.3mg-10mcg- 5mcg-0.9mg-109mg- 5mcg-109mg-30unit- 30unit-150mcg-45mcg- 45mcg-150mcg-150mcg- 200mg-80mg-2mg- 80mg-0.9mg-11mg-100mg- 150mcg-11mg-100mg- 1.5mg-300mcg-200mg- 1.5mg-300mcg-18mg- 18mg-10mg-3500unit- 10mg-3500unit-250mcg- 250mcg-20mg-1.7mg- 20mg-25mcg-1.7mg-6mcg- 6mcg-400unit-500mcg- 400unit-500mcg-30mcg- 30mcg-2mg-90mg, 35mcg- 2mg-90mg, 25mcg- 2mg-72mg-10mcg-55mcg- 12.5mg-2.5mg-1mg-5mcg- 150mcg-2.3mg-10mcg- 50mcg-250mg-75mcg- 5mcg-0.9mg-109mg- 2mg-50mcg-1mg-25mcg- 30unit-150mcg-45mcg- 2.5mg-13.5mcg-12.5mg- 200mg-80mg-11mg- 7.5mg-50mg-40mg-5mg- 100mg-1.5mg-300mcg- 40mg-250mcg-40mg- 18mg-10mg-3500unit- 10mcg-5mg-37.5mcg- 250mcg-20mg-25mcg- 40mg-5000unit-40mg- 1.7mg-6mcg-400unit- 200unit-200mg-50unit- 500mcg-30mcg-2mg- 40mg-40mg-100mg, 90mg, 35mcg-2mg-72mg- 66.667mcg-4.167mcg- 10mcg-55mcg-2.3mg- 66.667unit-33.333mg- 10mcg-5mcg-0.9mg- 33.333mcg-50mcg- 109mg-30unit-150mcg- 83.333mg-7.5mg- 45mcg-200mg-150mcg- 11.667mg-33.333mg- 80mg-11mg-100mg-1.5mg- 3.333mg-333.333mg- 300mcg-18mg-10mg- 33.333mg-33.333mg- 3500unit-250mcg-20mg- 16.667mg-1666.667unit- 25mcg-1.7mg-6mcg- 33.333mcg-16.667mg- 400unit-500mcg-30mcg- 266.667mcg-100mcg- 2mg-90mg, 35mcg-2mg- 16.667mg-133.333unit, 72mg-10mcg-55mcg- 35mcg-72mg-10mcg- 2.3mg-10mcg-5mcg- 55mcg-10mcg-5mcg- 0.9mg-109mg-30unit- 109mg-30unit-150mcg- 150mcg-45mcg-200mg- 45mcg-80mg-200mg- 150mcg-80mg-11mg- 0.9mg-2.3mg-100mg- 100mg-1.5mg-300mcg- 1250unit-2mg-150mcg- 18mg-3500unit-250mcg- 11mg-1.5mg-300mcg- 20mg-25mcg-1.7mg-10mg- 18mg-3500unit-250mcg- 6mcg-400unit-500mcg- 20mg-25mcg-1.7mg-10mg- Updated August 1, 2018

190 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 6mcg-400unit-500mcg- 5000unit-300mcg-25mg- 30mcg-2mg-90mg, 80mcg-2.1mg-7.5mcg- 33.333mg-33.333mcg- 400unit-400mcg-37.5mcg- 50mcg-83.333mg-7.5mg- 2.5mg-120mg, 50mg- 66.667mcg-11.667mg- 25mg-60mg-45mg-72.5mg- 4.167mcg-33.333mg- 10mcg-18mg-70mcg-4mg- 3.333mg-333.333mg-6mg- 10mcg-5mcg-48mg-60unit- 33.333mg-33.333mg- 150mcg-75mcg-100mg- 16.667mg-33.333mcg- 120mcg-150mcg-4mg- 16.667mg-266.667mcg- 80mg-2000unit-2mg-15mg- 66.667unit-100mcg- 40mg-4.5mg-3000unit- 16.667mg-1666.667unit- 250mcg-35mg-25mcg- 133.333unit, 25mg-75mg- 5.1mg-10mg-21mcg- 10mcg-18mg-70mcg- 400unit-400mcg-40mcg- 2.5mg-10mcg-5mcg-77mg- 6mg-120mg, 25mg-25mg- 45unit-150mcg-75mcg- 35mg-50mcg-12.5mg- 162mg-120mcg-150mcg- 35mg-25mcg-15mg-15mg- 2mg-80mg-2000unit-2mg- 35mg-5mcg-25mg-100mg- 15mg-100mg-1.9mg- 75mcg-5000unit-2.5mg- 3000unit-300mcg-25mg- 1mg-12.5mg-50mg-2.5mg- 25mcg-2.1mg-12.5mg- 15mg-175mcg-5mg-15mg- 7.5mcg-400unit-400mcg- 250mcg-15mg-5mg-5mg- 37.5mcg-2.5mg-120mg, 37.5mcg-15mg-15mcg- 33.333mcg-0.667mg- 100unit-5mg-200mcg- 1.667mg-3.333mg- 50unit-125mcg-15mg- 26.667mg-5mcg- 25mg-150mg, 16.67mg- 66.667unit-5mg-66.667mg- 66.67unit-2500unit- 1666.667unit-5mg- 16.67mg-33.33mg-25mcg- 16.667mg-66.667mg- 83.33mg-5mg-4.17mcg- 133.333mg-16.667mcg- 33.33mcg-0.4mg-16.5mg- 133.333unit-16.667mg- 8.33mcg-3.33mg-83.33mg- 133.333mg-16.667mg- 8.33mg-16.67mg-33.33mg- 333.333mcg-50mcg- 8.33mg-66.67mg- 16.667mg-333.333mg- 16.67mcg-16.67unit- 166.667mg, 8.333mg-1mg- 16.67mg-31.67mg- 10mg-50mg-37.5mcg- 133.33mcg-50mcg- 244.333mg-3.333mg- 16.67mg-100mg-200mg, 1.667mg-2.5mg-4.167mcg- 10mg-25mg-10mg-10mg- 33.333mg-8.333mg-1mg- 75mg-15mcg-105mcg- 4.167mg-8.333mg-5mg- 4mg-15mcg-7.5mcg-48mg- 8.333mg-10mg-25mg- 60unit-150mcg-112.5mcg- 1.667mg-1666.667unit- 200mg-180mg-225mcg- 2.667mcg-33.333unit- 10mg-2mg-80mg-3000unit- 1.667mg-66.667mcg-5unit- 2mg-22.5mg-100mg- 1000mcg-1.667mg-40mg, 1.5mg-350mcg-3000unit- 10mg-25mg-10mg-10mg- 300mcg-20mg-1.7mg- 10mg-36mg-10mcg-27mg- 15mg-30mcg-400unit- 70mcg-120mcg-2mg- 400mcg-30mcg-3mg- 10mcg-5mcg-77mg-45unit- 120mg, 12.667mg-1mg- 150mcg-75mcg-250mg- 30mg-5unit-5unit- 150mcg-40mg-2mg-15mg- 66.667mg-0.667mg-2.5mg- 100mg-1.875mg-12.5mg- 2.5mg-16.667mg- Updated August 1, 2018

191 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 4.167mcg-16.667mg- 133.33mcg-50mcg- 4.167mg-3.333mg-5mg- 16.67mg-100mg-200mg, 8.333mg-10mg-3.333mg- 1mg-5mg-25mg-10mg- 0.667mg-1666.667unit- 25mg-10mg-13mcg-72mg- 1666.667unit-2.667mcg- 200mcg-5mg-80mcg- 333.333unit-1.667mg- 5000unit-7.5mg-5mg- 1.667mg-66.667mcg-1mg- 10mg-6.5mcg-80mg- 1.667mg-20mg, 1mg- 60unit-200mcg-150mcg- 25mg-5mg-25mg-10mg- 165mg-200mcg-200mcg- 72mg-80mcg-5mg-10mg- 13mcg-2mg-80mg-3.5mg- 200mcg-130mg-60unit- 15mg-100mg-300mcg- 150mcg-165mg-15mg- 18mg-275mcg-40mg- 13mcg-3.5mg-200mcg- 5.1mg-10mg-18mcg- 200mcg-13mcg-2mg- 400unit-4.5mg-400mcg- 80mg-6.5mcg-208mcg- 60mcg-6mg-120mg, 7.5mg-100mg-18mg- 12.5mg-100mcg-25mg- 7500unit-5mg-5.1mg- 5mg-15mg-0.5mg-12.5mg- 10mg-18mcg-6mg-40mg- 20mg-5mg-36mg-6.5mcg- 4.5mg-400mcg-60mcg- 100mcg-3.75mg-100mcg- 120mg-400unit, 8.333mg- 6.5mcg-2.5mg-2.5mg- 1mg-15mg-1.667mg-50mg- 12.5mg-3.25mcg-65mg- 37.5mcg-236.667mg- 30unit-75mcg-82.5mg- 3.333mg-1.667mg-2.5mg- 1mg-40mg-1.75mg- 4.167mcg-33.333mg- 12.5mg-50mg-2.25mg- 8.333mg-1mg-4.167mg- 3750unit-37.5mcg-20mg- 8.333mg-5mg-8.333mg- 40mcg-2.55mg-5mg-9mcg- 10mg-8.333mg-0.667mg- 200unit-200mcg-150mcg- 1666.666unit-2.667mcg- 3mg-90mg, 20mg-0.5mg- 33.333unit-1.667mg- 12.5mg-100mcg-25mg- 66.667mcg-5unit-1000mcg- 15mg-12.5mg-5mg- 1.667mg-40mg, 16.67mg- 6.5mcg-100mcg-100mcg- 66.67unit-2500unit- 3.75mg-6.5mcg-2.5mg- 16.67mg-33.33mg-25mcg- 2.5mg-5mg-12.5mg- 83.33mg-5mg-4.17mcg- 3.25mcg-36mg-65mg- 0.33mg-33.33mcg-0.4mg- 30unit-75mcg-82.5mg- 16.5mg-8.33mcg-3.33mg- 1mg-40mg-1.75mg- 83.33mg-8.33mg-16.67mg- 12.5mg-50mg-2.25mg- 33.33mg-8.33mg-66.67mg- 5mg-3750unit-37.5mcg- 16.67mcg-16.67unit- 20mg-40mcg-2.55mg- 16.67mg-31.67mg- 9mcg-200unit-200mcg- 133.33mcg-50mcg- 150mcg-3mg-90mg, 1mg- 16.67mg-100mg-200mg, 25mg-5mg-25mg-1mg- 16.67mg-66.67unit- 500mcg-1mg-1mg-5mg- 2500unit-16.67mg- 2mg-90mg-13mcg- 33.33mg-25mcg-83.33mg- 200mcg-10mg-200mcg- 5mg-4.17mcg-0.33mg- 7.5mg-13mcg-2mg-5mg- 33.33mcg-0.4mg-16.5mg- 6.5mcg-130mg-60unit- 8.33mcg-3.33mg-83.33mg- 150mcg-200mcg-165mg- 3.33mg-8.33mg-16.67mg- 2mg-100mg-500mcg- 33.33mg-8.33mg-66.67mg- 3.5mg-15mg-100mg- 16.67mcg-66.67unit- 4.5mg-3.6mg-10mg- 16.67mg-31.67mg- 7500unit-500mcg-40mg- Updated August 1, 2018

192 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 80mcg-5.1mg-24mcg- 16.66mg-833.33unit- 400mcg-60mcg-6mg- 33.33mg-16.66mg-25mg- 120mg-400unit, 1mg-1mg- 1.66mg-16.66mcg-4.16mg- 25mg-1mg-0.5mg-1mg- 8.33mg-0.16mg-4.16mg- 25mg-5mg-2mg-13mcg- 8.33mg-33.33mg, 90mg-200mcg-10mg- 33.333mg-33.333mg- 80mcg-5000unit-7.5mg- 0.667mg-3.333mcg- 2mg-10mg-6.5mcg-80mg- 73.333mcg-0.667mg- 60unit-200mcg-150mcg- 1.667mcg-16mg- 165mg-200mcg-1mg- 133.333unit-50mcg-25mcg- 13mcg-2mg-100mg-0.5mg- 24mg-166.667mg- 3.5mg-15mg-100mg- 116.667mcg-50mcg- 300mcg-18mg-275mcg- 26.667mg-0.667mg-5mg- 40mg-5.1mg-10mg-24mcg- 33.333mg-16.667mg- 400unit-4.5mg-400mcg- 0.5mg-100mcg-3.333mg- 60mcg-6mg-120mg, 1666.667unit-83.333mcg- 3.333mg-66.667mcg- 6.667mg-3.333mcg- 50mg-10mg-15mg-5mg- 0.567mg-8.333mcg- 50mcg-0.667mg-100mcg- 133.333unit-166.667mcg- 25mcg-100mg-5mg-50mg- 10mcg-1mg-166.667mg, 0.667mg-5.333mg- 2mg-72mg-72mg-10mcg- 66.667mcg-22.333unit- 10mcg-20mcg-20mcg- 0.667mg-33.333mg- 120mcg-120mcg-2mg- 0.667mg-25mcg-20mg- 2mg-10mcg-10mcg-30unit- 1666.667unit-0.5mg-10mg- 30unit-75mcg-75mcg- 71.667mg-26.667mcg- 80mg-80mg-162mg- 20mg-166.667mcg- 162mg-100mg-100mg- 266.667unit-20mg-30mg- 150mcg-150mcg-15mg- 266.667mcg-200mcg- 15mg-1.5mg-1.5mg- 8.333mg-100mg, 12.5mg- 300mcg-300mcg-150mcg- 2.5mg-1mg-5mg-5mg- 150mcg-10mg-10mg- 12.5mg-0.5mg-12.5mg- 3500unit-3500unit-250mcg- 12.5mg-12.5mg-5mg- 250mcg-20mg-20mg- 36mg-6.5mcg-100mcg- 25mcg-25mcg-1.7mg- 3.75mg-100mcg-6.5mcg- 1.7mg-6mcg-6mcg-400unit- 2.5mg-2.5mg-3.25mcg- 400unit-400mcg-400mcg- 65mg-30unit-75mcg- 30mcg-30mcg-2mg-2mg- 104mcg-250mg-1mg- 60mg-60mg, 2mg-72mg- 40mg-1.75mg-7.5mg- 72mg-10mcg-10mcg- 100mg-6mg-13.5mg-15mg- 20mcg-20mcg-150mcg- 3750unit-37.5mcg-20mg- 150mcg-2mg-2mg-5mcg- 40mcg-8.5mg-9mcg- 5mcg-48mg-48mg-45unit- 200unit-200mcg-30mcg- 45unit-150mcg-150mcg- 5mg-60mg, 4.58mg- 75mcg-75mcg-80mg- 16.66unit-4.58mg-1.66mg- 80mg-200mg-200mg- 0.0125mg-25mg-16.66mg- 100mg-100mg-150mcg- 12.5mg-25mg-2.5mg- 150mcg-2mg-2mg-15mg- 0.33mg-0.16mg-12.5mg- 15mg-1.5mg-1.5mg- 0.016mg-0.83mg-41.66mg- 300mcg-300mcg-10mg- 1.66mg-16.66mg-1.66mg- 10mg-3500unit-3500unit- 66.66unit-4.16mg-4.16mg- 250mcg-250mcg-20mg- 8.33mg-4.16mg-2.5mg- 20mg-10mcg-10mcg- Updated August 1, 2018

193 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1.7mg-1.7mg-25mcg- 1.666mg-6.666mg- 25mcg-400unit-400unit- 1.666mg-6.666mg- 400mcg-400mcg-30mcg- 1.666mg-8.333mg- 30mcg-3mg-3mg-60mg- 33.333mg-3.333mg- 60mg, 45mcg-45mcg- 25mcg-10mg-50mcg- 72mg-72mg-10mcg- 83.333mg-5mg-0.333mg- 10mcg-55mcg-55mcg- 33.333mcg-0.333mg- 2.3mg-2.3mg-5mcg-5mcg- 20mg-16.666mcg- 0.9mg-0.9mg-110mg- 1.333mg-33.333mg-5mg- 110mg-50unit-50unit- 5000unit-33.333mg- 150mcg-150mcg-45mcg- 83.333unit-333.333mg- 45mcg-220mg-220mg- 1.333mg-8.333mg- 2mg-2mg-80mg-80mg- 6.666mg-8.333mg- 50mg-50mg-150mcg- 8.333mg-8.333mg- 150mcg-11mg-11mg- 8.333mg-8.333mg- 1.5mg-1.5mg-300mcg- 8.333mg-8.333mg- 300mcg-10mg-10mg- 8.333mcg-133.333unit- 2500unit-2500unit-250mcg- 8.333mg-8.333mg- 250mcg-20mg-20mg- 133.333mcg-16.666mcg- 30mcg-30mcg-1.7mg- 8.333mg-333.333mg 1.7mg-25mcg-25mcg- 500unit-500unit-500mcg- 500mcg-30mcg-30mcg- 3mg-3mg-90mg-90mg, 35mcg-35mcg-72mg- 72mg-10mcg-10mcg- 55mcg-55mcg-2.3mg- 2.3mg-10mcg-10mcg- 5mcg-5mcg-0.9mg-0.9mg- 109mg-109mg-30unit- 30unit-150mcg-150mcg- 45mcg-45mcg-80mg- 80mg-200mg-200mg-2mg- 2mg-100mg-100mg- 150mcg-150mcg-11mg- 11mg-1.5mg-1.5mg- 300mcg-300mcg-18mg- 18mg-10mg-10mg- 3500unit-3500unit-250mcg- 250mcg-20mg-20mg- 25mcg-25mcg-1.7mg- 1.7mg-6mcg-6mcg- 400unit-400unit-500mcg- 500mcg-30mcg-30mcg- 2mg-2mg-90mg-90mg, 8.333mg-3.333mg- 3.333mg-3.333mg- 33.333mg-33.333mg- 16.666mg-3.333mg- 3.333mg-3.333mg- 33.333mg-3.333mg- 11.666mg-0.833mg- Updated August 1, 2018

194 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ 15mg-15mg-180mcg- minerals tbcr 10mcg- 15mg-50mg-100mcg- 10mcg-25mg-150mcg- 50mg-15mg-10mcg- 5mg-150unit-4.6mg-25mg- 100mcg-100mcg-10mcg- 0.66mg-1.9mg-0.3mg- 50mg-10mcg-100mcg- 25mg-4mg-1.65mg-25mg- 25mg-18mg-1000unit- 75mg-75mg-10000unit- 30mg-50mg-100mg- 75mg-75mg-75mg-75mg- 100mg-100mg-100mg- 75mcg-75mg-400mcg- 100mg-100mg-100mcg- 75mcg-75mg-250mg- 100mg-400mcg-100mcg- 1000unit, 6.1mg-75mcg- 100mg-300mg 5mcg-25mcg-10mcg- MULTIVITAMIN ADULTS 4 RX/OTC 0.25mg-150unit-150mcg- TABS 10mg-10000unit-25mcg- MULTIVITAMIN MEN 4 RX/OTC 15mg-7.2mg-25mcg-50mg- TABS 25mcg-75mcg-10mg- 75mg-75mg-75mcg- MVW COMPLETE RX/OTC 75mcg-75mg-75mg- FORMULATION CAPS 400mcg-75mcg-75mg- 10MG-1.5MG-12MG- 250mg-400unit, 5mg- 20MG-800MCG-1.7MG- 4 25mg-25mcg-0.225mg- 16000UNIT-6MCG- 50mg-20mg-25mcg-25mg- 1500UNIT-200MCG- 6.1mg-20mg-25mg- 200UNIT-100MCG-1.9MG- 6000unit-25mg-100unit- 100MG 600unit-25mg-25mg- MVW COMPLETE RX/OTC FORMULATIOND3000 4 100mg-9000unit-100mg- 2 100mg-100mg-100mg- CAPS 100mg-150mcg-100mg- MVW COMPLETE RX/OTC 400mcg-100mcg-100mg- FORMULATIOND500 4 200mg, 12.5mg-25mg- CAPS 50mg-35mcg-5mg-60mcg- 18mg-37.5mcg-75mcg- MVW COMPLETE RX/OTC 35mg-1mg-5000unit-25mg- FORMULATIONMINIS 4 1mg-7.5mg-4mg-200unit- CAPS 25mg-25mg-12.5mg-6mg- NAT-RUL THERAVITE- 4 RX/OTC 20mg-15mg-25mg-50mg- M/HIGHPOTENCY TABS 50mg-125mcg-125mcg- NATRUL-100 TBCR 4 25mg-25mcg-200mcg- 50unit-150mcg-25mg- RX/OTC 125mg, 30mcg-25mg- NATRUL-MEGA-75 TABS 4 100mcg-20mg-15mg- RX/OTC 15mg-180mcg-50mg- NATRUL-VITES TABS 4 100mcg-100unit-50mg- RX/OTC 50mg-10mcg-100mcg- NICADAN TABS 4 50mcg-25000unit-100mcg- RX/OTC 15mg-25mg-30mg-18mg- NICADAN ZX TABS 4 50mg-100mg-100mg- RX/OTC 100mg-100mcg-100mg- NICAZEL FORTE TABS 4 100mg-100mg-1000unit- 100mg-100mcg-100mcg- NICAZEL TABS 4 RX/OTC 100mg-500mg, 25mg- 20mg-25000unit-100unit- Updated August 1, 2018

195 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NO IRON MULTIPLE RX/OTC ONE-A-DAY WOMENS RX/OTC VITAMIN/MINERALS 4 ACTIVE MIND & BODY 5 TABS TABS (Use Multiple Vitamins w/ Minerals) NUTRICAP TABS 4 RX/OTC ONE-A-DAY WOMENS RX/OTC OCULAR VITAMINS TABS 4 RX/OTC PETITES TABS (Use 5 Multiple Vitamins w/ Minerals) OCUVEL CAPS 5 ONE-A-DAY WOMENS RX/OTC OCUVITE ADULT 50+ 4 RX/OTC PLUS HEALTHY SKIN CAPS SUPPORT TABS (Use 5 Multiple Vitamins w/ OCUVITE ADULT 4 RX/OTC FORMULA CAPS Minerals) RX/OTC OCUVITE LUTEIN CAPS 4 RX/OTC OPTI-WOMAN TABS 4 RX/OTC OPTIVITE P.M.T. TABS RX/OTC ONCOVITE TABS 4 (Use Multiple Vitamins w/ 5 ONE DAILY MENS RX/OTC Minerals) FORMULA W/O IRON 4 OPURITY TABS 4 RX/OTC TABS PA MENS 50 PLUS ONE DAILY PLUS IRON 4 RX/OTC 4 TABS VITAPAK MISC ONE DAILY WOMENS 4 RX/OTC PA MENS VITAPAK MISC 4 TABS PA WOMENS 50 PLUS ONE-A-DAY ENERGY 4 RX/OTC 4 TABS VITAPAK MISC PA WOMENS VITAPAK ONE-A-DAY MENOPAUSE 4 RX/OTC 4 FORMULA TABS MISC PARVLEX TABS 4 RX/OTC ONE-A-DAY MENS 50+ 4 RX/OTC ADVANTAGE TABS PHYTOMULTI TABS 4 RX/OTC ONE-A-DAY MENS 4 RX/OTC HEALTH FORMULA TABS PREMIUM PACKETS 4 ONE-A-DAY MENS PRO 4 RX/OTC MISC EDGE TABS PRESCRIPTIVE ONE-A-DAY PROACTIVE RX/OTC 4 FORMULAS OPTIMAL 4 65+ TABS VITAMIN PACKS MENS ONE-A-DAY TEEN RX/OTC MISC ADVANTAGEFOR HIM 4 PRESCRIPTIVE TABS FORMULAS OPTIMAL 4 ONE-A-DAY WEIGHT RX/OTC VITAMIN PACKS WOMENS MISC SMART ADVANCED TABS 5 (Use Multiple Vitamins w/ PRESERVISION AREDS 2 4 RX/OTC Minerals) + MULTI VITAMIN CAPS ONE-A-DAY WOMENS RX/OTC 50+ ADVANTAGE TABS 5 (Use Multiple Vitamins w/ Minerals)

Updated August 1, 2018

196 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRESERVISION AREDS 2 RX/OTC RENAPLEX-D TABS 4 RX/OTC CAPS 200UNIT-1MG- 40MG-1MG-5MG-250MG, 4 REPLACE CAPS 4 RX/OTC 250MG-162.5MG-0.4MG- 87.5MG-17.4MG-0.5MG- RX/OTC 2.5MG-100UNIT-113MG REQ 49+ TABS 4 RX/OTC PRESERVISION AREDS 4 RX/OTC SAVISION CAPS 4 CAPS PRESERVISION AREDS 4 RX/OTC SENIOR VITES TBCR 4 TABS RX/OTC PRESERVISION/LUTEIN 4 RX/OTC SENTRY SENIOR TABS 4 CAPS SENTRY SENIOR/LUTEIN 4 RX/OTC PRO-CAL TABS 4 RX/OTC TABS RX/OTC PROCERV HP TABS 4 RX/OTC SENTRY TABS 4 RX/OTC PRORENAL+D TABS 4 RX/OTC SIDEROL TABS 4 SM ONE DAILY MENS RX/OTC PRORENAL+D/OMEGA-3 4 RX/OTC 4 CAPS TABS SM ONE DAILY WOMENS RX/OTC PROTECT CARDIO AF 4 RX/OTC 4 CAPS TABS RX/OTC PROTECT PLUS CAPS 4 RX/OTC SOLO TABS 4 RX/OTC STROVITE FORTE SYRP PROTECT PLUS NF LIQD 4 55MCG/15ML-5MG/15ML- 3MG/15ML-50MCG/15ML- PROTECT PLUS SO 4 RX/OTC CAPS 15MG/15ML-50MG/15ML- 10MG/15ML-17MG/15ML- PROTEGRA CAPS 4 RX/OTC 100MG/15ML-25MG/15ML- 4000UNIT/15ML- 5 PROVIT TABS 4 RX/OTC 20MCG/15ML- 400UNIT/15ML- QUENCH TABS 4 RX/OTC 15MG/15ML-1MG/15ML- 30UNIT/15ML- QUIN B STRONG TABS 4 RX/OTC 150MCG/15ML- 20MG/15ML-300MG/15ML QUINTABS-M TABS 4 RX/OTC STROVITE FORTE TABS RX/OTC 0.1MG-50MCG-60UNIT- RA CENTRAL-VITE TABS 4 RX/OTC 25MCG-1000UNIT-15MG- 3MG-50MG-20MG-10MG- RA CENTRAL-VITE 4 RX/OTC 25MG-3000UNIT-100MG- 5 UNDER 50MENS TABS 20MG-50MCG-0.8MG- RA CENTRAL-VITE RX/OTC 0.15MG-25MG-500MG UNDER 50WOMENS 4 (Use Multiple Vitamins w/ TABS Minerals) RAGUS TABS (Use RX/OTC STROVITE ONE TABS 4 RX/OTC Multiple Vitamins w/ 5 Minerals) SUPER ANTIOXIDANT 4 RX/OTC CAPS Updated August 1, 2018

197 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPERB NAILS TABS 4 RX/OTC ULTRA MEGA TWO TBCR 4

SUPPORT LIQD 4 RX/OTC ULTRA MENS PACK MISC 4

SYNAGEX CAPS 5 ULTRA WOMENS PACK 4 MISC SYNATEK CAPS 5 UNICOMPLEX-M TABS 4 RX/OTC RX/OTC T-VITES TABS 4 VITA-BOB CAPS 4 RX/OTC RX/OTC THERA M PLUS TABS 4 VITABEX CAPS 4 RX/OTC RX/OTC THERA-M TABS 4 VITALINE TOTAL 4 RX/OTC FORMULA 2 TABS RX/OTC THERA-TABS M TABS 4 VITALINE TOTAL 4 RX/OTC FORMULA 3 TABS THERABETIC MULTI- 4 RX/OTC VITAMIN TABS VITAMIN & MINERAL 4 RX/OTC SUPPLEMENT LIQD THERAGRAN-M RX/OTC ADVANCED 50 PLUS 4 VITAMIN D3 COMPLETE 4 RX/OTC TABS TABS VITAMINS TO GO THERAGRAN-M 4 RX/OTC 4 ADVANCED TABS MAXIMUM MISC VITAMINS TO GO MEN THERAGRAN-M PREMIER 4 RX/OTC 4 50 PLUS TABS MISC VITAMINS TO GO THERAGRAN-M PREMIER 4 RX/OTC 4 TABS WOMEN MISC RX/OTC VITAROCA PLUS TABS RX/OTC THERAGRAN-M TABS 4 (Use Multiple Vitamins w/ 5 Minerals) THERAMILL FORTE CAPS RX/OTC (Use Multiple Vitamins w/ 5 VITASANA TABS 4 RX/OTC Minerals) THERANATAL VITATRUM TABS 4 RX/OTC LACTATION COMPLETE 4 MISC VITRUM 50+ SENIOR 4 RX/OTC MULTI TABS THERANATAL 4 RX/OTC LACTATION ONE CAPS VP-ZEL TABS 4 RX/OTC THEREMS-H TABS 4 RX/OTC WHOLE FOOD 4 RX/OTC MULTIVITAMIN TABS RX/OTC THEREMS-M TABS 4 WOMENS 50+ MULTI RX/OTC RX/OTC VITAMIN& MINERAL 4 UDAMIN SP TABS 5 FORMULA TABS WOMENS BIOMULTIPLE RX/OTC ULTRA MEGA GOLD 4 4 TBCR TABS WOMENS MULTI VITAMIN RX/OTC ULTRA MEGA TBCR 4 & MINERAL FORMULA 4 TABS

Updated August 1, 2018

198 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WOMENS PACK MISC 4 pediatric multivitamins w/fl QL(1 ea daily); chew 0.25mg-15unit- AL; Up to 12 1.2mg-2500unit-4.5mcg- yrs old YELETS TEENAGE 4 RX/OTC FORMULA TABS 400unit-1.05mg-13.5mg- 1.05mg-0.3mg-60mg, Multivitamins 0.25mg-15unit-400unit- DEKAS ESSENTIAL LIQD 2500unit-1.2mg-4.5mcg- 70UNIT/ML-2000MCG/ML- 5 13.5mg-1.05mg-0.3mg- 2000UNIT/ML- 1.05mg-60mg, 0.5mg- 2000UNIT/ML 15unit-1.2mg-2500unit- 4.5mcg-400unit-1.05mg- FOLIKA-V TABS 5 13.5mg-1.05mg-0.3mg- 60mg, 0.5mg-15unit- INFUVITE ADULT INJ 5 400unit-2500unit-1.2mg- 4.5mcg-13.5mg-1.05mg- M.V.I. ADULT INJ 5 0.3mg-1.05mg-60mg, 0.5mg-2500unit-13.5mg- M.V.I.-12 WITHOUT 5 VITAMIN K INJ 1.2mg-4.5mcg-400unit- 1.05mg-0.3mg-15unit- MOMMYS BLISS 1.05mg-60mg, 15unit-1mg- MULTIVITAMINORGANIC 5 2500unit-13.5mg-1.2mg- 6 DROPS LIQD 4.5mcg-400unit-1.05mg- MULTIVITAMIN+ LIQD 5 0.3mg-1.05mg-60mg, 1mg- 15unit-1.2mg-2500unit- Ped MV w/ Fluoride 4.5mcg-400unit-1.05mg- 13.5mg-1.05mg-0.3mg- QL(50 ml per 6 60mg, 1mg-15unit-400unit- FLORIVA PLUS SOLN fill retail); AL; 2500unit-1.2mg-4.5mcg- Up to 12 yrs old 13.5mg-1.05mg-0.3mg- QL(1 ea daily); 1.05mg-60mg, 15unit- MULTIVITAMIN/FLUORID 6 E CHEW AL; Up to 12 0.5mg-1.05mg-13.5mg- yrs old 1.2mg-2500unit-4.5mcg- 400unit-0.3mg-1.05mg- 60mg, 15unit-0.5mg- 2500unit-13.5mg-1.2mg- 4.5mcg-400unit-1.05mg- 0.3mg-1.05mg-60mg, 15unit-0.25mg-2500unit- 13.5mg-1.2mg-4.5mcg- 400unit-1.05mg-0.3mg- 1.05mg-60mg

Updated August 1, 2018

199 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pediatric multivitamins w/fl QL(50 ml per POLY-VI-FLOR CHEW QL(6 ea per fill soln 0.25mg/ml-0.6mg/ml- fill retail); AL; 200MCG-1MG-15UNIT- retail) 8mg/ml-1500unit/ml- Up to 12 yrs old 400UNIT, 200MCG-0.5MG- 6 2mcg/ml-400unit/ml- 15UNIT-400UNIT, 0.5mg/ml-5unit/ml- 200MCG-0.25MG-15UNIT- 0.4mg/ml-35mg/ml, 400UNIT 0.25mg/ml-5unit/ml- 0.6mg/ml-8mg/ml- POLY-VI-FLOR FS STRP 5 1500unit/ml-2mcg/ml- POLY-VI-FLOR SUSP 6 400unit/ml-0.5mg/ml- 200MCG/ML-0.25MG/ML 0.4mg/ml-35mg/ml, 0.25mg/ml-5unit/ml- QL(1 ea daily); QUFLORA GUMMIES 6 8mg/ml-0.6mg/ml- CHEW AL; Up to 12 1500unit/ml-2mcg/ml- yrs old 400unit/ml-0.5mg/ml- QUFLORA PEDIATRIC QL(1 ea daily); 0.4mg/ml-35mg/ml, CHEW 108MCG-1MG- AL; Up to 12 0.5mg/ml-0.6mg/ml- 15UNIT-1MG-15MG- yrs old 8mg/ml-1500unit/ml- 1200UNIT-5MG-1.3MG- 2mcg/ml-400unit/ml- 4MCG-400UNIT-1.2MG- 0.5mg/ml-5unit/ml- 100MCG-1.5MG-60MG, 0.4mg/ml-35mg/ml, 108MCG-1MG-15UNIT- 0.5mg/ml-5unit/ml- 0.5MG-15MG-1200UNIT- 6 5MG-1.3MG-4MCG- 0.6mg/ml-8mg/ml- 6 1500unit/ml-2mcg/ml- 400UNIT-1.2MG-100MCG- 400unit/ml-0.5mg/ml- 1.5MG-60MG, 108MCG- 0.4mg/ml-35mg/ml, 1MG-15UNIT-0.25MG- 0.5mg/ml-5unit/ml-8mg/ml- 15MG-1200UNIT-5MG- 0.6mg/ml-1500unit/ml- 1.3MG-4MCG-400UNIT- 2mcg/ml-400unit/ml- 1.2MG-100MCG-1.5MG- 0.5mg/ml-0.4mg/ml- 60MG 35mg/ml, 5unit/ml- QUFLORA PEDIATRIC QL(50 ml per 0.5mg/ml-0.6mg/ml- SOLN 150MCG/ML- fill retail); AL; 8mg/ml-1500unit/ml- 1MG/ML-0.5MG/ML- Up to 12 yrs old 2mcg/ml-400unit/ml- 12MG/ML-1100UNIT/ML- 0.5mg/ml-0.4mg/ml- 2MG/ML-1MG/ML- 35mg/ml, 5unit/ml- 3MCG/ML-400UNIT/ML- 0.5mg/ml-8mg/ml- 1MG/ML-81MCG/ML- 0.6mg/ml-1500unit/ml- 12UNIT/ML-1MG/ML- 6 2mcg/ml-400unit/ml- 45MG/ML, 65MCG/ML- 0.5mg/ml-0.4mg/ml- 1MG/ML-0.25MG/ML- 35mg/ml, 5unit/ml- 10MG/ML-1000UNIT/ML- 0.25mg/ml-0.6mg/ml- 0.8MG/ML-0.6MG/ML- 8mg/ml-1500unit/ml- 2MCG/ML-400UNIT/ML- 2mcg/ml-400unit/ml- 0.5MG/ML-35MCG/ML- 0.5mg/ml-0.4mg/ml- 5UNIT/ML-0.4MG/ML- 35mg/ml 35MG/ML QL(50 ml per pediatric vitamins acd w/ 6 fill retail); AL; TRI-VI-FLOR SUSP 6 fluoride soln Up to 12 yrs old TRI-VI-FLORO SUSP 6 Ped Multi Vitamins w/Fl & FE Updated August 1, 2018

200 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESCAVITE CHEW 5 pediatric multiple vitamin w/ AL; Up to 12 minerals & c soln yrs old ; ESCAVITE D CHEW 6 0.6mg/ml-300mcg/ml- RX/OTC 7.5mg/ml-50unit/ml- 3mg/ml-6mg/ml- 6 AL; Up to 12 ESCAVITE LQ LIQD yrs old 3170unit/ml-4mcg/ml- 400unit/ml-0.5mg/ml- MYKIDZ IRON FL SUSP 6 15mcg/ml-0.6mg/ml- 45mg/ml, 50unit/ml- QL(50 ml per 5mg/ml-3mg/ml-45mg/ml- ped multivitamins w/fl & 6 fill retail); AL; iron soln 6mg/ml-400mcg/ml- 2 Up to 12 yrs old 0.6mg/ml-4627unit/ml- POLY-VI-FLOR/IRON QL(6 ea per fill 4mcg/ml-500unit/ml- CHEW 200MCG-0.5MG- 6 retail) 0.5mg/ml-15mcg/ml- 10MG-15UNIT-400UNIT 0.6mg/ml, 5mg/ml-3mg/ml- POLY-VI-FLOR/IRON 6mg/ml-400mcg/ml- SUSP 200MCG/ML- 6 0.6mg/ml-4627unit/ml- 7MG/ML-0.25MG/ML 4mcg/ml-500unit/ml- 0.5mg/ml-50unit/ml- QUFLORA FE PEDIATRIC 5 LIQD 15mcg/ml-0.6mg/ml- 45mg/ml TL-FLUORIVITE CHEW 5 Pediatric Multiple Vitamins & Minerals w/ Fluoride QL(50 ml per FLORIVA CHEW 20UNIT- TRI-VIT/FLUORIDE/IRON 6 SOLN fill retail); AL; 0.25MG-5MG-1MG- Up to 12 yrs old 2000UNIT-15MG-1.5MG- Ped Multiple Vitamins w/ Minerals 6MCG-600UNIT-1.8MG- 1.3MG-262MCG-40MCG- pediatric multiple vitamin w/ AL; Up to 12 75MG, 162MCG-20UNIT- minerals & c liqd 0.6mg/ml- yrs old ; 1MG-5MG-1MG- 5751unit/ml-3mg/ml- RX/OTC 2000UNIT-15MG-1.5MG- 5 5mg/ml-10mcg/ml- 6MCG-600UNIT-1.8MG- 15mg/ml-2mg/ml-3mg/ml- 2 1.3MG-100MCG-40MCG- 6mg/ml-400mcg/ml- 75MG, 162MCG-20UNIT- 400unit/ml-0.6mg/ml- 0.5MG-5MG-1MG- 50unit/ml-15mcg/ml- 2000UNIT-15MG-1.5MG- 0.6mg/ml-45mg/ml 6MCG-600UNIT-1.8MG- 1.3MG-100MCG-40MCG- 75MG TEXAVITE LQ LIQD 5 Pediatric Multiple Vitamins INFUVITE PEDIATRIC 5 SOLN M.V.I. PEDIATRIC SOLR 5 Prenatal Vitamins ACTIVE OB CAPS 5

Updated August 1, 2018

201 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATABEX EC TBEC 5 QL(1 ea daily); COMPLETENATE CHEW 5 AL; Up to 45 ATABEX OB TABS 5 yrs old CONCEPT DHA CAPS 5 BAL-CARE DHA MISC 5 CONCEPT OB CAPS 5 BP FOLINATAL PLUS B 4 AL; Up to 45 TABS yrs old DOTHELLE DHA CAPS 5 BP MULTINATAL PLUS AL; Up to 45 CHEW 3.5UNIT-2MG- yrs old ; DUET DHA 400 MISC 5 15MG-50MG-250MG- 4 RX/OTC 40MG-6MCG-1MG-2MG- DUET DHA BALANCED 5 50MG MISC BP MULTINATAL PLUS AL; Up to 45 4 AL; Up to 45 TABS 30UNIT-2MG-15MG- yrs old ELITE-OB TABS yrs old 100MG-3MG-200MG- 4 30MG-20MG-3.4MG- ENBRACE HR CAPS 5 12MCG-1MG-50MG-60MG EXTRA-VIRT PLUS DHA 5 C-NATE DHA CAPS 5 CAPS FOCALGIN 90 DHA MISC 5 CALCIUM PNV CAPS 5 FOCALGIN CA MISC 5 CITRANATAL 90 DHA 5 MISC FOLCAL DHA CAPS 5 CITRANATAL ASSURE 5 MISC FOLCAPS OMEGA 3 5 CAPS CITRANATAL B-CALM 4 AL; Up to 45 MISC yrs old FOLET DHA THPK 5 CITRANATAL BLOOM 5 DHA MISC FOLET ONE CAPS 5 CITRANATAL BLOOM 4 TABS FOLIVANE-OB CAPS 5 CITRANATAL DHA MISC 4 AL; Up to 45 yrs old HEMENATAL OB + DHA 5 MISC CITRANATAL HARMONY 4 AL; Up to 45 CAPS yrs old HEMENATAL OB TABS 5 CITRANATAL MEDLEY 4 QL(1 ea daily); CAPS INATAL GT TABS 4 AL; Up to 45 4 AL; Up to 45 yrs old CITRANATAL RX TABS yrs old INFANATE BALANCE 5 QL(1 ea daily); CAPS CO-NATAL FA TABS 5 AL; Up to 45 KOSHER PRENATAL 5 yrs old PLUS IRON TABS COMPLETE NATAL DHA 5 LEVOMEFOLATE DHA 5 MISC CAPS

Updated August 1, 2018

202 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); QL(1 ea daily); 4 AL; Up to 45 O-CAL FA TABS 4 AL; Up to 45 M-VIT TABS yrs old ; yrs old ; RX/OTC RX/OTC MACNATAL CN DHA 5 O-CAL PRENATAL TABS 5 CAPS OB COMPLETE 5 MARNATAL-F CAPS 5 ADVANCED CAPS MULTI PRENATAL TABS 5 OB COMPLETE GOLD 5 CAPS QL(1 ea daily); MYNATAL ADVANCE OB COMPLETE ONE 5 4 AL; Up to 45 CAPS TABS yrs old OB COMPLETE PETITE 5 MYNATAL CAPS 5 CAPS OB COMPLETE PREMIER 5 MYNATAL PLUS TABS 5 TABS QL(1 ea daily); OB COMPLETE TABS 4 AL; Up to 45 MYNATAL ULTRACAPLET 4 yrs old TABS AL; Up to 45 yrs old OB COMPLETE/DHA 5 CAPS MYNATAL-Z TABS 5 OBSTETRIX DHA MISC 5 RX/OTC MYNATE 90 PLUS TBCR 5 OBSTETRIX EC TABS 5 RX/OTC NATACHEW CHEW 5 OBSTETRIX ONE CAPS 5 NATALVIT TABS 5 OBTREX DHA MISC 5 RX/OTC NATELLE ONE CAPS 5 OBTREX TABS 5 RX/OTC NEEVO DHA CAPS 5 PNV FERROUS QL(1 ea daily); FUMARATE/DOCUSATE/F 5 AL; Up to 45 NESTABS ABC MISC 5 OLIC ACID TABS yrs old NESTABS DHA MISC 5 QL(1 ea daily); PNV FOLIC ACID + IRON 4 AL; Up to 45 MULTIVITAMIN TABS yrs old ; NESTABS ONE CAPS 5 RX/OTC NESTABS TABS 5 4 AL; Up to 45 PNV OB+DHA MISC yrs old NEWGEN TABS 5 PNV PRENATAL PLUS MULTIVITAMIN + DHA 5 NEXA PLUS CAPS 5 MISC QL(1 ea daily); QL(1 ea daily); PNV PRENATAL PLUS AL; Up to 45 AL; Up to 45 4 NIVA-PLUS TABS 4 MULTIVITAMIN TABS yrs old ; yrs old ; RX/OTC RX/OTC

Updated August 1, 2018

203 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PRENAISSANCE NEXT-B 5 PNV TABS 29-1 TABS 4 AL; Up to 45 TABS yrs old PRENAISSANCE PLUS 5 4 AL; Up to 45 CAPS PNV-DHA CAPS yrs old PRENATA CHEW 5 PNV-DHA+DOCUSATE 5 CAPS QL(1 ea daily); PRENATABS FA TABS 5 AL; Up to 45 PNV-OMEGA CAPS 5 yrs old PNV-SELECT TABS 4 AL; Up to 45 QL(1 ea daily); yrs old PRENATABS RX TABS 4 AL; Up to 45 yrs old PNV-TOTAL CAPS 5 PRENATAL + DHA THPK 5 PNV-VP-U CAPS 5 QL(1 ea daily); PR NATAL 400 EC MISC 5 PRENATAL 19 CHEW 5 AL; Up to 45 yrs old PR NATAL 400 MISC 5 QL(1 ea daily); PRENATAL 19 TABS 5 AL; Up to 45 PR NATAL 430 EC MISC 5 yrs old PRENATAL AND IRON 5 PR NATAL 430 MISC 5 TABS PRENATAL FORTE TABS 5 PRE-NATAL FORMULA 5 TABS PRENATAL LOW IRON 5 PREFERA OB TABS 5 TABS PRENATAL ONE DAILY 5 PREFERAOB +DHA MISC 5 TABS QL(1 ea daily); PREFERAOB ONE CAPS 5 PRENATAL PLUS IRON 4 AL; Up to 45 TABS yrs old PREMESISRX TABS 5 QL(1 ea daily); 4 AL; Up to 45 PRENA 1 TRUE MISC 5 PRENATAL PLUS TABS yrs old ; RX/OTC PRENA1 CHEW CHEW 5 PRENATAL TABS 11UNIT- 263MG-25MG-1.5MG- PRENA1 PEARL CPCR 5 27MG-4000UNIT-18MG- 1.7MG-4MCG-400UNIT- PRENAISSANCE 5 BALANCE CAPS 0.8MG-2.6MG-100MG, 5 160MG-11UNIT-200MG- PRENAISSANCE CAPS 5 25MG-1.84MG-27MG- 4000UNIT-18MG-1.7MG- PRENAISSANCE 5 4MCG-400UNIT-800MCG- HARMONY DHA MISC 2.6MG-100MG PRENAISSANCE NEXT 5 TABS

Updated August 1, 2018

204 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 22MG- QL(1 ea daily); PRIMACARE CAPS 5 2MG-25MG-1.84MG- AL; Up to 45 200MG-27MG-4000UNIT- 4 yrs old ; PROVIDA DHA CAPS 5 20MG-3MG-12MCG- RX/OTC 400UNIT-1MG-10MG- 120MG PROVIDA OB CAPS 5 PRENATAL TABS PUREFE OB PLUS CAPS 5 4000UNIT-200MG- 11UNIT-27MG-25MG- 5 R-NATAL OB CAPS 5 1.84MG-18MG-1.7MG- 4MCG-400UNIT-0.8MG- 2.6MG-100MG RELNATE DHA CAPS 5 RIGHT STEP PRENATAL PRENATAL VITAMIN 5 5 TABS TABS QL(1 ea daily); 4 AL; Up to 45 RULAVITE DHA CAPS yrs old PRENATAL VITAMINS 4 AL; Up to 45 PLUS LOW IRON TABS yrs old ; QL(1 ea daily); RX/OTC SE-NATAL 19 CHEW 5 AL; Up to 45 PRENATAL-U CAPS 5 yrs old QL(1 ea daily); PRENATE AM TABS 5 SE-NATAL 19 TABS 5 AL; Up to 45 yrs old PRENATE CHEW 5 SELECT-OB CHEW 5

PRENATE DHA CAPS 5 SELECT-OB+DHA MISC 5

PRENATE ELITE TABS 5 TARON-BC MISC 5 PRENATE ENHANCE 5 CAPS TARON-C DHA CAPS 5 PRENATE ESSENTIAL 5 CAPS TARON-PREX CAPS 5 PRENATE MINI CAPS 5 QL(1 ea daily); THERANATAL CORE 4 AL; Up to 45 NUTRITION TABS yrs old ; PRENATE PIXIE CAPS 5 RX/OTC PRENATE RESTORE 5 QL(1 ea daily); CAPS THRIVITE 19 TABS 5 AL; Up to 45 yrs old PRENATE STAR TABS 5 QL(1 ea daily); QL(1 ea daily); THRIVITE RX TABS 4 AL; Up to 45 yrs old 4 AL; Up to 45 PREPLUS TABS yrs old ; RX/OTC TL FOLATE TABS 5 PREQUE 10 TABS 5 TL-CARE DHA CAPS 5

QL(1 ea daily); TL-SELECT CAPS 5 PRETAB TABS 5 AL; Up to 45 yrs old Updated August 1, 2018

205 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRI-TABS DHA MISC 5 AL; Up to 45 VINATE CARE CHEW 4 yrs old ; QL(1 ea daily); RX/OTC TRIADVANCE TABS 4 AL; Up to 45 yrs old VINATE DHA RF CAPS 5 TRICARE PRENATAL 1 5 VINATE II TABS 5 CHEW TRICARE PRENATAL 5 VINATE M TABS 5 CHEW TRICARE PRENATAL 5 VINATE ONE TABS 5 COMPLEAT MISC VIRT NATE TABS 5 AL; Up to 45 TRICARE PRENATAL 5 yrs old DHA ONE CAPS QL(1 ea daily); TRICARE PRENATAL 5 VIRT-ADVANCE TABS 4 AL; Up to 45 DHA ONE/FOLATE CAPS yrs old TRICARE PRENATAL 5 THPK VIRT-C DHA CAPS 5 QL(1 ea daily); VIRT-NATE DHA CAPS 5 4 AL; Up to 45 TRICARE TABS yrs old ; 4 AL; Up to 45 RX/OTC VIRT-PN DHA CAPS yrs old QL(1 ea daily); TRINATAL GT TABS 4 AL; Up to 45 VIRT-PN PLUS CAPS 5 yrs old AL; Up to 45 VIRT-PN TABS 4 TRINATAL RX 1 TABS 5 yrs old VIRT-SELECT CAPS 5 TRINATE TABS 5 AL; Up to 45 yrs old QL(1 ea daily); TRISTART DHA CAPS 5 VIRT-VITE GT TABS 4 AL; Up to 45 yrs old TRISTART ONE CAPS 5 VIRTPREX CAPS 5

TRIVEEN-DUO DHA MISC 5 VITA-PREN TABS 5

TRIVEEN-PRX RNF CAPS 5 VITAFOL FE+ CPPK 5 ULTIMATECARE ONE 5 VITAFOL GUMMIES 5 CAPS CHEW ULTIMATECARE ONE NF 5 CAPS VITAFOL ULTRA CAPS 5 VEMAVITE-PRX 2 CAPS 5 VITAFOL-NANO TABS 5

VENA-BAL DHA MISC 5 VITAFOL-OB TABS 5 QL(1 ea daily); VIL-RX TABS 4 AL; Up to 45 VITAFOL-OB+DHA MISC 5 yrs old VITAFOL-ONE CAPS 5

Updated August 1, 2018

206 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITAMEDMD ONE 5 ALLERWELL ALLERGY 4 RX/OTC RX/QUATREFOLIC CAPS FORMULA TABS VITAMEDMD PLUS 5 BILBERRY PLUS CAPS 5 RX/OTC RX/QUATREFOLIC MISC BIOTIN PLUS KERATIN RX/OTC VITAMEDMD REDICHEW 5 4 RX CHEW TABS BRAIN MIGHT/DHA & CO 4 RX/OTC VITAPEARL CPCR 5 Q10 TABS VITATRUE MISC 5 BRAIN TABS 4 RX/OTC

VIVA DHA CAPS 5 CA-PLUS TABS 4 RX/OTC

5 AL; Up to 45 CAL-CO3Y CAPS 5 RX/OTC VOL-NATE TABS yrs old QL(1 ea daily); CARDIO TONE TABS 4 RX/OTC AL; Up to 45 VOL-PLUS TABS 4 yrs old ; CARDIOPRESS CAPS 5 RX/OTC RX/OTC QL(1 ea daily); CAROZYME CAPS 5 RX/OTC VOL-TAB RX TABS 4 AL; Up to 45 yrs old CENTRUM 4 RX/OTC PERFORMANCE TABS VP-CH PLUS CAPS 5 CENTRUM SPECIALIST 4 RX/OTC ENERGY TABS VP-CH-PNV CAPS 5 CHOLASE CONTROL 5 RX/OTC CAPS VP-GGR-B6 PRENATAL 5 TABS COLLAGEN ULTRA CAPS 5 RX/OTC VP-HEME OB + DHA 5 MISC CU-PLUS TABS 4 RX/OTC VP-HEME OB TABS 5 CVS HAIR/SKIN/NAILS 4 RX/OTC TABS VP-HEME ONE CAPS 5 ELON MATRIX 5000 4 RX/OTC TABS VP-PNV-DHA CAPS 5 ELON MATRIX PLUS 4 RX/OTC ZATEAN-CH CAPS 5 TABS ELON MATRIX 5000 4 RX/OTC 4 AL; Up to 45 COMPLETE TABS ZATEAN-PN DHA CAPS yrs old ELON MATRIX 4 RX/OTC ZATEAN-PN PLUS CAPS 5 COMPLETE TABS RX/OTC Specialty Vitamins Products ELON R3 TABS 4 ADRENAL STRESS CALM 4 RX/OTC GLUCO COR CAPS 5 RX/OTC TABS RX/OTC ADRENOID CAPS 5 RX/OTC GLYCOTROL CAPS 5 GLYCOTROL COMPLETE RX/OTC ADVANCED COLLAGEN 4 RX/OTC 5 TABS CAPS Updated August 1, 2018

207 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GREEN SOURCE TABS 4 RX/OTC MILPAN TABS 4 RX/OTC

HAIR FARE TABS 4 RX/OTC MM BIOTIN/KERATIN 5 RX/OTC CAPS HAIR NOURISHING 4 RX/OTC RX/OTC SUPPLEMENT TABS MPS CAPS 5 HEALTHY HEART 4 RX/OTC MULTI-GLAN TABS 4 RX/OTC COMPLEX TABS RX/OTC HEART SAVIOR CAPS 5 RX/OTC NEW LIFE HAIR TABS 4 RX/OTC HEART TABS 4 RX/OTC ORCHIC TABS 4 RX/OTC HM ESTROPLUS TABS 4 RX/OTC OVARY TABS 4 RX/OTC INULOSE BLOOD SUGAR 5 RX/OTC PARATHYROID TABS 4 SUPPORT CAPS RX/OTC KIDNEY TABS 4 RX/OTC PITUITARY TABS 4 RX/OTC LIPIDSHIELD PLUS TABS 4 RX/OTC PROSTATE TABS 4 RX/OTC LIPOTRIAD VISION 5 RX/OTC RA EAR CARE TABS 4 SUPPORT CAPS RETAINE VISION CAPS 5 RX/OTC LIPOTRIAD VISION 5 RX/OTC SUPPORTPLUS CAPS specialty vitamins products 2 RX/OTC LIPOTRIAD VISIONARY 5 RX/OTC caps CAPS specialty vitamins products 2 RX/OTC LONGEVITY CAPS 5 RX/OTC tabs SPLEEN TABS 4 RX/OTC LONGEVITY PLUS CAPS 5 RX/OTC STOMACH TABS 4 RX/OTC LUNG TABS 4 RX/OTC SUPPORT-500 CAPS 5 RX/OTC LYMPH TABS 4 RX/OTC SYNERTROPIN CAPS 5 RX/OTC M2 CALCIUM TABS 4 RX/OTC THERABETIC EYE 4 RX/OTC M2 CHROMIUM TABS 4 RX/OTC HEALTH TABS RX/OTC MAMMARY TABS 4 RX/OTC THYMUS TABS 140 MG 4

MENOPAUSE RELIEF 4 RX/OTC ULTRA MAN TBCR 5 TABS ULTRA WOMAN TBCR 5 MG-PLUS PROTEIN TABS 4 RX/OTC UTERUS TABS 4 RX/OTC MIL ADREGEN TABS 4 RX/OTC VITA-RX DIABETIC 5 RX/OTC MILADRENE FORTE 4 RX/OTC VITAMIN CAPS TABS

Updated August 1, 2018

208 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITAMINS FOR THE HAIR 4 RX/OTC cyclobenzaprine hcl tabs 2 QL(3 ea daily) TABS RX/OTC CYCLOPHENE 5 ZN-PLUS TABS 4 RAPIDPAQ CREA Vitamin Mixtures ENOVARX- CYCLOBENZAPRINE HCL 5 COD LIVER OIL FOR KIDS 5 RX/OTC CREA OIL FEXMID TABS (Use 5 QL(3 ea daily) COD LIVER OIL OIL RX/OTC Cyclobenzaprine HCl) 4000UNIT/5ML- 400UNIT/5ML, 5 FIRST-BACLOFEN 1 5 5000UNIT/5ML- SUSP 500UNIT/5ML, FIRST-BACLOFEN 5 5 SUSP CVS COD LIVER OIL OIL 5 RX/OTC GABLOFEN SOLN 5 NICOMIDE TABS 5 GABLOFEN SOSY 5 NORWEGIAN COD LIVER 5 RX/OTC OIL OIL LIORESAL INTRATHECAL 5 SOLN QC COD LIVER OIL OIL 5 RX/OTC LORZONE TABS 5 RA COD LIVER OIL OIL 5 RX/OTC METAXALONE TABS 400 4 QL(4 ea daily) MUSCULOSKELETAL THERAPY AGENTS - MG Drugs to Treat Spasms metaxalone tabs 800 mg 2 QL(4 ea daily) Articular Cartilage Repair Therapy methocarbamol soln 2 CARTICEL IMPL 5 methocarbamol tabs 2 MACI SHEE 5 orphenadrine citrate soln ij 2 Central Muscle Relaxants 30 mg/ml, 60 mg/2ml ACTIVE- orphenadrine citrate tb12 or 2 QL(2 ea daily) CYCLOBENZAPRINE KIT 5 100 mg CREA PARAFON FORTE DSC 5 AMRIX CP24 5 TABS (Use Chlorzoxazone) ROBAXIN SOLN (Use 5 baclofen tabs or 10 mg, 20 2 Methocarbamol) mg ROBAXIN TABS (Use 5 BACLOFEN TABS OR 5 4 Methocarbamol) MG ROBAXIN-750 TABS (Use 5 carisoprodol tabs 250 mg 2 QL(3 ea daily) Methocarbamol) SKELAXIN TABS (Use 5 QL(4 ea daily) carisoprodol tabs 350 mg 2 QL(4 ea daily) Metaxalone) SOMA TABS 250 MG (Use QL(3 ea daily) CHLORZOXAZONE TABS 5 5 250 MG Carisoprodol) SOMA TABS 350 MG (Use QL(4 ea daily) CHLORZOXAZONE TABS 4 5 500 MG Carisoprodol) Updated August 1, 2018

209 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TABRADOL FUSEPAQ 5 EUFLEXXA SOSY 5 PA; SP SUSP PA; SP TABRADOL RAPIDPAQ 5 GEL-ONE PRSY 4 SUSP PA; SP tizanidine hcl caps 2 mg 2 GELSYN-3 SOSY 4 PA; SP tizanidine hcl caps 4 mg 2 QL(9 ea daily) GENVISC 850 SOSY 5 PA; SP tizanidine hcl caps 6 mg 2 QL(6 ea daily) HYALGAN SOLN 5 PA; SP tizanidine hcl tabs 2 mg, 4 2 HYALGAN SOSY 5 mg HYMOVIS SOSY 5 PA; SP ZANAFLEX CAPS 2 MG 5 (Use Tizanidine HCl) MONOVISC SOSY 5 PA; SP ZANAFLEX CAPS 4 MG 5 QL(9 ea daily) (Use Tizanidine HCl) ORTHOVISC SOSY 5 PA; SP ZANAFLEX CAPS 6 MG 5 QL(6 ea daily) (Use Tizanidine HCl) SUPARTZ FX SOSY 5 PA; SP ZANAFLEX TABS 4 MG 5 (Use Tizanidine HCl) SUPARTZ SOSY 5 PA; SP Direct Muscle Relaxants SYNVISC ONE SOSY 5 PA; SP DANTRIUM CAPS (Use 5 QL(4 ea daily) Dantrolene Sodium) SYNVISC SOSY 5 PA; SP DANTRIUM IV SOLR (Use 5 Dantrolene Sodium) VISCO-3 SOSY 5 PA; SP dantrolene sodium caps or 2 QL(4 ea daily) 25 mg, 50 mg, 100 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus dantrolene sodium solr iv 2 20 mg Nasal Agent Combinations RYANODEX SUSR 5 DERMACINRX AZENASE 5 PAK THPK Muscle Relaxant Combinations DYMISTA SUSP 5 carisoprodol w/ aspirin & 2 QL(8 ea daily) codeine tabs Nasal Agents - Misc. carisoprodol w/ aspirin tabs 2 QL(8 ea daily) DERMACINRX TICANASE 5 PAK THPK CYCLO/GABA10/300 5 PACK THPK TICASPRAY THPK 5 LORVATUS PHARMAPAK 5 KIT Nasal Anti-infectives BACTROBAN NASAL 5 METAXALL CP KIT 5 OINT TIZANIDINE COMFORT 5 Nasal Antiallergy PAC MISC ASTEPRO SOLN (Use 5 Viscosupplements Azelastine HCl)

Updated August 1, 2018

210 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azelastine hcl soln 2 QNASL CHILDRENS 5 AERS olopatadine hcl (nasal) soln 2 RHINOCORT AQUA SUSP 5 RX/OTC (Use Budesonide (Nasal)) PATANASE SOLN (Use 5 triamcinolone acetonide 2 RX/OTC Olopatadine HCl (Nasal)) (nasal) aero Nasal Anticholinergics VERAMYST SUSP 5 RX/OTC ipratropium bromide (nasal) 1 soln XHANCE EXHU 5 Nasal Steroids ZETONNA AERS 5 BECONASE AQ SUSP 5 Sympathomimetic Decongestants budesonide (nasal) susp 1 RX/OTC ADRENALIN SOLN 5 FLONASE ALLERGY RX/OTC TYZINE PEDIATRIC RELIEF CHILDRENS 5 5 SUSP (Use Fluticasone NASAL DROPS SOLN Propionate (Nasal)) NEUROMUSCULAR AGENTS - Drugs to FLONASE ALLERGY RX/OTC Relax/Paralyze Muscles RELIEF SUSP (Use 5 Fluticasone Propionate ALS Agents (Nasal)) RILUTEK TABS (Use 5 Riluzole) FLONASE SENSIMIST 5 RX/OTC SUSP riluzole tabs 2 FLUNISOLIDE SOLN 4 Depolarizing Muscle Relaxants fluticasone propionate 2 RX/OTC ANECTINE SOLN 5 (nasal) susp QUELICIN SOLN (Use mometasone furoate 2 5 (nasal) susp Succinylcholine Chloride) succinylcholine chloride NASACORT ALLERGY 4 RX/OTC 2 24HR AERO soln ij 20 mg/ml NASACORT ALLERGY RX/OTC SUCCINYLCHOLINE CHLORIDE SOSY IV 100 24HR AERO (Use 5 5 Triamcinolone Acetonide MG/5ML, 140 MG/7ML, (Nasal)) 200 MG/10ML NASACORT ALLERGY RX/OTC Muscular Dystrophy Agents 24HR CHILDRENS AERO 5 (Use Triamcinolone EXONDYS 51 SOLN 5 Acetonide (Nasal)) Neuromuscular Blocking Agent - Neurotoxins NASONEX SUSP (Use Mometasone Furoate 5 BOTOX SOLR 5 PA; SP (Nasal)) DYSPORT SOLR 5 PA; SP OMNARIS SUSP 5 MYOBLOC SOLN 5 PA; SP QNASL AERS 5

Updated August 1, 2018

211 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XEOMIN SOLR 5 PA; SP DEXTROSE POWD XX 5 RX/OTC

Nondepolarizing Muscle Relaxants dextrose soln iv 5 %, 10 %, 2 50 %, 70 % atracurium besylate soln 2 FRUCTOSE GRAN 5 RX/OTC cisatracurium besylate soln 10 mg/5ml, 20 mg/10ml, 2 FRUCTOSE POWD 5 200 mg/20ml CISATRACURIUM Lipids BESYLATE SOSY 10 5 fat emulsion emul 2 MG/5ML MIVACRON SOLN 5 INTRALIPID EMUL 5 RX/OTC NIMBEX SOLN (Use 5 NEOKE MCT70 POWD 5 Cisatracurium Besylate) PANCURONIUM 4 SMOFLIPID EMUL 5 BROMIDE SOLN 1 MG/ML Lipotropics pancuronium bromide soln 2 1 mg/ml, 2 mg/ml CHOLINE BITARTRATE 5 POWD rocuronium bromide soln 2 50 mg/5ml, 100 mg/10ml LECITHIN GRAN OR 5 RX/OTC ROCURONIUM BROMIDE 5 SOSY 50 MG/5ML LECITHIN GRAN XX 5 RX/OTC vecuronium bromide solr 2 10 mg, 20 mg Misc. Nutritional Substances VECURONIUM BROMIDE 5 CARDIOVID PLUS CAPS 5 SOSY 10 MG/10ML VECURONIUM Protein-Carbohydrate-Lipid Combinations BROMIDE/SODIUM 5 CHLORIDE SOLN KABIVEN EMUL 5 NUTRIENTS PERIKABIVEN EMUL 5 Carbohydrates Proteins alcohol soln 2 acetylcysteine (nutrient) 2 RX/OTC caps DEXTROSE 20% SOLN 5 ADDITIONS FOOD 5 ENHANCER POWD DEXTROSE 25% SOLN 4 ALANINE POWD 5 RX/OTC

DEXTROSE 30% SOLN 4 amino acid electrolyte 2 infusion soln DEXTROSE 40% SOLN 5 amino acid infusion soln 2 DEXTROSE ANHYDROUS 5 RX/OTC POWD amino acids caps 130mg- 2 RX/OTC 10mg-130mg-130mg, DEXTROSE 5 RX/OTC MONOHYDRATE POWD

Updated August 1, 2018

212 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMINOSYN AMINOSYN II SOLN 7%/ELECTROLYTES 5 31.3MEQ/L- SOLN 505MG/100ML- 517MG/100ML- 713MG/100ML- 462MG/100ML- 140MG/100ML- 280MG/100ML- 350MG/100ML- 50.3MEQ/L- 210MG/100ML- 209MG/100ML- 120MG/100ML- 700MG/100ML- 189MG/100ML- 735MG/100ML- 490MG/100ML- 371MG/100ML- 695MG/100ML- 350MG/100ML, 33.3MEQ/L- 614MG/100ML- 627MG/100ML- 865MG/100ML- 561MG/100ML- 170MG/100ML- 5 340MG/100ML- 425MG/100ML- 61.1MEQ/L- 255MG/100ML- 253MG/100ML- 146MG/100ML- 850MG/100ML- 230MG/100ML- 893MG/100ML- 595MG/100ML- 450MG/100ML- 844MG/100ML- 425MG/100ML, 38MEQ/L- 722MG/100ML- 738MG/100ML- 1018MG/100ML- 660MG/100ML- 200MG/100ML- 400MG/100ML- 500MG/100ML- 71.8MEQ/L- 300MG/100ML- 298MG/100ML- 172MG/100ML- 1000MG/100ML- 270MG/100ML- Updated August 1, 2018

213 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1050MG/100ML- AMINOSYN-PF 7% SOLN 5 700MG/100ML- 530MG/100ML- AMINOSYN-PF SOLN 5 993MG/100ML- 500MG/100ML, 45.3MEQ/L- AMINOSYN-RF SOLN 5 722MG/100ML- 738MG/100ML- BENEPROTEIN POWD 5 1018MG/100ML- 660MG/100ML- CARDIOWHEY POWD 5 200MG/100ML- CLINIMIX 400MG/100ML- 2.75%/DEXTROSE 5% 5 500MG/100ML- SOLN 71.8MEQ/L- 300MG/100ML- CLINIMIX 298MG/100ML- 4.25%/DEXTROSE 10% 5 172MG/100ML- SOLN 1000MG/100ML- CLINIMIX 270MG/100ML- 4.25%/DEXTROSE 20% 5 1050MG/100ML- SOLN 700MG/100ML- CLINIMIX 530MG/100ML- 4.25%/DEXTROSE 25% 5 993MG/100ML- SOLN 500MG/100ML CLINIMIX AMINOSYN II SOLN 4.25%/DEXTROSE 5% 5 50MEQ/L-1083MG/100ML- SOLN 1107MG/100ML- 1527MG/100ML- CLINIMIX 5%/DEXTROSE 5 990MG/100ML- 15% SOLN 300MG/100ML- CLINIMIX 5%/DEXTROSE 5 600MG/100ML- 20% SOLN 750MG/100ML- CLINIMIX 5%/DEXTROSE 5 107.6MEQ/L- 25% SOLN 450MG/100ML- 5 CLINIMIX E 447MG/100ML- 2.75%/DEXTROSE 10% 5 258MG/100ML- SOLN 1500MG/100ML- 405MG/100ML- CLINIMIX E 1575MG/100ML- 2.75%/DEXTROSE 5% 5 1050MG/100ML- SOLN 795MG/100ML- CLINIMIX E 1490MG/100ML- 4.25%/DEXTROSE 10% 5 750MG/100ML (Use Amino SOLN Acid Infusion) CLINIMIX E 4.25%/DEXTROSE 25% 5 AMINOSYN M SOLN 5 SOLN AMINOSYN SOLN 5 CLINIMIX E 4.25%/DEXTROSE 5% 5 AMINOSYN-HBC SOLN 5 SOLN

Updated August 1, 2018

214 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINIMIX E L-CYSTINE POWD 5 RX/OTC 5%/DEXTROSE 15% 5 SOLN L-GLUTAMIC ACID POWD 5 RX/OTC CLINIMIX E 5%/DEXTROSE 20% 5 L-GLUTAMINE CRYS 5 SOLN CLINIMIX E L-GLUTAMINE POWD 5 RX/OTC 5%/DEXTROSE 25% 5 SOLN L-GLUTATHIONE CRYS 5 CLINIMIX N14G30E SOLN 5 L-HISTIDINE MONOHYDROCHLORIDE 5 CLINIMIX N9G20E SOLN 5 CRYS CVS WHEY PROTEIN L-HISTIDINE MONOHYDROCHLORIDE 5 POWD 140MG-85MG, 5 180MG/39GM, MONOHYDRATE POWD 300MG/39GM L-HISTIDINE POWD 5 RX/OTC CYTO CARN POWD 5 RX/OTC L-ISOLEUCINE POWD XX 5 RX/OTC DL-ALANINE POWD 5 RX/OTC L-LEUCINE POWD XX 5 RX/OTC DL-LEUCINE POWD 5 RX/OTC L-METHIONINE POWD XX 5 RX/OTC DL-METHIONINE POWD 5 RX/OTC L-PHENYLALANINE 5 RX/OTC POWD DL-PHENYLALANINE 5 RX/OTC POWD L-PROLINE POWD XX 5 RX/OTC FREAMINE HBC 6.9% 5 SOLN L-TAURINE POWD 5 RX/OTC FREAMINE III SOLN 5 L-THREONINE CRYS XX 5 GLUTAMINE POWD XX 5 RX/OTC L-TRYPTOPHAN CAPS 5 RX/OTC OR GLUTATHIONE POWD XX 5 RX/OTC L-TRYPTOPHAN POWD 5 RX/OTC XX GLUTATHIONE-L POWD 5 RX/OTC L-TYROSINE POWD XX 5 RX/OTC GLUTATHIONE-L 5 RX/OTC REDUCED POWD L-VALINE CRYS XX 5 HEPATAMINE SOLN 4 L-VALINE POWD XX 5 RX/OTC L-ALANINE POWD 5 RX/OTC LEUCINE POWD XX 5 RX/OTC L-ARGININE BASE POWD 5 RX/OTC METHIONINE POWD XX 5 RX/OTC L-ARGININE POWD XX 5 RX/OTC NATURAL WHEY POWD 5 L-CYSTEINE HCL SOLN 4

Updated August 1, 2018

215 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEOKE ALCAR POWD 5 RX/OTC RXOSINE POWD 5 RX/OTC

NEPHRAMINE SOLN 5 SYNTHAMIN 17 SOLN 5

NUTRESTORE PACK 5 TAURINE LIQD XX 5

PHLEXY-10 CAPS 4 RX/OTC TAURINE POWD XX 5 RX/OTC

PRE PROTEIN POWD 5 THREONINE POWD 5 RX/OTC

PREMASOL SOLN 5 THREOSTAT POWD 5 RX/OTC

PROCALAMINE SOLN 5 TRAVASOL SOLN 5

PROCEL 100 POWD 5 TROPHAMINE SOLN 0.05GM/100ML- PROCEL POWD 0.41GM/100ML- 0.015GM/100ML- 5GM/6.6GM-23MG/6.6GM- 5 40MG/6.6GM- 0.73GM/100ML- 35MG/6.6GM 0.49GM/100ML- RX/OTC 0.12GM/100ML- PROLINE POWD 5 0.25GM/100ML- 0.47GM/100ML- PROSOL SOLN 5 0.29GM/100ML- 0.29GM/100ML- 5 PROSYNMINIC POWD 5 0.2GM/100ML- 0.84GM/100ML- PROTEIN POWD 0.14GM/100ML- 4940MG/30GM- 0.49GM/100ML- 1352MG/30GM- 0.3GM/100ML- 1872MG/30GM- 0.19GM/100ML- 1300MG/30GM- 0.23GM/100ML- 260MG/30GM- 0.32GM/100ML- 1040MG/30GM- 0.22GM/100ML- 1326MG/30GM- 0.014GM/100ML (Use 676MG/30GM- Amino Acid Infusion) 1326MG/30GM- 5 364MG/30GM- 2132MG/30GM- 962MG/30GM- 338MG/30GM- 1664MG/30GM- 2990MG/30GM- 1352MG/30GM- 1118MG/30GM- 1040MG/30GM, RENAMENT POWD 10GM/46.4GM- 25MG/46.4GM- 5 50MG/46.4GM- 35MG/46.4GM

Updated August 1, 2018

216 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TROPHAMINE SOLN carteolol hcl (ophth) soln 2 1.2GM/100ML-5MEQ/L- 0.5GM/100ML- CARTEOLOL HCL SOLN 4 0.68GM/100ML- 0.025GM/100ML- 1.2GM/100ML- COMBIGAN SOLN 4 0.82GM/100ML- COSOPT PF SOLN (Use 0.2GM/100ML- Dorzolamide HCl-Timolol 5 0.42GM/100ML- Maleate) 0.78GM/100ML-97MEQ/L- 5 0.48GM/100ML- COSOPT SOLN (Use QL(10 ml per 0.48GM/100ML- Dorzolamide HCl-Timolol 5 fill retail) 0.34GM/100ML- Maleate) 1.4GM/100ML- dorzolamide hcl-timolol QL(10 ml per 0.24GM/100ML- maleate soln 2%-0.5%, 2 fill retail) 0.32GM/100ML- 22.3mg/ml-6.8mg/ml 0.38GM/100ML- dorzolamide hcl-timolol 0.54GM/100ML- maleate soln 20mg/ml- 2 0.36GM/100ML 5mg/ml TRYPTOPHAN CAPS 5 RX/OTC DORZOLAMIDE QL(10 ml per HCL/TIMOLOL MALEATE 4 fill retail) TRYPTOPHAN POWD 5 RX/OTC SOLN ISTALOL SOLN 5 UNJURY POWD 5 ISTALOL SOLN (Use 5 UNJURY UNFLAVORED 5 Timolol Maleate (Ophth)) POWD levobunolol hcl soln 2 VALINE POWD XX 5 RX/OTC METIPRANOLOL SOLN 4 WELLNESS PROTEIN 5 SHAKE POWD timolol maleate (ophth) solg 2 WHEY PROTEIN 5 CONCENTRATE POWD timolol maleate (ophth) soln 2 WHEY PROTEIN POWD 5 TIMOLOL MALEATE OPHTHALMIC GEL 4 OPHTHALMIC AGENTS - Drugs to Treat the Eye FORMING SOLG Artificial Tears and Lubricants TIMOLOL/BRIMONIDE/DO 5 RZOLAMIDE SOLN LACRISERT INST 5 TIMOLOL/BRIMONIDINE/ DORZOLAMIDE/LATANOP 5 Beta-blockers - Ophthalmic ROST SOLN BETAGAN SOLN (Use 5 TIMOLOL/DORZOLAMIDE/ 5 Levobunolol HCl) LATANOPROST SOLN betaxolol hcl (ophth) soln 2 TIMOLOL/LATANOPROST 5 SOLN BETIMOL SOLN 4 TIMOPTIC OCUDOSE 5 SOLN BETOPTIC-S SUSP 4

Updated August 1, 2018

217 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIMOPTIC SOLN (Use 5 LUCENTIS SOSY 0.5 5 Timolol Maleate (Ophth)) MG/0.05ML TIMOPTIC-XE SOLG 0.25 MACUGEN SOLN 5 PA; SP % (Use Timolol Maleate 5 (Ophth)) Ophthalmic Adrenergic Agents TIMOPTIC-XE SOLG 0.25 4 %, 0.5 % ALPHAGAN P SOLN 0.1 % 4 Cycloplegic Mydriatics ALPHAGAN P SOLN 0.15 % (Use Brimonidine 5 ATROPINE SULFATE 5 OINT OP 1 % Tartrate) ATROPINE SULFATE 4 apraclonidine hcl soln 2 SOLN OP 1 % BRIMONIDE/DORZOLAMI 5 CYCLOGYL SOLN 0.5 % 5 QL(15 ml per DE P-F SOLN (Use Cyclopentolate HCl) fill retail) CYCLOGYL SOLN 1 %, 2 brimonidine tartrate soln 2 % (Use Cyclopentolate 5 HCl) IOPIDINE SOLN 0.5 % 5 (Use Apraclonidine HCl) CYCLOMYDRIL SOLN 5 IOPIDINE SOLN 1 % 5 cyclopentolate hcl soln 0.5 2 QL(15 ml per % fill retail) SIMBRINZA SUSP 4 cyclopentolate hcl soln 1 2 %, 2 % Ophthalmic Anti-infectives homatropine hbr soln 2 AZASITE SOLN 5 BACITRACIN OINT OP 4 ISOPTO ATROPINE SOLN 4 500 UNIT/GM bacitracin-polymyxin b 2 QL(4 gm per fill Miotics (ophth) oint retail) ISOPTO CARPINE SOLN 5 (Use Pilocarpine HCl) BESIVANCE SUSP 4

MIOCHOL-E SOLR 5 BETADINE OPHTHALMIC 5 PREP SOLN MIOSTAT SOLN 5 BLEPH-10 SOLN (Use QL(15 ml per Sulfacetamide Sodium 5 fill retail) PHOSPHOLINE IODIDE 5 (Ophth)) SOLR CEFUROXIME pilocarpine hcl soln 2 SODIUM/SODIUMCHLORI 5 DE SOLN Ophthalmic - Angiogenesis Inhibitors CILOXAN OINT 5 EYLEA SOLN 5 PA; SP CILOXAN SOLN (Use 5 LUCENTIS SOLN 0.3 PA; SP Ciprofloxacin HCl (Ophth)) MG/0.05ML, 0.5 5 ciprofloxacin hcl (ophth) 2 MG/0.05ML soln LUCENTIS SOSY 0.3 PA; SP 5 2 QL(4 gm per fill MG/0.05ML erythromycin (ophth) oint retail)

Updated August 1, 2018

218 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gatifloxacin (ophth) soln 2 2 QL(8 ml per fill trifluridine soln retail) QL(4 gm per fill GENTAK OINT 4 VIGAMOX SOLN (Use 5 QL(3 ml per fill retail) Moxifloxacin HCl (Ophth)) retail) gentamicin sulfate (ophth) QL(4 gm per fill 2 VIROPTIC SOLN (Use 5 QL(8 ml per fill oint retail) Trifluridine) retail) gentamicin sulfate (ophth) 2 soln ZIRGAN GEL 5 levofloxacin (ophth) soln 2 ZYMAXID SOLN (Use 5 Gatifloxacin (Ophth)) MITOSOL KIT 5 Ophthalmic Decongestants phenylephrine hcl (ophth) 2 MOXEZA SOLN 4 soln moxifloxacin hcl (ophth) 2 QL(3 ml per fill Ophthalmic Immunomodulators soln retail) RESTASIS EMUL 4 MOXIFLOXACIN HYDROCHLORDIE/SODIU 5 RESTASIS MULTIDOSE 4 M CHLORIDE SOLN EMUL NATACYN SUSP 5 Ophthalmic Integrin Antagonists XIIDRA SOLN 4 neomycin-bacitracin zn- 2 QL(4 gm per fill polymyxin oint retail) Ophthalmic Kinase Inhibitors neomycin-polymyxin- 2 QL(10 ml per gramicidin soln fill retail) RHOPRESSA SOLN 5 NEOSPORIN SOLN (Use QL(10 ml per Neomycin-Polymyxin- 5 fill retail) Ophthalmic Local Anesthetics Gramicidin) AKTEN GEL 5 OCUFLOX SOLN (Use 5 Ofloxacin (Ophth)) ALCAINE SOLN (Use 5 Proparacaine HCl) ofloxacin (ophth) soln 2 proparacaine hcl soln 2 polymyxin b-trimethoprim 2 QL(10 ml per soln fill retail) tetracaine hcl (ophth) soln 2 POLYTRIM SOLN (Use 5 QL(10 ml per Polymyxin B-Trimethoprim) fill retail) Ophthalmic Photodynamic Therapy Agents sulfacetamide sodium 2 QL(15 ml per VISUDYNE SOLR 5 PA; SP (ophth) soln fill retail) SULFACETAMIDE 5 Ophthalmic Steroids SODIUM OINT OP ALREX SUSP 4 2 QL(5 ml per fill tobramycin (ophth) soln retail) bacitracin-poly-neomycin- 2 hc oint TOBREX OINT 5 BLEPHAMIDE S.O.P. 5 TOBREX SOLN (Use 5 QL(5 ml per fill OINT Tobramycin (Ophth)) retail) BLEPHAMIDE SUSP 5

Updated August 1, 2018

219 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXAMETHASONE QL(5 ml per fill OMNIPRED SUSP (Use SODIUM PHOSPHATE 4 retail) Prednisolone Acetate 5 SOLN OP 0.1 % (Ophth)) DOUBLE PM SOLR 5 OZURDEX IMPL 5

DUREZOL EMUL 4 PRED FORTE SUSP (Use Prednisolone Acetate 5 FLAREX SUSP 5 (Ophth)) PRED MILD SUSP 5 fluorometholone (ophth) 2 susp PRED-G S.O.P. OINT 5 FML FORTE SUSP 5 PRED-G SUSP 5 FML LIQUIFILM SUSP (Use Fluorometholone 5 prednisolone acetate 2 (Ophth)) (ophth) susp FML OINT 5 PREDNISOLONE 4 ACETATE P-F SUSP ILUVIEN IMPL 5 PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 5 LOTEMAX GEL 4 % PREDNISOLONE/MOXIFL 5 LOTEMAX OINT 5 OXACIN SOLN PREDNISOLONE/MOXIFL LOTEMAX SUSP 4 OXACIN/BROMFENAC 5 SOLN MAXIDEX SUSP 5 PREDNISOLONE/MOXIFL MAXITROL OINT QL(5 gm per fill OXACIN/KETOROLAC 5 10000UNIT/GM- retail) SOLN 3.5MG/GM-0.1% (Use 5 RETISERT IMPL 5 Neomycin-Polymy- Dexameth) sulfacetamide sod- 2 MAXITROL SUSP QL(5 ml per fill prednisolone soln QL(4 gm per fill 10000UNIT/ML-3.5MG/ML- 5 retail) TOBRADEX OINT 4 0.1% (Use Neomycin- retail) Polymy-Dexameth) TOBRADEX ST SUSP 4 neomycin-polymy- QL(5 gm per fill dexameth oint 2 retail) TOBRADEX SUSP (Use 10000unit/gm-3.5mg/gm- Tobramycin- 5 0.1% Dexamethasone) neomycin-polymy- QL(5 ml per fill tobramycin- 2 dexameth susp 2 retail) dexamethasone susp 10000unit/ml-3.5mg/ml- 0.1% TRIESENCE SUSP 5 NEOMYCIN/POLYMYXIN/ QL(8 ml per fill HYDROCORTISONE 4 retail) TRIPLE PMB SOLR 5 SUSP TRIPLE PMK SOLR 5

Updated August 1, 2018

220 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VEXOL SUSP 5 BROMFENAC SOLN 4

ZYLET SUSP 4 BROMSITE SOLN 5 Ophthalmic Surgical Aids BSS PLUS SOLN (Use Ophthalmic Irrigation 5 AMVISC PLUS SOLN 5 Solution - Intraocular) cromolyn sodium (ophth) 2 QL(10 ml per AMVISC SOLN 5 soln fill retail) BIOLON SOLN 5 CYSTARAN SOLN 5 diclofenac sodium (ophth) CELLUGEL SOLN (Use 5 2 Hypromellose (Intraocular)) soln 2 QL(0.34 ml GELFILM OP FILM 5 dorzolamide hcl soln daily) HEALON GV SOLN 5 DORZOLAMIDE HCL 4 QL(0.34 ml SOLN daily) HEALON SOLN 5 ELESTAT SOLN (Use 5 Epinastine HCl (Ophth)) HEALON5 SOLN 5 EMADINE SOLN 5 hypromellose (intraocular) 2 soln epinastine hcl (ophth) soln 2 PROVISC SOLN 5 EYEAID IRRIGATING SOLUTION SOLN (Use 5 SHELLGEL SOLN 5 Ophthalmic Irrigation Solution) Ophthalmics - Misc. QL(3 ml per fill flurbiprofen sodium soln 2 ACULAR LS SOLN (Use retail) Ketorolac Tromethamine 5 (Ophth)) ILEVRO SUSP 5 ACULAR SOLN (Use JETREA SOLN 0.375 5 PA; SP Ketorolac Tromethamine 5 MG/0.3ML (Ophth)) JETREA SOLN 0.5 5 ACUVAIL SOLN 5 MG/0.2ML ketorolac tromethamine 2 ALOCRIL SOLN 5 (ophth) soln ketotifen fumarate (ophth) 2 ALOMIDE SOLN 5 soln LASTACAFT SOLN 5 2 QL(6 ml per fill azelastine hcl (ophth) soln retail) NEVANAC SUSP 5 AZOPT SUSP 4 OCUFEN SOLN (Use 5 QL(3 ml per fill BEPREVE SOLN 5 Flurbiprofen Sodium) retail) olopatadine hcl soln 2 bromfenac sodium (ophth) 2 soln

Updated August 1, 2018

221 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ophthalmic irrigation 2 CETRAXAL SOLN 4 solution - intraocular soln CIPROFLOXACIN SOLN ophthalmic irrigation 2 4 solution soln OT 0.2 % FLOXIN OTIC SOLN (Use PATADAY SOLN (Use 5 5 Olopatadine HCl) Ofloxacin (Otic)) PATANOL SOLN (Use 5 ofloxacin (otic) soln 2 Olopatadine HCl) PAZEO SOLN 4 OTIPRIO SUSP 5 Otic Combinations PROLENSA SOLN 4 CIPRO HC SUSP 5 TRUSOPT SOLN (Use 5 QL(0.34 ml Dorzolamide HCl) daily) CIPRODEX SUSP 4 QL(8 ml per fill ZADITOR SOLN (Use retail) Ketotifen Fumarate 5 (Ophth)) COLY-MYCIN S SUSP 5 Prostaglandins - Ophthalmic CORTANE-B AQUEOUS 5 SOLN BIMATOPROST SOLN 4 neomycin-polymyxin-hc 2 QL(10 ml per (otic) soln fill retail) LATANOPROST SOLN 4 QL(0.09 ml daily) neomycin-polymyxin-hc 2 QL(0.09 ml (otic) susp latanoprost soln 2 daily) OTOVEL SOLN 5 LUMIGAN SOLN 5 PRAMOTIC LIQD 4 RESCULA SOLN 5 Otic Steroids TRAVATAN Z SOLN 4 DERMOTIC OIL (Use Fluocinolone Acetonide 5 TRAVOPROST SOLN 4 (Otic)) fluocinolone acetonide 2 VYZULTA SOLN 5 PA (otic) oil hydrocortisone w/acetic 2 QL(10 ml per XALATAN SOLN (Use 5 QL(0.09 ml acid soln fill retail) Latanoprost) daily) OXYTOCICS - Drugs to Prevent/Control Uterine ZIOPTAN SOLN 4 Bleeding OTIC AGENTS - Drugs to Treat the Ear Oxytocics methylergonovine maleate 2 Otic Agents - Miscellaneous soln QL(15 ml per acetic acid (otic) soln 2 methylergonovine maleate 2 fill retail) tabs ACETIC ACID/ALUMINUM 4 oxytocin soln 2 ACETATE SOLN Otic Anti-infectives OXYTOCIN/DEXTROSE 5 SOLN

Updated August 1, 2018

222 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXYTOCIN/DEXTROSE/L GAMMAKED SOLN 5 PA; SP ACTATED RINGERS 5 SOLN GAMMAPLEX SOLN 5 PA; SP OXYTOCIN/LACTATED 5 RINGERS SOLN GAMUNEX-C SOLN 5 PA; SP OXYTOCIN/SODIUM 5 CHLORDIE SOLN HEPAGAM B SOLN 5 PA; SP OXYTOCIN/SODIUM 5 CHLORIDE SOLN HIZENTRA SOLN 5 PA; SP PITOCIN SOLN (Use 5 PA; SP Oxytocin) HYPERHEP B S/D SOLN 5 PASSIVE IMMUNIZING AND TREATMENT HYPERRHO S/D MINI- 5 PA; SP AGENTS - Antibody Drugs to Treat Low Immune DOSE SOSY System HYPERRHO S/D SOSY 5 PA; SP Antitoxins-Antivenins HYPERTET S/D INJ 5 ANASCORP SOLR 5 MICRHOGAM ULTRA- 5 PA; SP ANTIVENIN FILTEREDPLUS SOSY LATRODECTUS 5 MACTANS KIT NABI-HB SOLN 5 PA; SP ANTIVENIN MICRURUS 5 FULVIUS SOLR OCTAGAM SOLN 5 PA; SP ANTIVENIN NORTH PA; SP AMERICANCORAL 5 PRIVIGEN SOLN 5 SNAKE SOLR RHOGAM ULTRA- 5 PA; SP CROFAB SOLR 5 FILTERED PLUS SOSY PA; SP Immune Serums RHOPHYLAC SOSY 5 BIVIGAM SOLN 5 PA; SP VARIZIG SOLN 5 PA; SP CARIMUNE 5 PA; SP WINRHO SDF SOLN 5 NANOFILTERED SOLR CUVITRU SOLN 5 PA; SP Monoclonal Antibodies SYNAGIS SOLN 5 PA; SP CYTOGAM INJ 5 PA; SP Passive Immunizing Agents - Combinations FLEBOGAMMA DIF SOLN 5 PA; SP HYQVIA KIT 5 PA; SP GAMASTAN INJ 5 PA; SP PENICILLINS - Drugs to Treat Bacterial Infections GAMASTAN S/D INJ 5 PA; SP Aminopenicillins GAMMAGARD LIQUID 5 PA; SP 2 SOLN amoxicillin caps GAMMAGARD S/D IGA PA; SP amoxicillin chew 2 LESS THAN 1MCG/ML 5 SOLR Updated August 1, 2018

223 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMOXICILLIN ER TB24 4 amoxicillin & pot clavulanate susr amoxicillin susr 2 400mg/5ml-57mg/5ml, 2 200mg/5ml-28.5mg/5ml, 250mg/5ml-62.5mg/5ml, amoxicillin tabs 2 600mg/5ml-42.9mg/5ml ampicillin caps 250 mg, 2 amoxicillin & pot QL(30 ea per 500 mg clavulanate tabs 250mg- 2 fill retail) 125mg AMPICILLIN CAPS 500 4 MG amoxicillin & pot QL(20 ea per ampicillin sodium solr ij 1 clavulanate tabs 500mg- 2 fill retail) gm, 2 gm, 10 gm, 250 mg, 2 125mg, 875mg-125mg 500 mg amoxicillin & pot QL(13.34 ea clavulanate tb12 1000mg- 2 daily) AMPICILLIN SODIUM 4 SOLR IJ 125 MG 62.5mg AMOXICILLIN/CLAVULAN QL(20 ea per AMPICILLIN SODIUM 4 4 SOLR IV 1 GM ATE POTASSIUM CHEW fill retail) ampicillin & sulbactam ampicillin sodium solr iv 2 2 2 gm, 10 gm sodium solr AMPICILLIN-SULBACTAM AMPICILLIN SUSR 125 4 4 MG/5ML, 250 MG/5ML SOLR 1GM-2GM AUGMENTIN ES-600 MOXATAG TB24 4 SUSR (Use Amoxicillin & 5 Pot Clavulanate) Natural Penicillins AUGMENTIN SUSR 5 BICILLIN L-A SUSP 5 125MG/5ML-31.25MG/5ML PENICILLIN G AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML POTASSIUM IN ISO- 5 5 OSMOTIC DEXTROSE (Use Amoxicillin & Pot SOLN Clavulanate) AUGMENTIN TABS QL(20 ea per penicillin g potassium solr 2 500MG-125MG, 875MG- 5 fill retail) 125MG (Use Amoxicillin & PENICILLIN G PROCAINE 5 SUSP Pot Clavulanate) AUGMENTIN XR TB12 QL(13.34 ea PENICILLIN G SODIUM 4 SOLR (Use Amoxicillin & Pot 5 daily) Clavulanate) penicillin v potassium solr 2 125 mg/5ml, 250 mg/5ml BICILLIN C-R SUSP 5 PENICILLIN V piperacillin sodium- 2 POTASSIUM SOLR 125 4 tazobactam sodium solr MG/5ML, 250 MG/5ML UNASYN BULK PACK penicillin v potassium tabs 2 SOLR (Use Ampicillin & 5 250 mg, 500 mg Sulbactam Sodium) PFIZERPEN SOLR (Use 5 UNASYN SOLR (Use Penicillin G Potassium) Ampicillin & Sulbactam 5 Penicillin Combinations Sodium)

Updated August 1, 2018

224 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOSYN SOLN CREAM BASE NIOSOMES 5 0.375GM/50ML- CREA 3GM/50ML-5%, CREAM-HEAVY BASE 5 0.5GM/100ML- 5 NIOSOME CREA 4GM/100ML-5%, 0.25GM/50ML-2GM/50ML- HORMONE CREAM BASE 5 5% NIOSOMES CREA ZOSYN SOLR 0.375GM- HORMONE CREAM- 3GM, 0.25GM-2GM, HEAVY BASENIOSOMES 5 0.5GM-4GM, 4.5GM-36GM 5 CREA (Use Piperacillin Sodium- lanolin oint 2 RX/OTC Tazobactam Sodium) RX/OTC Penicillinase-Resistant Penicillins white petrolatum gel 2 BACTOCILL IN 5 PROGESTINS - Hormone Replacement/Modifying DEXTROSE SOLN Drugs dicloxacillin sodium caps 2 Progestins AYGESTIN TABS (Use nafcillin sodium solr ij 1 gm, 2 5 2 gm Norethindrone Acetate) EC-RX PROGESTERONE NAFCILLIN SODIUM 4 5 SOLR IV 1 GM, 2 GM 10% CREA hydroxyprogesterone 2 PA; SP NAFCILLIN SOLN 5 caproate oil 250 mg/ml oxacillin sodium solr 2 MAKENA OIL IM 250 PA; SP MG/ML (Use 5 Hydroxyprogesterone PHARMACEUTICAL ADJUVANTS Caproate) Liquid Vehicles MAKENA SOAJ SC 275 5 PA; SP BACTERIOSTATIC MG/1.1ML medroxyprogesterone WATER 4 2 FORINJECTION/BENZYL acetate tabs ALCOHOL SOLN MEGACE ES SUSP (Use glycine diluent soln 2 PA; SP Megestrol Acetate 5 (Appetite)) PH 12 STERILE DILUENT PA; SP megestrol acetate 2 FORFLOLAN SOLN (Use 5 (appetite) susp Glycine Diluent) norethindrone acetate tabs 2 saline, bacteriostatic soln 2 PROGESTERONE 10% 5 STERILE DILUENT FOR PA; SP KIT CREA FLOLAN SOLN (Use 5 progesterone micronized 2 QL(1 ea daily) Glycine Diluent) caps 100 mg STERILE DILUENT FOR PA; SP 4 progesterone micronized 2 QL(0.6667 ea REMODOULIN SOLN caps 200 mg daily) water for injection, sterile 2 soln progesterone oil 2 Semi Solid Vehicles

Updated August 1, 2018

225 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROMETRIUM CAPS 100 QL(1 ea daily) galantamine hydrobromide 2 QL(1 ea daily) MG (Use Progesterone 5 cp24 8 mg, 16 mg, 24 mg Micronized) GALANTAMINE QL(6 ml daily) PROMETRIUM CAPS 200 QL(0.6667 ea HYDROBROMIDE SOLN 4 4 MG (Use Progesterone 5 daily) MG/ML Micronized) galantamine hydrobromide 2 QL(2 ea daily) PROVERA TABS (Use tabs 4 mg, 8 mg, 12 mg Medroxyprogesterone 5 memantine hcl cp24 7 mg, 2 Acetate) 14 mg, 21 mg, 28 mg PSYCHOTHERAPEUTIC AND NEUROLOGICAL memantine hcl soln 2 2 QL(10 ml daily) AGENTS - MISC. - Drugs to Treat Mental and mg/ml Emotional Conditions memantine hcl tabs 2 Agents for Chemical Dependency memantine hcl tabs 5 mg, 2 QL(2 ea daily) acamprosate calcium tbec 2 10 mg NAMENDA SOLN 10 QL(10 ml daily) ANTABUSE TABS (Use 5 Disulfiram) MG/5ML (Use Memantine 5 HCl) disulfiram tabs 2 NAMENDA TABS 5 MG, 10 5 QL(2 ea daily) MG (Use Memantine HCl) LUCEMYRA TABS 5 NAMENDA TITRATION Anti-Cataplectic Agents PAK TABS (Use 5 Memantine HCl) XYREM SOLN 5 SP NAMENDA XR CP24 (Use 5 Memantine HCl) Antidementia Agents NAMENDA XR TITRATION 4 ARICEPT TABS 23 MG PACK CP24 (Use Donepezil 5 Hydrochloride) NAMZARIC C4PK 4 ARICEPT TABS 5 MG, 10 QL(1 ea daily) MG (Use Donepezil 5 NAMZARIC CP24 4 Hydrochloride) RAZADYNE ER CP24 (Use QL(1 ea daily) donepezil hydrochloride 2 Galantamine 5 tabs 23 mg Hydrobromide) donepezil hydrochloride 2 QL(1 ea daily) RAZADYNE TABS (Use QL(2 ea daily) tabs 5 mg, 10 mg Galantamine 5 Hydrobromide) donepezil hydrochloride 2 tbdp 5 mg, 10 mg rivastigmine pt24 13.3 2 EXELON CAPS OR 3 MG, QL(2 ea daily) mg/24hr 6 MG, 1.5 MG, 4.5 MG 5 rivastigmine pt24 4.6 2 QL(1 ea daily) (Use Rivastigmine Tartrate) mg/24hr, 9.5 mg/24hr EXELON PT24 TD 13.3 QL(2 ea daily) MG/24HR (Use 5 rivastigmine tartrate caps 2 Rivastigmine) Combination Psychotherapeutics EXELON PT24 TD 4.6 QL(1 ea daily) MG/24HR, 9.5 MG/24HR 5 CHLORDIAZEPOXIDE/AMI 4 (Use Rivastigmine) TRIPTYLINE TABS

Updated August 1, 2018

226 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACINRX DPN PAK 5 LEMTRADA SOLN 5 PA; SP THPK olanzapine-fluoxetine hcl 2 OCREVUS SOLN 5 caps PA; SP PERPHENAZINE/AMITRIP 4 QL(4 ea daily) PLEGRIDY SOPN 5 TYLINE TABS PA; SP SYMBYAX CAPS (Use PLEGRIDY SOSY 5 Olanzapine-Fluoxetine 5 HCl) PLEGRIDY STARTER 5 PA; SP PACK SOPN Fibromyalgia Agents PLEGRIDY STARTER 5 PA; SP 4 PA; QL(2 ea PACK SOSY SAVELLA TABS daily) REBIF REBIDOSE SOAJ 4 PA; SP SAVELLA TITRATION 4 PA; QL(0.1507 PACK MISC ea daily) REBIF REBIDOSE 4 PA; SP Hypoactive Sexual Desire Disorder (HSDD) TITRATIONPACK SOAJ PA; SP ADDYI TABS 5 REBIF SOSY 4 REBIF TITRATION PACK 4 PA; SP Movement Disorder Drug Therapy SOSY AUSTEDO TABS 5 TECFIDERA CPDR 4 PA; SP PA INGREZZA CAPS 5 TECFIDERA STARTER 4 PA; SP PACK MISC tetrabenazine tabs 2 PA; SP TYSABRI CONC 4 PA; SP XENAZINE TABS (Use 5 PA; SP Tetrabenazine) ZINBRYTA SOSY 5 PA; SP Multiple Sclerosis Agents Postherpetic Neuralgia (PHN)/Neuropathic Pain PA; SP AMPYRA TB12 5 ACTIVE- 5 PAC/GABAPENTIN THPK AUBAGIO TABS 4 PA; SP CONVENIENCE PAK 5 THPK AVONEX KIT 5 PA; SP GRALISE STARTER MISC 4 PA AVONEX PEN AJKT 5 PA; SP GRALISE TABS 4 PA AVONEX PSKT 5 PA; SP LYRICA CR TB24 5 PA BETASERON KIT 5 PA; SP SMARTRX GABA KIT 5 THPK COPAXONE SOSY (Use 5 PA; SP Glatiramer Acetate) SMARTRX GABA-V KIT 5 THPK EXTAVIA KIT 5 PA; SP Premenstrual Dysphoric Disorder (PMDD) Agents PA; SP GILENYA CAPS 4 FLUOXETINE CAPS 4 ST glatiramer acetate sosy 2 PA; SP

Updated August 1, 2018

227 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluoxetine hcl (pmdd) tabs 2 NICOTROL INHALER 6 PV INHA SARAFEM TABS (Use 5 PV Fluoxetine HCl (PMDD)) NICOTROL NS SOLN 6 Pseudobulbar Affect (PBA) Agents ZYBAN TB12 (Use QL(2 ea daily) Bupropion HCl (Smoking 5 NUEDEXTA CAPS 4 QL(2 ea daily) Deterrent)) Psychotherapeutic and Neurological Agents - Vasomotor Symptom Agents BRISDELLE CAPS (Use ERGOLOID MESYLATES 4 TABS Paroxetine Mesylate 5 (Vasomotor)) ORAP TABS (Use 5 Pimozide) paroxetine mesylate 2 (vasomotor) caps pimozide tabs 2 RESPIRATORY AGENTS - MISC. - Drugs to Restless Leg Syndrome (RLS) Agents Treat Lung Conditions Alpha-Proteinase Inhibitor (Human) HORIZANT TBCR 5 QL(2 ea daily) ARALAST NP SOLR 5 PA; SP Smoking Deterrents PA; SP bupropion hcl (smoking 6 QL(2 ea daily) GLASSIA SOLN 5 deterrent) tb12 PROLASTIN-C SOLN 1000 5 PA; 30 rtl lmt CHANTIX CONTINUING 6 QL(2 ea daily) MG/20ML day(s),; SP MONTHPAK TABS PROLASTIN-C SOLR 1000 5 PA; SP CHANTIX STARTING 6 QL(53 ea per MG MONTH PAK TABS 365 days retail) ZEMAIRA SOLR 5 PA; SP CHANTIX TABS 6 QL(2 ea daily) Cystic Fibrosis Agents NICODERM CQ PT24 (Use 5 QL(1 ea daily) Nicotine) KALYDECO PACK 5 PA; SP NICORETTE GUM (Use 5 PV Nicotine Polacrilex) KALYDECO TABS 5 PA; SP NICORETTE LOZG (Use 5 PV Nicotine Polacrilex) ORKAMBI TABS 5 PA; SP NICORETTE MINI LOZG 5 PV PA; SP (Use Nicotine Polacrilex) PULMOZYME SOLN 5 NICORETTE STARTER PV PA; SP KIT GUM (Use Nicotine 5 SYMDEKO TBPK 5 Polacrilex) Pleural Sclerosing Agents nicotine polacrilex gum 6 PV SCLEROSOL 5 INTRAPLEURAL AERP nicotine polacrilex lozg 6 PV STERILE TALC POWDER 5 SUSR nicotine pt24 6 QL(1 ea daily) Pulmonary Fibrosis Agents NICOTINE PV PA; SP TRANSDERMAL SYSTEM 6 ESBRIET CAPS 4 KIT

Updated August 1, 2018

228 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESBRIET TABS 4 PA; SP doxycycline (monohydrate) 2 caps OFEV CAPS 4 doxycycline (monohydrate) 2 susr Respiratory Agents - Misc. doxycycline (monohydrate) 2 tabs CUROSURF SUSP 5 doxycycline hyclate caps or 2 INFASURF SUSP 5 50 mg, 100 mg doxycycline hyclate solr iv 2 SURVANTA 5 100 mg INTRATRACHEAL SUSP doxycycline hyclate tabs or SULFONAMIDES - Drugs to Treat Bacterial 20 mg, 75 mg, 100 mg, 150 2 Infections mg Sulfonamides DOXYCYCLINE HYCLATE 5 TABS OR 50 MG SULFADIAZINE TABS 5 doxycycline hyclate tbec or 50 mg, 75 mg, 100 mg, 150 2 TETRACYCLINES - Drugs to Treat Bacterial mg, 200 mg Infections MINOCIN CAPS OR 50 Tetracycline Combinations MG, 75 MG, 100 MG (Use 5 AVIDOXY DK KIT 5 Minocycline HCl) MINOCIN SOLR IV 100 5 BENZODOX 30 KIT THPK 5 MG minocycline hcl caps 50 2 BENZODOX 60 KIT THPK 5 mg, 75 mg, 100 mg minocycline hcl tabs 50 mg, 2 Tetracyclines 75 mg, 100 mg ACTICLATE TABS (Use 5 minocycline hcl tb24 45 2 PA Doxycycline Hyclate) mg, 90 mg, 135 mg ADOXA PAK 1/100 TABS minocycline hcl tb24 65 2 (Use Doxycycline 5 mg, 115 mg (Monohydrate)) MONODOX CAPS (Use ADOXA PAK 1/150 TABS Doxycycline 5 (Use Doxycycline 5 (Monohydrate)) (Monohydrate)) ADOXA PAK 2/100 TABS MORGIDOX 1X100MG KIT 5 (Use Doxycycline 5 MORGIDOX 1X50MG KIT 5 (Monohydrate)) KIT ADOXA TABS (Use Doxycycline 5 MORGIDOX 2X100MG KIT 5 (Monohydrate)) NUTRIDOX KIT 5 demeclocycline hcl tabs 2 SOLODYN TB24 55 MG, 5 DORYX MPC TBEC 5 80 MG, 105 MG SOLODYN TB24 65 MG, DORYX TBEC (Use 5 115 MG (Use Minocycline 5 Doxycycline Hyclate) HCl) Updated August 1, 2018

229 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TARGADOX TABS 5 levothyroxine sodium tabs or 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, tetracycline hcl caps 250 2 2 mg, 500 mg 112 mcg, 125 mcg, 137 TETRACYCLINE HCL mcg, 150 mcg, 175 mcg, CAPS 500 MG (Use 5 200 mcg, 300 mcg Tetracycline HCl) liothyronine sodium soln 2 VIBRAMYCIN CAPS 100 MG (Use Doxycycline 5 liothyronine sodium tabs 2 Hyclate) VIBRAMYCIN SUSR 25 NATURE-THROID NT-2.5 5 MG/5ML (Use Doxycycline 5 TABS (Monohydrate)) NATURE-THROID TABS 5 VIBRAMYCIN SYRP 50 5 MG/5ML SYNTHROID TABS (Use 4 Levothyroxine Sodium) XIMINO CP24 5 PA thyroid tabs 2 THYROID AGENTS - Drugs to Regulate Thyroid Hormones THYROLAR-1 TABS 5 Antithyroid Agents THYROLAR-1/2 TABS 5 methimazole tabs 2 THYROLAR-1/4 TABS 5 propylthiouracil tabs 2 THYROLAR-2 TABS 5 TAPAZOLE TABS (Use 5 Methimazole) THYROLAR-3 TABS 5 Thyroid Hormones TIROSINT CAPS 5 ARMOUR THYROID TABS 15 MG, 120 MG (Use 5 TRIOSTAT SOLN (Use 5 Thyroid) Liothyronine Sodium) ARMOUR THYROID TABS 5 180 MG, 240 MG, 300 MG WESTHROID TABS 5 ARMOUR THYROID TABS WP THYROID TABS 5 30 MG, 60 MG, 90 MG 4 (Use Thyroid) TOXOIDS CYTOMEL TABS (Use 5 Liothyronine Sodium) Toxoid Combinations LEVOTHYROXINE 6 PV SODIUM SOLR IV 100 4 ADACEL SUSP MCG, 500 MCG BOOSTRIX SUSP 6 PV LEVOTHYROXINE SODIUM SOLR IV 200 5 DAPTACEL SUSP 5 MCG DIPHTHERIA/TETANUS PV TOXOIDS ADSORBED 6 PEDIATRIC SUSP

Updated August 1, 2018

230 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INFANRIX SUSP 6 PV BENTYL TABS (Use 5 Dicyclomine HCl) PV KINRIX SUSP 6 chlordiazepoxide hcl- 2 clidinium bromide caps PV PEDIARIX SUSP 6 CUVPOSA SOLN 5 PV PENTACEL SUSR 6 dicyclomine hcl caps 2 PV QUADRACEL SUSP 6 dicyclomine hcl soln 2 PV TENIVAC INJ 6 dicyclomine hcl tabs 2 TETANUS/DIPHTHERIA PV DONNATAL ELIX TOXOIDS-ADSORBED 6 0.1037MG/5ML- SUSP 0.0065MG/5ML- ULCER DRUGS - Drugs to Treat Bowel, Intestine 0.0194MG/5ML- 5 and Stomach Conditions 16.2MG/5ML (Use Phenobarbital- Antispasmodics Hyoscyamine-Atropine- ANASPAZ TBDP (Use 5 Scopolamine) Hyoscyamine Sulfate) GLYCATE TABS 5 ATROPEN SOAJ 5 glycopyrrolate soln ij 0.4 ATROPINE SULFATE 5 mg/2ml, 0.2 mg/ml, 1 2 SOLN IJ 0.4 MG/0.5ML mg/5ml, 4 mg/20ml ATROPINE SULFATE 4 GLYCOPYRROLATE SOLN IJ 0.4 MG/ML SOSY IV 0.4 MG/2ML, 0.6 5 MG/3ML, 1 MG/5ML atropine sulfate soln ij 1 2 mg/ml, 8 mg/20ml glycopyrrolate tabs or 1 2 ATROPINE SULFATE mg, 2 mg SOLN IJ 8 MG/20ML (Use 5 GLYCOPYRROLATE 5 Atropine Sulfate) TABS OR 1.5 MG ATROPINE SULFATE 5 hyoscyamine sulfate elix or 2 SOSY IJ 0.5 MG/5ML 0.125 mg/5ml atropine sulfate sosy ij 1 2 hyoscyamine sulfate soln 2 mg/10ml or 0.125 mg/ml ATROPINE SULFATE hyoscyamine sulfate subl sl 2 SOSY IV 0.8 MG/2ML, 2 5 0.125 mg MG/5ML, 1 MG/2.5ML hyoscyamine sulfate tabs 2 BELLADONNA & OPIUM 5 or 0.125 mg SUPP hyoscyamine sulfate tb12 2 QL(4 ea daily) BELLADONNA or 0.375 mg ALKALOIDS & OPIUM 5 hyoscyamine sulfate tbdp 2 SUPP or 0.125 mg BENTYL CAPS (Use 5 LEVBID TB12 (Use 5 QL(4 ea daily) Dicyclomine HCl) Hyoscyamine Sulfate) BENTYL SOLN (Use 5 Dicyclomine HCl) Updated August 1, 2018

231 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEVSIN SOLN IJ 0.5 5 famotidine soln iv 20 MG/ML mg/2ml, 40 mg/4ml, 200 2 LEVSIN TABS OR 0.125 mg/20ml MG (Use Hyoscyamine 5 famotidine susr or 40 2 QL(10 ml daily) Sulfate) mg/5ml LEVSIN/SL SUBL (Use 5 2 QL(2 ea daily); Hyoscyamine Sulfate) famotidine tabs or 20 mg RX/OTC LIBRAX CAPS (Use famotidine tabs or 40 mg 2 QL(2 ea daily) Chlordiazepoxide HCl- 5 Clidinium Bromide) nizatidine caps 150 mg 2 QL(2 ea daily) methscopolamine bromide 2 tabs nizatidine caps 300 mg 2 QL(1 ea daily) phenobarbital- hyoscyamine-atropine- NIZATIDINE SOLN 15 4 QL(20 ml daily) MG/ML scopolamine elix 2 0.1037mg/5ml- PEPCID AC MAXIMUM QL(2 ea daily); 0.0065mg/5ml- STRENGTH TABS (Use 5 RX/OTC 0.0194mg/5ml-16.2mg/5ml Famotidine) PEPCID SUSR 40 MG/5ML QL(10 ml daily) PROPANTHELINE 4 5 BROMIDE TABS (Use Famotidine) PEPCID TABS 20 MG (Use QL(2 ea daily); ROBINUL FORTE TABS 5 5 (Use Glycopyrrolate) Famotidine) RX/OTC PEPCID TABS 40 MG (Use QL(2 ea daily) ROBINUL SOLN (Use 5 5 Glycopyrrolate) Famotidine) ranitidine hcl caps or 150 QL(2 ea daily) ROBINUL TABS (Use 5 2 Glycopyrrolate) mg SYMAX DUOTAB TBCR 5 ranitidine hcl caps or 300 2 QL(1 ea daily) mg H-2 Antagonists ranitidine hcl soln ij 150 2 mg/6ml CIMETIDINE HCL SOLN 4 QL(20 ml daily) ranitidine hcl soln ij 50 2 QL(2 ml daily) QL(4 ea daily); mg/2ml cimetidine tabs 200 mg 2 RX/OTC ranitidine hcl syrp or 15 QL(20 ml daily) QL(4 ea daily) mg/ml, 75 mg/5ml, 150 2 cimetidine tabs 300 mg 2 mg/10ml QL(2 ea daily) cimetidine tabs 400 mg 2 ranitidine hcl tabs or 150 2 QL(2 ea daily); mg RX/OTC QL(1 ea daily) cimetidine tabs 800 mg 2 ranitidine hcl tabs or 300 2 QL(2 ea daily) mg DEPRIZINE FUSEPAQ 5 TAGAMET HB TABS (Use 5 QL(4 ea daily); SUSR Cimetidine) RX/OTC DEPRIZINE RAPIDPAQ 5 ZANTAC 150 MAXIMUM QL(2 ea daily); SUSR STRENGTH TABS (Use 5 RX/OTC FAMOTIDINE PREMIXED 4 Ranitidine HCl) SOLN ZANTAC SOLN IJ 25 5 MG/ML

Updated August 1, 2018

232 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZANTAC SOLN IJ 25 NEXIUM 24HR CLEAR ST; QL(1 ea MG/ML (Use Ranitidine 5 MINIS CPDR (Use 5 daily); RX/OTC HCl) Esomeprazole Magnesium) ZANTAC SOLN IJ 50 QL(2 ml daily) NEXIUM 24HR CPDR (Use 5 ST; QL(1 ea MG/2ML (Use Ranitidine 5 Esomeprazole Magnesium) daily); RX/OTC HCl) NEXIUM CPDR 20 MG ST; QL(1 ea ZANTAC TABS OR 150 5 QL(2 ea daily); (Use Esomeprazole 5 daily); RX/OTC MG (Use Ranitidine HCl) RX/OTC Magnesium) ZANTAC TABS OR 300 5 QL(2 ea daily) NEXIUM CPDR 40 MG ST; QL(1 ea MG (Use Ranitidine HCl) (Use Esomeprazole 5 daily) Magnesium) Misc. Anti-Ulcer NEXIUM I.V. SOLR (Use 5 CARAFATE SUSP 1 5 QL(40 ml daily) Esomeprazole Sodium) GM/10ML NEXIUM PACK 5 MG, 10 CARAFATE TABS 1 GM 5 QL(4 ea daily) 5 ) MG, 20 MG, 40 MG, 2.5 (Use Sucralfate MG QL(4 ea daily) sucralfate tabs 2 OMEPRAZOLE + SYRSPEND SFALKA 5 Proton Pump Inhibitors SUSP ACIPHEX SPRINKLE 5 omeprazole cpdr 10 mg, 40 2 ST; QL(1 ea CPSP mg daily) ACIPHEX TBEC (Use ST; QL(1 ea 5 2 ST; QL(1 ea Rabeprazole Sodium) daily) omeprazole cpdr 20 mg daily); RX/OTC ST; QL(1 ea DEXILANT CPDR 4 pantoprazole sodium solr iv 2 daily) 40 mg esomeprazole magnesium ST; QL(1 ea 2 pantoprazole sodium tbec 2 ST; QL(1 ea cpdr 20 mg daily); RX/OTC or 20 mg, 40 mg daily) esomeprazole magnesium ST; QL(1 ea 2 PREVACID 24HR CPDR 5 ST; QL(1 ea cpdr 40 mg daily) (Use Lansoprazole) daily); RX/OTC ESOMEPRAZOLE 4 PREVACID CPDR 15 MG 5 ST; QL(1 ea SODIUM SOLR 20 MG (Use Lansoprazole) daily); RX/OTC esomeprazole sodium solr 2 PREVACID CPDR 30 MG 5 ST; QL(1 ea 40 mg (Use Lansoprazole) daily) ESOMEPRAZOLE PREVACID SOLUTAB 5 STRONTIUM CPDR 49.3 5 TBDP (Use Lansoprazole) MG, 24.65 MG PRILOSEC CPDR 10 MG, 5 ST; QL(1 ea FIRST-LANSOPRAZOLE 5 40 MG (Use Omeprazole) daily) SUSP PRILOSEC CPDR 20 MG 5 ST; QL(1 ea FIRST-OMEPRAZOLE 5 (Use Omeprazole) daily); RX/OTC SUSP PRILOSEC PACK 10 MG, ST; QL(1 ea 5 lansoprazole cpdr 15 mg 2 2.5 MG daily); RX/OTC PROTONIX PACK OR 40 ST; QL(1 ea 5 lansoprazole cpdr 30 mg 2 MG daily) PROTONIX SOLR IV 40 lansoprazole tbdp 15 mg, 2 MG (Use Pantoprazole 5 30 mg Sodium)

Updated August 1, 2018

233 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROTONIX TBEC OR 20 ST; QL(1 ea Urinary Anti-infective Combinations MG, 40 MG (Use 5 daily) Pantoprazole Sodium) HYOPHEN TABS 4 ST; QL(1 ea rabeprazole sodium tbec 2 methenamine-hyosc- daily) methylene blue-benzoic 2 Ulcer Drugs - Prostaglandins acid-phenyl sal tabs methenamine-hyosc- CYTOTEC TABS (Use 5 QL(4 ea daily) Misoprostol) methylene blue-sod phos- 2 QL(4 ea daily) phenyl sal caps misoprostol tabs 2 methenamine-hyosc- methylene blue-sod phos- 2 Ulcer Therapy Combinations phenyl sal tabs amoxicillin-clarithromycin 2 methenamine-hyoscamine- w/ lansoprazole misc methylene blue-sodium 2 OMECLAMOX-PAK MISC 5 phosphate caps methenamine-hyoscamine- omeprazole-sodium ST; QL(1 ea methylene blue-sodium 2 bicarbonate caps 20mg- 2 daily); RX/OTC phosphate tabs 1100mg omeprazole-sodium ST; QL(1 ea URIMAR-T TABS 4 bicarbonate caps 40mg- 2 daily) 1100mg UROGESIC-BLUE TABS (Use Methenamine- 5 omeprazole-sodium Hyoscamine-Methylene bicarbonate pack 20mg- 2 Blue-Sodium Phosphate) 1680mg, 40mg-1680mg PREVPAC MISC (Use UTA CAPS 4 Amoxicillin-Clarithromycin 5 w/ Lansoprazole) Urinary Anti-infectives FURADANTIN SUSP (Use 5 QL(40 ml daily) PYLERA CAPS 4 Nitrofurantoin) ZEGERID CAPS 20MG- ST; QL(1 ea HIPREX TABS (Use 5 Methenamine Hippurate) 1100MG (Use 5 daily); RX/OTC Omeprazole-Sodium MACROBID CAPS (Use Bicarbonate) Nitrofurantoin Monohyd 5 ZEGERID CAPS 40MG- ST; QL(1 ea Macro) 1100MG (Use 5 daily) MACRODANTIN CAPS Omeprazole-Sodium (Use Nitrofurantoin 5 Bicarbonate) Macrocrystal) ZEGERID OTC CAPS (Use ST; QL(1 ea methenamine hippurate 2 Omeprazole-Sodium 5 daily); RX/OTC tabs Bicarbonate) methenamine mandelate 2 ZEGERID PACK 20MG- tabs 1680MG, 40MG-1680MG 5 (Use Omeprazole-Sodium MONUROL PACK 5 Bicarbonate) nitrofurantoin macrocrystal 2 URINARY ANTI-INFECTIVES - Drugs to Treat caps Bladder/Kidney Infections nitrofurantoin monohyd 2 macro caps Updated August 1, 2018

234 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitrofurantoin susp 2 QL(40 ml daily) bethanechol chloride tabs 2

URINARY ANTISPASMODICS - Drugs to Treat URECHOLINE TABS (Use 5 Miscellaneous Bladder Spasms Bethanechol Chloride) Urinary Antispasmodic - Antimuscarinics Urinary Antispasmodics - Direct Muscle Relaxants darifenacin hydrobromide 2 QL(1 ea daily) flavoxate hcl tabs 2 tb24 DETROL LA CP24 (Use 5 QL(1 ea daily) VACCINES Tolterodine Tartrate) Bacterial Vaccines DETROL TABS (Use 5 QL(2 ea daily) Tolterodine Tartrate) ACTHIB SOLR 6 PV DITROPAN XL TB24 (Use 5 QL(2 ea daily) Oxybutynin Chloride) BEXSERO SUSY 6 PV ENABLEX TB24 (Use 5 QL(1 ea daily) PV Darifenacin Hydrobromide) MENACTRA INJ 6 GELNIQUE GEL 4 MENHIBRIX SOLR 6 PV

GELNIQUE PUMP GEL 4 MENOMUNE-A/C/Y/W-135 6 PV INJ oxybutynin chloride syrp 5 2 QL(16 ml daily) PV mg/5ml MENVEO SOLR 6 oxybutynin chloride tabs 5 2 QL(3 ea daily) PV mg PNEUMOVAX 23 INJ 6 oxybutynin chloride tb24 5 QL(2 ea daily) 2 PNEUMOVAX 23/1 DOSE 6 PV mg, 10 mg, 15 mg INJ OXYTROL FOR WOMEN 5 RX/OTC PV PTTW PREVNAR 13 SUSP 6 OXYTROL PTTW 5 RX/OTC TRUMENBA SUSY 6 PV tolterodine tartrate cp24 2 2 QL(1 ea daily) Viral Vaccines mg, 4 mg AFLURIA 2016-2017 SUSP 6 PV tolterodine tartrate tabs 1 2 QL(2 ea daily) mg, 2 mg AFLURIA 2017-2018 SUSP 6 PV TOVIAZ TB24 5 AFLURIA 2018-2019 SUSP 6 PV trospium chloride cp24 60 2 QL(1 ea daily) mg AFLURIA PF 2016-2017 6 PV SUSY trospium chloride tabs 20 2 mg AFLURIA PF 2017-2018 6 PV SUSY VESICARE TABS 4 QL(1 ea daily) AFLURIA PF 2018-2019 6 PV Urinary Antispasmodics - Beta-3 Adrenergic SUSY AFLURIA QUADRIVALENT 6 PV MYRBETRIQ TB24 4 2016-2017 SUSY Urinary Antispasmodics - Cholinergic Agonists AFLURIA QUADRIVALENT 6 PV 2017-2018 SUSP

Updated August 1, 2018

235 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AFLURIA QUADRIVALENT 6 PV FLUCELVAX PV 2017-2018 SUSY QUADRIVALENT 2018- 6 2019 SUSP AFLURIA QUADRIVALENT 6 PV 2018-2019 SUSP FLUCELVAX PV QUADRIVALENT 2018- 6 AFLURIA QUADRIVALENT 6 PV 2018-2019 SUSY 2019 SUSY PV FLULAVAL PV CERVARIX SUSP 6 QUADRIVALENT 2014- 6 2015 SUSY ENGERIX-B INJ 6 PV FLULAVAL PV PV QUADRIVALENT 2016- 6 ENGERIX-B SUSP 6 2017 SUSP FLUAD 2016-2017 SUSY 6 PV FLULAVAL PV QUADRIVALENT 2016- 6 FLUAD 2017-2018 SUSY 6 PV 2017 SUSY FLULAVAL PV FLUAD 2018-2019 SUSY 6 PV QUADRIVALENT 2017- 6 2018 SUSP FLUARIX QUADRIVALENT 6 PV FLULAVAL PV 2016-2017 SUSY QUADRIVALENT 2017- 6 FLUARIX QUADRIVALENT 6 PV 2018 SUSY 2017-2018 SUSY FLULAVAL PV FLUARIX QUADRIVALENT 6 PV QUADRIVALENT 2018- 6 2018-2019 SUSY 2019 SUSP FLUBLOK 2015-2016 6 PV FLULAVAL PV SOLN QUADRIVALENT 2018- 6 2019 SUSY FLUBLOK 2016-2017 6 PV SOLN FLUVIRIN 2015-2016 6 PV SUSP FLUBLOK 2017-2018 6 PV SOLN FLUVIRIN 2015-2016 6 PV FLUBLOK PV SUSY QUADRIVALENT 2017- 6 FLUVIRIN 2016-2017 6 PV 2018 SOSY SUSP FLUBLOK PV FLUVIRIN 2016-2017 6 PV QUADRIVALENT 2018- 6 SUSY 2019 SOSY FLUVIRIN 2017-2018 6 PV FLUCELVAX 2015-2016 6 PV SUSP SUSY FLUVIRIN 2017-2018 6 PV FLUCELVAX PV SUSY QUADRIVALENT 2016- 6 FLUZONE HIGH-DOSE PF 6 PV 2017 SUSY 2016-2017 SUSY FLUCELVAX PV FLUZONE HIGH-DOSE PF 6 PV QUADRIVALENT 2017- 6 2017-2018 SUSY 2018 SUSP FLUZONE HIGH-DOSE PF 6 PV FLUCELVAX PV 2018-2019 SUSY QUADRIVALENT 2017- 6 2018 SUSY

Updated August 1, 2018

236 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUZONE INTRADERMAL PV ROTARIX SUSR 6 PV QUADRIVALENT 2016- 6 2017 SUPN ROTATEQ SOLN 6 PV FLUZONE INTRADERMAL PV QUADRIVALENT 2017- 6 SHINGRIX SUSR 6 AL; At least 50 2018 SUPN yrs old; PV FLUZONE PV TWINRIX SUSP 6 PV QUADRIVALENT 2016- 6 2017 SUSP VAQTA SUSP 6 PV FLUZONE PV QUADRIVALENT 2016- 6 VARIVAX INJ 6 PV 2017 SUSY FLUZONE PV ZOSTAVAX SUSR 6 PV QUADRIVALENT 2017- 6 2018 SUSP VAGINAL PRODUCTS - Drugs to Treat Vaginal FLUZONE PV Infections and Low Hormones QUADRIVALENT 2017- 6 Miscellaneous Vaginal Products 2018 SUSY FLUZONE PV FEM PH GEL 4 QUADRIVALENT 2018- 6 2019 SUSP INTRAROSA INST 5 FLUZONE PV RELAGARD GEL 4 QUADRIVALENT 2018- 6 2019 SUSY Spermicides PV GARDASIL 9 SUSP 6 ENCARE SUPP 6 PV GARDASIL 9 SUSY 6 nonoxynol-9 gel 6 GARDASIL SUSP 6 PV OPTIONS CONCEPTROL VAGINAL 5 HAVRIX SUSP 6 PV CONTRACEPTIVE GEL (Use Nonoxynol-9) HEPLISAV-B SOLN 6 AL; At least 18 OPTIONS GYNOL II yrs old; PV VAGINALCONTRACEPTIV 6 IPOL INACTIVATED IPV 6 PV E GEL INJ SHUR-SEAL GEL 6 M-M-R II INJ 6 PV MEDICAL PROVIDER EZ PV TODAY SPONGE MISC 6 FLU SHOT 2015-2016 6 VCF VAGINAL PSKT CONTRACEPTIVE FILM 6 MEDICAL PROVIDER PV FILM SINGLE USE EZ FLU 6 VCF VAGINAL SHOT PSKT CONTRACEPTIVE FOAM 6 PROQUAD INJ 6 PV FOAM Vaginal Anti-infectives RECOMBIVAX HB SUSP 6 PV

Updated August 1, 2018

237 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVC CREA 5 estradiol vaginal tabs 10 2 mcg CLEOCIN CREA VA 2 % QL(40 gm per (Use Clindamycin 5 fill retail) ESTRING RING 5 Phosphate Vaginal) FEMRING RING 5 CLEOCIN SUPP VA 100 5 MG PREMARIN CREA VA 4 QL(1.434 gm 0.625 MG/GM daily) clindamycin phosphate 2 QL(40 gm per vaginal crea fill retail) VAGIFEM TABS (Use 5 Estradiol Vaginal) CLINDESSE CREA 5 Vaginal Progestins GYNAZOLE-1 CREA 5 CRINONE GEL 4 METROGEL-VAGINAL QL(70 gm per GEL (Use Metronidazole 5 fill retail) ENDOMETRIN INST 4 Vaginal) FIRST-PROGESTERONE QL(70 gm per metronidazole vaginal gel 2 VGS 100 COMPOUNDING 5 fill retail) KIT SUPP 4 QL(3 ea per fill FIRST-PROGESTERONE MICONAZOLE 3 SUPP retail) VGS 200 5 miconazole nitrate vaginal 2 COMPOUNDING KIT kit SUPP MONISTAT 3 FIRST-PROGESTERONE COMBINATION PACK KIT 5 VGS 400 COMPOUNDING 5 (Use Miconazole Nitrate KIT SUPP Vaginal) FIRST-PROGESTERONE NUVESSA GEL 5 VGS 50 COMPOUNDING 5 KIT SUPP TERAZOL 3 CREA (Use 5 QL(20 gm per VASOPRESSORS - Drugs to Treat Heart and Terconazole Vaginal) fill retail) Circulation Conditions TERAZOL 7 CREA (Use 5 QL(45 gm per Terconazole Vaginal) fill retail) Anaphylaxis Therapy Agents QL(0.0667 ea 5 QL(20 gm per ADRENACLICK SOAJ 4 TERCONAZOLE CREA fill retail) daily) terconazole vaginal crea 2 QL(45 gm per ADRENALIN SOLN 5 0.4 % fill retail) ADYPHREN AMP II KIT terconazole vaginal crea 2 QL(20 gm per 5 0.8 % fill retail) KIT ADYPHREN AMP KIT KIT 5 terconazole vaginal supp 2 QL(3 ea per fill 80 mg retail) ADYPHREN II KIT 5 Vaginal Estrogens ESTRACE CREA VA 0.1 QL(1.434 gm ADYPHREN KIT KIT 5 MG/GM (Use Estradiol 5 daily) Vaginal) epinephrine (anaphylaxis) 4 QL(0.0667 ea soaj daily) estradiol vaginal crea 0.1 2 QL(1.434 gm mg/gm daily) EPINEPHRINE SOAJ 0.15 4 QL(0.0667 ea MG/0.3ML daily) Updated August 1, 2018

238 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPINEPHRINESNAP-V 5 LEVOPHED SOLN (Use 5 KIT Norepinephrine Bitartrate) 4 QL(0.0667 ea midodrine hcl tabs 2 EPIPEN 2-PAK SOAJ daily) norepinephrine bitartrate 2 EPISNAP KIT 5 soln EPY II KIT KIT 5 NOREPINEPHRINE BITARTRATE/DEXTROSE 5 EPY KIT KIT 5 SOLN NOREPINEPHRINE Neurogenic Orthostatic Hypotension (NOH) - BITARTRATE/SODIUM 5 CHLORIDE SOLN NORTHERA CAPS 5 NOREPINEPHRINE Vasopressors BITARTRATE/SODIUM 5 CHLORIDE SOSY AKOVAZ SOLN (Use Ephedrine Sulfate 5 NOREPINEPHRINE/DEXT 5 (Pressors)) ROSE SOLN NOREPINEPHRINE/SODI 5 dobutamine hcl soln 2 UM CHLORIDE SOLN NOREPINEPHRINE/SODI 5 dobutamine in d5w soln 2 UM CHLORIDE SOSY phenylephrine hcl dopamine hcl soln 40 2 2 mg/ml (pressors) soln PHENYLEPHRINE HCL DOPAMINE HCL SOLN 80 4 4 MG/ML, 160 MG/ML SOLN IJ 10 MG/ML dopamine in d5w soln 2 PHENYLEPHRINE HYDROCHLORIDE/DEXT 5 ROSE SOLN ephedrine sulfate 2 (pressors) soln PHENYLEPHRINE HYDROCHLORIDE/SODIU 5 EPHEDRINE SULFATE 5 SOLN M CHLORIDE SOLN PHENYLEPHRINE EPHEDRINE SULFATE 5 SOSY HYDROCHLORIDE/SODIU 5 EPHEDRINE M CHLORIDE SOSY SULFATE/SODIUMCHLOR 5 PHENYLEPHRINE/SODIU 5 IDE SOSY M CHLORIDE SOLN VAZCULEP SOLN (Use EPINEPHRINE HCL SOLN 5 Phenylephrine HCl 5 (Pressors)) epinephrine soln 1 mg/ml 2 VITAMINS epinephrine sosy 1 2 mg/10ml Oil Soluble Vitamins EPINEPHRINE/DEXTROS 5 AQUASOL A 5 E SOLN PARENTERAL SOLN EPINEPHRINE/SODIUM 5 BABY DDROPS LIQD (Use 5 CHLORIDE SOLN Cholecalciferol)

Updated August 1, 2018

239 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cholecalciferol caps 400 6 AL; At least 65 BIOTIN POWD XX 5 RX/OTC unit yrs old RX/OTC cholecalciferol chew 400 6 AL; At least 65 BIOTIN-D POWD 5 unit yrs old CALCIUM ASCORBATE RX/OTC cholecalciferol liqd 400 6 5 unit/ml, 400 unt/0.03ml DIHYDRATE POWD CALCIUM ASCORBATE RX/OTC cholecalciferol tabs 400 6 AL; At least 65 5 unit yrs old POWD XX CALCIUM RX/OTC D-VI-SOL LIQD (Use 5 Cholecalciferol) PANTOTHENATE POWD 5 XX DRISDOL CAPS (Use 5 AL; At least 65 Ergocalciferol) yrs old CALCIUM-D- 5 RX/OTC PANTOTHENATE POWD ERGOCAL CAPS 5 NIACIN POWD OR 4 ergocalciferol caps or 6 AL; At least 65 50000 unit yrs old NIACIN POWD XX 5 RX/OTC ERGOCALCIFEROL 5 RX/OTC POWD XX NIACINAMIDE POWD XX 5 MEPHYTON TABS (Use 5 RX/OTC Phytonadione) NICOTINAMIDE POWD 5 phytonadione soln ij 1 2 PARA-AMINOBENZOIC 5 mg/0.5ml ACID POWD phytonadione tabs or 5 mg 2 POTABA CAPS 5 VITAMIN D2 TABS 400 6 POTASSIUM P- 5 UNIT AMINOBENZOATE POWD VITAMIN D3 LIQD 1200 6 PYRIDOXINE HCL POWD 5 RX/OTC UNIT/15ML XX VITAMIN E ACETATE 5 pyridoxine hcl soln ij 100 2 POWD mg/ml VITAMIN K1 SOLN 4 SODIUM ASCORBATE 5 GRAN XX WELLESSE VITAMIN D3 6 SODIUM ASCORBATE 5 RX/OTC LIQD POWD XX WHEAT GERM OIL 5 sodium ascorbate soln ij 2

Water Soluble Vitamins THIAMINE HCL POWD XX 5 RX/OTC 4-AMINOBENZOIC ACID 5 POTASSIUM SALT POWD thiamine hcl soln ij 100 2 mg/ml AMINOBENZOIC ACID 5 POWD THIAMINE 5 RX/OTC HYDROCHLORIDE POWD ASCORBIC ACID GRAN 5 OR ascorbic acid soln ij 500 2 mg/ml

Updated August 1, 2018

240 Index 1ST RELIEF TOPICAL SPRAY ACCU-CHEK COMPACT PLUS ACTICOAT 7 4"X5" 102 96 CLEAR CONTROL SOLUTION ACTICOAT ABSORBENT 2ND SKIN MOIST BURN (2 LEVELS) 142 ANTIMICROBIAL DRESSING PADS1.5"X2" 102 ACCU-CHEK GUIDE 4"X5" 102 2ND SKIN MOIST BURN CONTROL ACTICOAT ANTIMICROBIAL PADS2"X3" 102 LEVEL1/LEVEL2 142 DRESSING 2"X2" 102 2ND SKIN MOIST BURN ACCU-CHEK SMARTVIEW ACTICOAT ANTIMICROBIAL PADS3"X4" 102 CONTROL 142 DRESSING 4"X4" 102 2ND SKIN MOIST DRESSING ACCUCAINE 96 ACTICOAT FLEX 3 BARRIER KIT 102 ACCUPRIL 40 DRESSING 4"'X4" 102 2ND SKIN MOIST GEL PADS ACTIDOM DMX 73 1"X1" 102 ACCURETIC 42 2ND SKIN MOIST GEL PADS 3" ACCUTREND GLUCOSE ACTIGALL 125 ROUND 102 CONTROL 142 ACTIMARIS WOUND GEL 102 2ND SKIN QUICK HEAL 102 ACD FORMULA A 22 ACTIMMUNE 51 3ML GLASS SYR KIT/1ML ACD FORMULA B 22 ACTIQ 7 NAHEP/SWAB/GAUZE/TIP ACD-A NOCLOT-50 22 CAP/NDL STOPPER 116 ACTIVASE 129 3ML GLASS SYR KIT/1ML acebutolol hcl 61 ACTIVE FE 130 NAHEP/SWAB/PREP/CAP/NDL ACEON 40 ACTIVE INJECTION KIT BLM- ST/LABEL/DRAP 116 ACETADOTE 34 1 69 4-AMINOBENZOIC ACID acetaminophen w/ codeine 11 ACTIVE INJECTION KIT BM69 POTASSIUM SALT 240 acetaminophen-caff-dihydrocod ACTIVE INJECTION KIT D 69 5 DAY 98 11 ACTIVE INJECTION KIT DL 69 5ML GLASS SYR KIT/1ML ACETAMINOPHEN/CAFFEINE NAHEP/SWAB/GAUZE/TIP ACTIVE INJECTION KIT /DIHYDROCODEINE 11 DLM 69 CAP/NDL STOPPER 116 acetazolamide 118 5ML GLASS SYR KIT/1ML ACTIVE INJECTION KIT KET- NAHEP/SWAB/PREP/CAP/NDL acetazolamide sodium 118 L 4 acetic acid 127 ACTIVE INJECTION KIT ST/LABEL/DRAP 116 KETMARC-L 4 8-MOP 83 acetic acid (otic) 222 ACTIVE INJECTION KIT KL- A + D PERSONAL CARE ACETIC ACID/ALUMINUM 3 69 LOTION 89 ACETATE 222 ACTIVE INJECTION KIT KM69 A.A.G.C. KIT IN acetylcysteine 76 TERODERM 80 ACTIVE INJECTION KIT L 69 acetylcysteine (antidote) 34 abacavir sulfate 56,57 ACTIVE INJECTION KIT LM- acetylcysteine (nutrient) 212 2 135 abacavir sulfate-lamivudine 57 ACIDOPHILUS 31 ACTIVE INJECTION KIT LM- abacavir sulfate-lamivudine- DEP-1 69 zidovudine 57 ACIDOPHILUS HIGH- 31 ACTIVE INJECTION KIT LM- ABANEU-SL 130 POTENCY DEP-2 69 ACIDOPHILUS PEARLS 31 ABDEK 160 ACTIVE INJECTION KIT M- ACIDOPHILUS PROBIOTIC ABELCET 35 1 69 BLEND 31 ACTIVE OB 201 ABILIFY 56 ACIDOPHILUS SUPER ACTIVE-CYCLOBENZAPRINE ABILIFY MAINTENA 56 PROBIOTIC 31 ACIDOPHILUS/GOAT KIT 209 ABRAXANE 52 MILK 31 ACTIVE-KETOPROFEN KIT 80 ABSORICA 76 ACIPHEX 233 ACTIVE-PAC/GABAPENTIN 227 ABSTRAL 7 233 ACIPHEX SPRINKLE ACTIVE-PREP KIT I 80 acamprosate calcium 226 83 acitretin ACTIVE-PREP KIT II 80 ACANYA 76 85 ACLOVATE ACTIVE-PREP KIT III 80 acarbose 28 4 ACTEMRA ACTIVE-PREP KIT IV 80 ACCOLATE 19 235 ACTHIB ACTIVE-PREP KIT V 81 ACCU-CHEK AVIVA 142 ACTICLATE 229 ACTIVE-TRAMADOL KIT 80 ACTICOAT 7 2"X2" 102 ACTIVELLA 123

Index 1 ACTIVITE EC 160 ADOXA PAK 1/100 229 AFLURIA PF 2017-2018 235 ACTIVNUTRIENTS 160 ADOXA PAK 1/150 229 AFLURIA PF 2018-2019 235 ACTONEL 119 ADOXA PAK 2/100 229 AFLURIA QUADRIVALENT ACTOPLUS MET 28 ADRENACLICK 238 2016-2017 235 AFLURIA QUADRIVALENT ACTOPLUS MET XR 28 ADRENAL C FORMULA 159 2017-2018 235 ACTOS 30 ADRENAL STRESS AFLURIA QUADRIVALENT ACUICYN ANTIMICROBIAL CALM 207 2018-2019 236 EYELID & EYELASH ADRENALIN 211 AFREZZA 30 HYGIENE 100 ADRENOID 207 AGAMATRIX CONTROL ACUICYN DAILY EYELID & ADVAIR DISKUS 20 HIGH 143 EYELASH CLEANSER 100 AGAMATRIX CONTROL ACULAR 221 ADVAIR HFA 20 NORMAL 143 ADVANCE INTUITION AGAMATRIX CONTROL ACULAR LS 221 CONTROL SOLUTION 143 ACURA CONTROL SOLUTION NORMAL& HIGH 143 ADVANCE MICRO-DRAW AGGRASTAT 128 HIGH 142 CONTROL LEVEL 1-2 143 ACURA CONTROL SOLUTION ADVANCE MICRO-DRAW AGGRENOX 129 LOW 143 NORMAL CONTROL 143 AGRYLIN 129 ACURA CONTROL SOLUTION ADVANCED ALLERGY AIF #2 DRUG NORMAL 143 COLLECTION KIT 85 PREPARATIONKIT 80 ACUVAIL 221 ADVANCED AM/PM 160 AIF #3 DRUG PREPARATION acyclovir 60 ADVANCED C PLUS 159 KIT 80 acyclovir sodium 60 AIRDUO RESPICLICK ADVANCED COLLAGEN 207 113/14 20 ACYCLOVIR SODIUM 60 ADVANCED DIABETIC AIRDUO RESPICLICK acyclovir topical 84 MULTIVITAMIN 232/14 20 ACZONE 76 FORMULA 160 AIRDUO RESPICLICK 55/1420 ADVANCED PROBIOTIC 31 ADACEL 230 AKOVAZ 239 ADVANCED PROBIOTIC ADALAT CC 62 10 31 AKTEN 219 adapalene 76 ADVOCATE CONTROL AKTIPAK 76 ADAPALENE 76 SOLUTIONHIGH 143 AKYNZEO 35 ADVOCATE CONTROL adapalene-benzoyl peroxide 76 SOLUTIONLOW 143 ALA SCALP 85 ADAPTIC NON-ADHERING ADVOCATE REDI-CODE+ ALA-QUIN 81 DRESSING 3" X 3" 102 CONTROL SOLUTION ALAHIST DM 73 ADASUVE 55 HIGH 143 ALANINE 212 ADAZIN 96 ADVOCATE REDI-CODE+ ALBENZA 14 ADCETRIS 47 CONTROL SOLUTION LOW 143 ALBOLENE 89 ADCIRCA 64 ADYNOVATE 128 albuterol sulfate 20 ADDERALL 1 ADYPHREN AMP II KIT 238 ALBUTEROL SULFATE ER 20 ADDERALL XR 1 ADYPHREN AMP KIT 238 ALCAINE 219 ADDITIONS FOOD ENHANCER 212 ADYPHREN II 238 alclometasone dipropionate 85 ADDYI 227 ADYPHREN KIT 238 ALCOH-GLOVE CONTOURED WIPE 147 adefovir dipivoxil 59 ADZENYS ER 1 alcohol 212 ADEMPAS 64 ADZENYS XR-ODT 1 ALCOHOL PADS 147 ADENOCARD 18 AEROSPAN 19 ALCOHOL PREP PADS 147 adenosine 18 AFINITOR 49 ALCOHOL PREPS 147 ADENOSINE 18 AFINITOR DISPERZ 49 ALCOHOL SWABS 147 ADMELOG 30 AFLURIA 2016-2017 235 ALCOHOL SWABSTICK 147 ADMELOG SOLOSTAR 30 AFLURIA 2017-2018 235 ALCOHOL WIPES 147 ADOXA 229 AFLURIA 2018-2019 235 ALCORTIN A 81 AFLURIA PF 2016-2017 235

Index 2 ALDACTAZIDE 118 ALLEVYN GENTLE alprostadil 156 ALDACTONE 119 BORDER 102 ALREX 219 ALLEVYN GENTLE BORDER ALDARA 95 HEEL 102 ALTABAX 81 ALDURAZYME 121 ALLEVYN GENTLE BORDER ALTACE 40 ALECENSA 49 LITE 102 ALTOPREV 39 ALLEVYN GENTLE BORDER ALENDRONATE SODIUM 119 MULTISITE 102 ALUNBRIG 49 alendronate sodium 119 ALLEVYN GENTLE BORDER ALUVEA 89 ALENDRONATE SODIUM 119 SACRUM 102 ALVESCO 19 alendronate sodium 119 ALLEVYN HEEL 102 amantadine hcl 53 ALER-DRYL 37 ALLEVYN LIFE 102 AMARYL 31 ALEVAMAX 89 ALLEVYN LIFE HEEL 102 AMBI 60PSE/400GFN 73 ALEVICYN ANTIPRURITIC ALLEVYN LIFE SACRUM102 AMBIEN 134 GEL 98 ALLEVYN NON- AMBIEN CR 134 ALEVICYN ANTIPRURITIC ADHESIVE 102 SG 98 ALLEVYN PLUS AMBISOME 36 ALEVICYN PLUS 99 ADHESIVE 102 AMCINONIDE 85 ALFERON N 51 ALLEVYN PLUS CAVITY 102 AMD FOAM DRESSING 4"X4" 138 alfuzosin hcl 127 ALLEVYN PLUS SACRUM 102 AMD FOAM ALIGN 31 ALLEVYN SACRUM 103 DRESSING/TOPSHEET ALIGN EXTRA STRENGTH 31 ALLEVYN THIN 138 4"X4" 138 ALIMTA 46 ALLEVYN TRACHEOSTOMY AMELUZ 83 ALINIA 15 3-1/2"X3-1/2" 103 AMERGE 150 ALIVE ENERGY 50+ 160 ALLO-PAX 83 AMERIGEL WOUND allopurinol 128 DRESSING 103 ALIVE MENS ENERGY 160 AMICAR 133 ALIVE ONCE DAILY WOMENS allopurinol sodium 128 AMIDATE 126 50+ ULTRA POTENCY 160 ALLZITAL 6 ALIVE ONCE DAILY WOMENS amikacin sulfate 2 ULTRA POTENCY 160 almotriptan malate 149 amiloride & ALIVE WOMENS 50+ 160 ALOCANE EMERGENCY hydrochlorothiazide 118 BURN MAXIMUM amiloride hcl 119 ALIVE WOMENS ENERGY160 STRENGTH 96 ALIVIO PATCH 96 amino acid electrolyte ALOCRIL 221 infusion 212 ALKERAN 46 ALOE 10000 & amino acid infusion 212 PROBIOTICS 31 ALLEGRA ALLERGY 37 amino acids 212 ALLEGRA ALLERGY ALOE AFTERSUN CHILDRENS 37 LOTION 89 AMINOBENZOIC ACID 240 ALLEGRA-D 12 HOUR alogliptin benzoate 29 AMINOCAPROIC ACID 133 ALLERGY & CONGESTION 73 alogliptin-metformin hcl 28 aminophylline 21 ALLEGRA-D 24 HOUR alogliptin-pioglitazone 28 AMINOSYN 214 ALLERGY & CONGESTION 73 ALLERWELL ALLERGY ALOMIDE 221 AMINOSYN FORMULA 207 ALOPRIM 128 7%/ELECTROLYTES 213 ALLEVYN ADHESIVE 102 ALOQUIN 81 AMINOSYN II 213,214 ALLEVYN AG ADHESIVE 102 ALORA 123 AMINOSYN M 214 ALLEVYN AG GENTLE alosetron hcl 126 AMINOSYN-HBC 214 BORDER 102 ALOXI 34 AMINOSYN-PF 214 ALLEVYN AG NON- AMINOSYN-PF 7% 214 ADHESIVE 102 ALPHA-KETOGLUTARIC ACID 67 AMINOSYN-RF 214 ALLEVYN AG SACRUM 102 ALPHAGAN P 218 amiodarone hcl 18 ALLEVYN COMPRESSION102 alprazolam 17 AMIODARONE ALLEVYN GENTLE 102 ALPRAZOLAM INTENSOL17 HYDROCHLORIDE/DEXTROSE 18

Index 3 AMITIZA 125 ANASPAZ 231 APTIVUS 57 amitriptyline hcl 27 ANASTIA 96 AQUA GLYCOLIC FACE AMLACTIN CERAPEUTIC 90 anastrozole 48 CREAM 90 AQUA GLYCOLIC HAND & AMLACTIN ULTRA 90 ANCOBON 36 BODYLOTION 90 amlodipine besylate 62 ANDRODERM 13 AQUA LACTEN 90 amlodipine besylate-atorvastatin ANDROGEL 13 AQUACEL calcium 64 ANDROGEL PUMP 13 EXTRA/HYDROFIBER 103 amlodipine besylate-benazepril AQUACEL hcl 42 ANDROID 13 EXTRA/HYDROFIBER2 X amlodipine besylate-olmesartan ANDROXY 13 2 103 medoxomil 42 ANECTINE 211 AQUACEL amlodipine besylate- ANGELIQ 123 EXTRA/HYDROFIBER6 X valsartan 42 6 103 amlodipine-valsartan- ANIMI-3 130 AQUACEL FOAM hydrochlorothiazide 42 ANIMI-3/VITAMIN D 130 3.2"X3.2" 103 AMMONUL 121 ANODYNERX 96 AQUACEL FOAM 4"X4" 103 amoxapine 27 ANORO ELLIPTA 20 AQUACEL FOAM 5"X5" 103 amoxicillin 223 ANTABUSE 226 AQUACEL FOAM 6"X6" 103 amoxicillin & pot ANTARA 38 AQUACEL FOAM 6"X8" 103 clavulanate 224 ANTICOAGULANT CITRATE 103 AMOXICILLIN ER 224 AQUACEL FOAM 7"X7" DEXTROSE SOLUTION A 22 AQUACEL FOAM 8"X5.5" 103 amoxicillin-clarithromycin w/ ANTICOAGULANT CITRATE lansoprazole 234 PHOSPHATE DEXTROSE AQUACEL FOAM 8"X7" 103 AMOXICILLIN/CLAVULANATE SOLUTION 22 AQUACEL HYDROFIBER POTASSIUM 224 ANTICOAGULANT SODIUM WOUNDDRESSING/0.39X18" AMPHADASE 154 CITRATE 22 103 amphetamine- ANTIOXIDANT FORTE 160 AQUADEKS 160 dextroamphetamine 1 ANTIVENIN LATRODECTUS AQUADERM AMPHOTERICIN B 36 MACTANS 223 TREATMENT/MOISTURIZER ampicillin 224 ANTIVENIN MICRURUS 90 AMPICILLIN 224 FULVIUS 223 AQUAMED 90 ANTIVENIN NORTH AQUASITE IMPREGNATED ampicillin & sulbactam AMERICANCORAL sodium 224 DRESSING 2"X2" 103 SNAKE 223 AQUASITE IMPREGNATED ampicillin sodium 224 ANTIZOL 34 DRESSING 4"X4" 103 AMPICILLIN SODIUM 224 ANUSOL-HC 14 AQUASITE IMPREGNATED ampicillin sodium 224 DRESSING 4"X8" 103 ANZEMET 34 AMPICILLIN-SULBACTAM 224 AQUASITE IMPREGNATED AP-HIST DM 73 GAUZE 2"X2" 103 227 AMPYRA AP-ZEL 160 AQUASITE IMPREGNATED GAUZE 4"X4" 103 AMRIX 209 APATATE FORTE 160 AMVISC 221 AQUASITE SHEET DRESSING APEXICON E 85 4"X4" 103 AMVISC PLUS 221 APIDRA 30 AQUASOL A AMYTAL SODIUM 133 APIDRA SOLOSTAR 30 PARENTERAL 239 ANACAINE 96 AQUORAL 157 APLENZIN 26 ANAFRANIL 27 APLICARE ALCOHOL ARALAST NP 228 anagrelide hcl 129 SWABSTICK 148 ARANESP ALBUMIN ANALPRAM ADVANCED 14 APOKYN 53 FREE 130 ARAVA 6 ANALPRAM-HC 14 apraclonidine hcl 218 ARCALYST 3 ANAPROX DS 4 aprepitant 35 ARCAPTA NEOHALER 20 ANASCORP 223 APRISO 125 ARESTIN 157 ANASEPT 56 APTENSIO XR 1 ARGATROBAN 22 APTIOM 23

Index 4 argatroban 22 ASMANEX TWISTHALER 14 atracurium besylate 212 ARGATROBAN 22 METERED DOSES 19 ATRALIN 76 ASMANEX TWISTHALER 30 ARGLAES FILM 2-3/8" X 3- METERED DOSES 20 ATRAPRO ANTIPRURITIC 1/8" 103 ASMANEX TWISTHALER 60 HYDROGEL 103 ARGLAES FILM 3" X 14" 103 METERED DOSES 20 ATRAPRO CP 103 ARGLAES FILM 4" X 4-3/4"103 ASMANEX TWISTHALER 7 ATRAPRO DERMAL ARGLAES FILM 4-3/4" X METERED DOSES 20 SPRAY 103 10" 103 aspirin 7 ATRIPLA 57 ARGLAES ISLAND 2-3/8" X 3- ASPIRIN-CAFFEINE- ATROPEN 231 1/8" 103 DIHYDROCODEINE 11 ATROPINE SULFATE 218,231 ARGLAES ISLAND 4" X 4- aspirin-dipyridamole 129 atropine sulfate 231 3/4" 103 ASSURE 3 CONTROL LEVEL ARGLAES ISLAND 4-3/4" X 1/2 143 ATROPINE SULFATE 231 10" 103 ASSURE 4 CONTROL LEVEL atropine sulfate 231 ARICEPT 226 1/2 143 ATROPINE SULFATE 231 ARIMIDEX 48 ASSURE DOSE NORMAL ATROVENT HFA 19 aripiprazole 56 CONTROL 143 ASSURE DOSE AUBAGIO 227 ARISTADA 56 NORMAL/HIGH AUGMENTED ARISTADA INITIO 56 CONTROL 143 BETAMETHASONE ARIXTRA 21 ASSURE ID SAFETY PEN DIPROPIONATE 85 armodafinil 1 NEEDLES 30G X 3/16" 148 AUGMENTIN 224 ASSURE II CONTROL LEVEL AUGMENTIN ES-600 224 ARMONAIR RESPICLICK 1 143 113 19 ASSURE II CONTROL LEVEL AUGMENTIN XR 224 ARMONAIR RESPICLICK 1/2 143 AURUM 155 232 19 ASSURE PRISM CONTROL AURYXIA 126 ARMONAIR RESPICLICK LEVEL 1/2 143 55 19 ASSURE PRO CONTROL AUSTEDO 227 ARMOUR THYROID 230 LEVEL1/2 143 AUTOJECT 2 148 ARNICA FLOWER 100 ASTAGRAF XL 154 AVADERM 96 ARNICA LG 67 ASTEPRO 210 AVALIDE 42 ARNUITY ELLIPTA 19 ASTERO 96 AVANDIA 30 AROMASIN 48 ASTRINGYN 133 AVAPRO 41 ARRANON 46 AT LAST CONTROL AVAR 76 ARTHROTEC 50 4 SOLUTION 143 AVAR LS 77 ARTHROTEC 75 4 ATABEX EC 202 AVAR LS CLEANSER 77 articaine-epinephrine 135 ATABEX OB 202 AVAR-E LS 77 artificial saliva 157 ATACAND 41 AVASTIN 47 ARTISS 133 ATACAND HCT 42 AVC 238 ARZE-JECT-A 69 atazanavir sulfate 57 AVEED 13 ARZERRA 47 ATELVIA 119 AVEENO ACTIVE NATURALS ARZOL SILVER NITRATE atenolol 61 DAILY MOISTURIZING BODY APPLICATORS 84 atenolol & chlorthalidone 42 YOGURT 90 ASACOL HD 125 ATGAM 154 AVEENO ACTIVE NATURALS DAILY MOISTURIZING BODY ASCLERA 156 ATIVAN 17 YOGURT/APRICO 90 ASCORBIC ACID 240 atomoxetine hcl 1 AVEENO ACTIVE NATURALS ascorbic acid 240 ATOPADERM 99 SKIN RELIEF MOISTURE ASCRIPTIN 7 REPAIR 90 ATOPICLAIR 99 AVEENO DAILY ASMANEX HFA 19 atorvastatin calcium 39 MOISTURIZINGSPF 15 90 ASMANEX TWISTHALER 120 atovaquone 15 AVEENO INTENSE RELIEF METERED DOSES 19 atovaquone-proguanil hcl 44 HAND 90

Index 5 AVEENO POSITIVELY AZOR 42 BASIC AM 160 AGELESSFIRMING BODY 90 AZULFIDINE 125 BASIC PM 160 AVEENO POSITIVELY AGELESSSKIN AZULFIDINE EN-TABS 125 BASIS FACIAL STRENGTHENING BODY B-12 COMPLIANCE MOISTURIZER 100 CREAM 90 INJECTIONKIT 129 BASIS OVERNIGHT 100 AVEENO POSITIVELY B-12 KIT 129 BASLE 90 AGELESSSKIN B-6 FOLIC ACID 130 BAXDELA 124 STRENGTHENING HAND b-complex vitamins 157,158 BAYER BREEZE 2 HIGH CREAM 90 b-complex w/ c & folic CONTROL 143 AVEENO POSITIVELY BAYER BREEZE 2 LOW NOURISHING 24-HOUR ULTRA- acid 158 b-complex w/ minerals 159 CONTROL 143 HYDRATING 90 BAYER BREEZE 2 NORMAL AVEENO POSITIVELY B12 FOLATE 130 CONTROL 143 RADIANT 90 BABY DDROPS 239 BAYER CONTOUR HIGH AVEENO POSITIVELY bacitracin 14 CONTROL 143 RADIANTOVERNIGHT BAYER CONTOUR LOW HYDRATING FACIAL BACITRACIN 218 CONTROL 143 MOISTURI 90 bacitracin-poly-neomycin-hc BAYER CONTOUR NORMAL AVEENO STRESS RELIEF 219 CONTROL 143 MOISTURIZING 90 bacitracin-polymyxin b BD 3ML LL SYR/PREFILL LITH AVELOX 124 (ophth) 218 HEP/GZ/SWAB/CAP/NDL AVELOX ABC PACK 124 BACLOFEN 80 STP/ICE BAG 116 AVENOVA 100 baclofen 209 BD 3ML LL SYR/PREFILL LITH BACLOFEN 209 HEP/GZ/SWAB/CAP/NDL AVENOVA/NEUTROX 100 STP/LBL/ICE 116 AVIDOXY DK 229 BACMIN 160 BD 3ML LL SYR/PREFILL LITH AVODART 127 BACTERIOSTATIC WATER HEP/TIP CAP/NDL FORINJECTION/BENZYL STOP/SAFETYCONE 116 AVOGEL DRESSING/4" X ALCOHOL 225 4" 103 BD 3ML LL SYR/PREFILL LITH BACTOCILL IN HEP/TIP CAP/NEEDLE AVOGEL DRESSING/6" X DEXTROSE 225 48" 103 STOP/22GX1" 116 AVOGEL DRESSING/8" X BACTRIM 15 BD AUTOSHIELD DUO 30G X 8" 103 BACTRIM DS 15 3/16" 148 BD PUDENDAL/LOCAL AVOGEL SHEET/8" X 8" 103 BACTROBAN 81 BLOCKTRAY 1% AVONEX 227 BACTROBAN NASAL 210 LIDOCAINE 136 AVONEX PEN 227 BAL IN OIL 34 BD SWABS SINGLE USE 148 AVYCAZ 65 BAL-CARE DHA 202 BD SWABS SINGLE USE AXERT 150 BALAMINE DM 73 BUTTERFLY 148 AXIRON 13 BALCOLTRA 67 BEAU RX 101 AYGESTIN 225 balsalazide disodium 125 BECONASE AQ 211 azacitidine 46 BAND-AID GAUZE PADS BELBUCA 12 BELEODAQ 49 AZASAN 154 LARGE4" X 4" 138 BAND-AID GAUZE PADS BELLADONNA 67 AZASITE 218 MEDIUM 3" X 3" 138 AZATHIOPRINE 154 BAND-AID GAUZE PADS BELLADONNA & OPIUM 231 BELLADONNA ALKALOIDS & azathioprine 154 SMALL2" X 2" 138 BAND-AID MIRASORB GAUZE OPIUM 231 azelastine hcl 211 SPONGES LARGE 4" X BELSOMRA 134 azelastine hcl (ophth) 221 4" 138 benazepril & AZELEX 77 BANZEL 23 hydrochlorothiazide 42 AZILECT 54 BARACLUDE 59 benazepril hcl 40 BARIATRIC BENDAMUSTINE AZITHROMYCIN 137 HYDROCHLORIDE 46 azithromycin 137 MULTIVITAMINS/IRON 160 BASAGLAR KWIKPEN 30 BENDEKA 46 AZOPT 221 BENEPROTEIN 214

Index 6 BENICAR 41 BETAMETHASONE BIOBRANE 5"X5" 103 BENICAR HCT 42 COMBO 70 BIOBRANE GLOVES betamethasone dipropionate BENLYSTA 156 LARGE 103 (topical) 85 BIOBRANE GLOVES BENSAL HP 95 betamethasone dipropionate MEDIUM 103 BENTYL 231 augmented 85 BIOBRANE GLOVES betamethasone sod phosphate BENZAC AC WASH 77 PEDIATRIC 103 & acetate 70 BIOBRANE GLOVES BENZACLIN 77 BETAMETHASONE SODIUM SMALL 104 BENZACLIN WITH PUMP 77 PHOSPHATE/BETAMETHASO BIOBRANE-L 10"X15" 104 NE ACETATE 70 BENZALKONIUM BIOBRANE-L 5"X15" 104 CHLORIDE 56 betamethasone valerate 85 BENZAMYCIN 77 BETAPACE 62 BIOBRANE-L 5"X5" 104 BENZEFOAM 77 BETAPACE AF 62 BIOCAL 160 BENZEFOAM ULTRA 77 BETASERON 227 BIODESP DM 73 BENZIQ 77 betaxolol hcl 61 bioflavonoid products 159 BIOGUARD GAUZE SPONGE BENZIQ LS 77 betaxolol hcl (ophth) 217 2"X2" 8 PLY 138 BENZIQ WASH 77 bethanechol chloride 235 BIOGUARD GAUZE SPONGES BENZNIDAZOLE 14 BETHKIS 2 4"X4" 12 PLY 138 benzocaine (dental) 156 BETIMOL 217 BIOHM PROBIOTIC SUPPLEMENT 31 BENZODOX 30 KIT 229 BETOPTIC-S 217 BIOHM PROBIOTIC BENZODOX 60 KIT 229 BEVESPI AEROSPHERE 20 SUPPLEMENT/VITAMIN C 31 benzoin compound 100 BEVYXXA 21 BIOLON 221 BENZOIN TINCTURE 100 bexarotene 51 BIOSPEC DMX 73 BENZOIN TINCTURE BEXSERO 235 BIOSUPP 160 PLAIN 100 BEYAZ 67 BIOTALAN CLEAR 158 benzonatate 73 BIATAIN ADHESIVE FOAM BIOTECT PLUS 160 benzoyl peroxide 77 DRESSING 4"X4" 138 BIOTENE DRY MOUTH BENZOYL PEROXIDE 77 BIATAIN FOAM DRESSING MOISTURIZING SPRAY 157 benzoyl peroxide 77 4"X4" 138 BIOTIN 240 BIAXIN 137,138 BENZOYL PEROXIDE 8% 77 BIOTIN PLUS KERATIN 207 BENZOYL PEROXIDE bicalutamide 48 BIOTIN-D 240 CLEANSER 77 BICILLIN C-R 224 bisacodyl-peg 3350-pot chloride- benzoyl peroxide- BICILLIN L-A 224 sod bicarb-sod chloride 135 erythromycin 77 BICNU 46 bisoprolol & benztropine mesylate 53 hydrochlorothiazide 42 BIDIL 64 bisoprolol fumarate 61 BEPREVE 221 BIEST/PROGESTERONE 12 BERINERT 128 3 BIVIGAM 223 BESIVANCE 218 BIFERARX 130 BL INJECTION KIT 135 BETA 1 KIT 69 BIKTARVY 57 BLACK CHERRY CONCENTRATE 155 BETA CARE 90 BILBERRY PLUS 207 BLEO 15K 49 BETA INJECT KIT 69 BILTRICIDE 14 bleomycin sulfate 49 BETA XMA 90 BIMATOPROST 222 BLEPH-10 218 BETADINE OPHTHALMIC BINOSTO 119 BLEPHAMIDE 219 PREP 218 BIO-35 GLUTEN-FREE 160 BETAGAN 217 BLEPHAMIDE S.O.P. 219 BIO-35 IRON FREE 160 BETALIDO 69 BLINCYTO 47 BIO-STATIN 36 BETALOAN SUIK 70 BLOOD GLUCOSE BIOBRANE 10"X15" 103 BETAMETHASONE METERS 143 ACETATE/BETAMETHASONE BIOBRANE 15"X20" 103 BLOOD GLUCOSE TEST 70 BIOBRANE 5"X15" 103 STRIPS 117

Index 7 BLOXIVERZ 45 BT INJECTION KIT 70 BUTORPHANOL BOCASAL 157 BUCALSEP 56 TARTRATE 12 butorphanol tartrate 12 BODY CHOICE HOODIA budesonide 70 BUTRANS 12 WEIGHTLOSS/HIGH budesonide (inhalation) 20 FIBER 155 BYDUREON 29 BONIVA 119 budesonide (nasal) 211 BUFFERED BYDUREON BCISE 29 BONJESTA 35 LIDOCAINE/SODIUM BYDUREON PEN 29 BOOSTRIX 230 BICARBONATE 135 BYETTA 29 BORDERED GAUZE 138 BUFFERED BYSTOLIC 61 BORIC ACID 100 LIDOCAINE/SODIUMBICARBO NATE 135 BYVALSON 42 BOSULIF 49 bumetanide 118 C-NATE DHA 202 BOTOX 211 BUMEX 118 CA-PLUS 207 BP CLEANSING WASH 77 BUNAVAIL 12 cabergoline 123 BP FOLINATAL PLUS B 202 BUPHENYL 121 CABOMETYX 49 BP MULTINATAL PLUS 202 bupivacaine hcl 136 CADIRAMD 96 BP VIT 3 130 BUPIVACAINE CADUET 64 BPO 77 HYDROCHLORIDE 136 CAFCIT 1 BUPIVACAINE BPO CREAMY WASH CAFERGOT 149 COMPLETEPACK 77 HYDROCHLORIDE/SODIUM BRAFTOVI 49 CHLORIDE 136 caffeine citrate 1 CAFFEINE/SODIUM BRAIN 207 bupivacaine in dextrose 136 bupivacaine w/ BENZOATE 1 BRAIN MIGHT/DHA & CO CAL-CO3Y 207 Q10 207 epinephrine 135 BRAVELLE 120 BUPIVILOG KIT 70 CAL-DAY 1000 160 BREO ELLIPTA 20 BUPRENEX 12 CALAN 62 BREVIBLOC 61 BUPRENORPHINE 12 CALAN SR 62 BREVIBLOC PREMIXED 61 buprenorphine hcl 12 CALCIFOL 151 BREVIBLOC PREMIXED buprenorphine hcl-naloxone hcl calcipotriene 83 DOUBLESTRENGTH 61 dihydrate 12 calcipotriene-betamethasone BREVICON-28 67 bupropion hcl 26 dipropionate 85 bupropion hcl (smoking BRIDION 34 calcitonin (salmon) 119 deterrent) 228 CALCITRIOL 83 BRILINTA 129 BURIED TREASURE ACTIVE BRIMONIDE/DORZOLAMIDE P- 55PLUS SENIOR calcitriol 121 F 218 COMPLEX 160 CALCITRIOL 121 brimonidine tartrate 218 buspirone hcl 17 calcitriol 121 BRISDELLE 228 busulfan 46 calcium acetate (phosphate BRIVIACT 23 BUSULFEX 46 binder) 126 CALCIUM ASCORBATE 240 BROMFENAC 221 butalbital-acetaminophen 6 CALCIUM ASCORBATE butalbital-acetaminophen- bromfenac sodium (ophth) 221 DIHYDRATE 240 BROMI-LOTION 99 caffeine 6 butalbital-acetaminophen- calcium chloride (dihydrate)151 bromocriptine mesylate 53 caffeine w/ codeine 11 CALCIUM DISODIUM BROMPHENIRAMINE 37 butalbital-aspirin-caffeine 6 VERSENATE 34 brompheniramine & butalbital-aspirin-caffeine calcium gluconate 151 phenyleph 73 w/cod 11 CALCIUM BROMPHENIRAMINE BUTALBITAL/ACETAMINOPH GLUCONATE/DEXTROSE 151 TANNATE 37 EN 6 CALCIUM BROMSITE 221 BUTALBITAL/ASPIRIN/CAFFEI GLUCONATE/SODIUMCHLORID BROVANA 20 NE 6 E 151 butenafine hcl 81 CALCIUM BSS PLUS 221 PANTOTHENATE 240 BUTISOL SODIUM 133

Index 8 CALCIUM PNV 202 CARDIOPRESS 207 CATAPRES-TTS-3 42 CALCIUM-D-PANTOTHENATE CARDIOVID PLUS 212 CATHFLO ACTIVASE 129 240 CARDIOWHEY 214 CAYA 142 CALCIUM-FOLIC ACID PLUS D 151 CARDIZEM 62 CEDAX 66 CALDOLOR 4 CARDIZEM CD 62 cefaclor 65 CALICYLIC 99 CARDIZEM LA 62 CEFACLOR 65 CALQUENCE 49 CARDURA 41 CEFACLOR ER 65 CAM 90 CARDURA XL 127 cefadroxil 65 CAMBIA 149 CARESENS CONTROL A CEFAZOLIN 65 SOLUTION 143 cefazolin sodium 65 CAMPATH 47 CARETOUCH ALCOHOL CAMPTOSAR 52 PREP PADS 148 CEFAZOLIN SODIUM 65 CANASA 125 CARIMUNE CEFAZOLIN SODIUM/DEXTROSE 65 CANCIDAS 35 NANOFILTERED 223 carisoprodol 209 CEFAZOLIN SODIUM/SODIUM candesartan cilexetil 41 CHLORIDE 65 candesartan cilexetil- carisoprodol w/ aspirin 210 CEFAZOLIN/SODIUM hydrochlorothiazide 42 carisoprodol w/ aspirin & CHLORIDE 65 CAPASTAT SULFATE 45 codeine 210 cefdinir 66 CARNITOR 121 capecitabine 46 CEFDITOREN PIVOXIL 66 CARNITOR SF 121 CAPEX 85 CEFEPIME 66 CAROSPIR 119 CAPHOSOL 157 cefepime hcl 66 CAROZYME 207 CAPITAL/CODEINE 11 CEFEPIME/DEXTROSE 66 CARRADRES 104 CAPRELSA 49 cefixime 66 CARRAGAUZE 2 X 2 104 capsaicin-menthol 96 CEFOTAN 65 CARRAGAUZE 4 X 4 104 CAPSIDERM 96 cefotaxime sodium 66 CARRAGAUZE STRIPS 104 captopril 40 CEFOTAXIME SODIUM 66 CARRASMART 104 CAPTOPRIL/HYDROCHLOROT CEFOTETAN 65 CARRASMART FOAM 138 HIAZIDE 42 cefotetan disodium 65 CAPXIB KIT 4 CARRASORB M DRIGEL104 CEFOTETAN/DEXTROSE 65 CARAC 83 CARRASYN HYDROGEL cefoxitin sodium 65 CARAFATE 233 WOUND DRESSING 104 CARRASYN V HYDROGEL CEFOXITIN SODIUM 65 CARBAGLU 121 WOUNDDRESSING 104 cefpodoxime proxetil 66 carbamazepine 23 CARRINGTON MOISTURE cefprozil 65 CARBAPHEN 12 73 BARRIER 100 CARRINGTON MOISTURE ceftazidime 66 CARBAPHEN 12 PED 73 BARRIER/ZINC 100 CEFTAZIDIME/DEXTROSE 66 CARBATROL 23 CARTEOLOL HCL 217 CEFTIBUTEN 66 carbidopa 53 carteolol hcl (ophth) 217 CEFTIN 65 carbidopa-levodopa 53 CARTICEL 209 CEFTRIAXONE IN ISO- CARBIDOPA/LEVODOPA/ENTA carvedilol 61 OSMOTIC DEXTROSE 66 CAPONE 53 ceftriaxone sodium 66 carbinoxamine maleate 37 carvedilol phosphate 61 CEFTRIAXONE SODIUM 66 CARBOCAINE 136 CASCARA SAGRADA 135 ceftriaxone sodium 66 CARBOFLEX ODOR CONTROL CASODEX 48 DRESSING 104 caspofungin acetate 35 CEFTRIAXONE/DEXTROSE 66 carbonyl iron 132 CASPOFUNGIN cefuroxime axetil 65 carboplatin 46 ACETATE 35 cefuroxime sodium 65 CARDENE IV 62 CATAPRES 42 CATAPRES-TTS-1 42 CEFUROXIME CARDIO TONE 207 SODIUM/SODIUMCHLORIDE cardioplegic soln 64 CATAPRES-TTS-2 42 218

Index 9 CELACYN POST-PROCEDURE CENTRUM ULTRA CHELIDONIUM PACK 104 MENS 162 COMPOUND 155 CELEBRATE MULTI- CENTRUM ULTRA CHEMET 33 COMPLETE18 160 WOMENS 162 CHEMSTRIP-K 117 CELEBRATE MULTI- CENTRUM WOMEN 162 CHENODAL 125 COMPLETE36 161 cephalexin 65 CELEBRATE MULTI- CHERACOL PLUS 74 CEPHALEXIN 65 COMPLETE45 161 CHERACOL-D COUGH 74 CELEBRATE MULTI- CERACADE 99 CHILDRENS ADVIL 4 COMPLETE60 161 CERAVE 90 CHILDRENS MOTRIN 4 CELEBREX 4 CERAVE AM SPF 30 90 celecoxib 4 CHILDRENS PROBIOTIC CERAVE PM 90 PEARLS 31 CELESTONE-SOLUSPAN 70 CERAVE RENEWING SA 90 CHLORAMPHENICOL SODIUM CELEXA 26 CERAVE SA RENEWING 90 SUCCINATE 16 chlordiazepoxide hcl 18 CELLCEPT 154 CERDELGA 129 CELLCEPT chlordiazepoxide hcl-clidinium INTRAVENOUS 154 CEREBYX 25 bromide 231 CELLUGEL 221 CEREZYME 129 CHLORDIAZEPOXIDE/AMITRIP TYLINE 226 CELLULAR SECURITY 161 CEROVITE ADVANCED FORMULA 162 CHLORHEXIDINE CELONTIN 25 CERTAVITE GLUCONATE 56 CEM-UREA 89 SENIOR/ANTIOXIDANT chlorhexidine gluconate (mouth- CEMILL PLUS 159 NUTRIENTS 162 throat) 157 chloroprocaine hcl 137 CENFOL 130 CERVARIX 236 CESAMET 35 CHLOROQUINE CENTANY 81 PHOSPHATE 44 CETACAINE 96 CENTANY AT 81 chloroquine phosphate 44 CETAPHIL 90 CENTRATEX 130 CHLOROTHIAZIDE 119 CETAPHIL DAILY ADVANCE CENTRAVITES 50 PLUS 161 ULTRA HYDRATING 90 chlorothiazide 119 CENTRAVITES ADULTS 161 CETAPHIL DAILY FACIAL chlorothiazide sodium 119 CENTRUM 161,162 MOISTURIZER 90 chlorpheniramine & CENTRUM ADULTS 161 CETAPHIL DERMACONTROL phenylephrine 74 MOISTURIZER/SPF 30 90 chlorpheniramine & CENTRUM CARDIO 161 CETAPHIL pseudoeph 74 CENTRUM MEN 161 MOISTURIZING 90 CHLORPROMAZINE HCL 55 CETAPHIL CENTRUM chlorpromazine hcl 55 PERFORMANCE 207 RESTORADERM 90 CENTRUM SILVER 162 CETAPHIL THERAPEUTIC chlorpropamide 31 CENTRUM SILVER HAND 91 chlorthalidone 119 50+MEN 161 cetirizine hcl 37 CHLORZOXAZONE 209 CENTRUM SILVER cetirizine-pseudoephedrine CHOICEFUL 50+WOMEN 161 74 MULTIVITAMIN 162 CENTRUM SILVER ADULT CETRAXAL 222 CHOLASE CONTROL 207 50+ 161 CETROTIDE 120 CENTRUM SILVER ULTRA CHOLBAM 125 MENS 162 CETYLEV 34 cholecalciferol 240 CENTRUM SILVER ULTRA cevimeline hcl 157 cholestyramine 38 WOMENS 162 CHANTIX 228 cholestyramine light 38 CENTRUM SPECIALIST CHANTIX CONTINUING choline & mag salicylate 7 ENERGY 207 MONTHPAK 228 CENTRUM SPECIALIST CHANTIX STARTING MONTH CHOLINE BITARTRATE 212 HEART 162 PAK 228 choline fenofibrate 38 CENTRUM SPECIALIST CHEK-STIX COMBO PAK CHORIONIC IMMUNE SUPPORT 162 URINALYSIS CONTROL 117 GONADOTROPIN 120 CENTRUM SPECIALIST CHEK-STIX CONTROL 117 VISION 162 CHROMIUM CHLORIDE 153

Index 10 CIALIS 64 CITRANATAL clindamycin phosphate- CICA-CARE 104 HARMONY 202 tretinoin 78 CITRANATAL MEDLEY 202 CLINDAMYCIN CICLODAN CREAM KIT 81 CITRANATAL RX 202 PHOSPHATE/BENZOYL CICLODAN SOLUTION KIT 81 PEROXIDE 78 CITRUS BERGAMOT 2 ciclopirox 81 CLINDESSE 238 cladribine 47 ciclopirox olamine 81 CLINICAL NUTRIENTS 45-PLUS CLAFORAN 66 WOMEN 162 cidofovir 59 CLARINEX 37 CLINICAL NUTRIENTS 50-PLUS CIFEREX 130 MEN 162 CLARINEX-D 12 HOUR 74 CIFRAZOL 130 CLINICAL NUTRIENTS CLARITHROMYCIN 138 cilostazol 129 ANTIOXIDANT 162 clarithromycin 138 CLINICAL NUTRIENTS FOR CILOXAN 218 CLEAN & CLEAR MORNING FEMALE TEENS 162 CIMDUO 57 BURST HYDRATING CLINICAL NUTRIENTS FOR cimetidine 232 MOISTURIZER 91 MALE TEENS 162 clemastine fumarate 37 CLINICAL NUTRIENTS FOR CIMETIDINE HCL 232 MEN 162 CIMZIA 125 CLEMASTINE CLINICAL NUTRIENTS FOR FUMARATE 37 CIMZIA STARTER KIT 125 WOMEN 162 CLENPIQ 135 CINQAIR 19 CLINIMIX 2.75%/DEXTROSE CLEOCIN 16,238 5% 214 CINRYZE 128 CLEOCIN IN D5W 16 CLINIMIX 4.25%/DEXTROSE CIPRO 124 CLEOCIN PEDIATRIC 10% 214 CIPRO HC 222 GRANULES 16 CLINIMIX 4.25%/DEXTROSE 20% 214 CIPRO I.V.-IN D5W 124 CLEOCIN PHOSPHATE 16 CLINIMIX 4.25%/DEXTROSE CIPRO XR 124 CLEOCIN-T 77 25% 214 CIPRODEX 222 CLEVER CHOICE COMFORT CLINIMIX 4.25%/DEXTROSE CIPROFLOXACIN 124 EZPATCH 96 5% 214 CLEVER CHOICE GLUCOSE CLINIMIX 5%/DEXTROSE ciprofloxacin 124 CONTROL HIGH 143 15% 214 CIPROFLOXACIN 222 CLEVER CHOICE GLUCOSE CLINIMIX 5%/DEXTROSE CIPROFLOXACIN HCL 124 CONTROL LOW 143 20% 214 CLIMARA 123 CLINIMIX 5%/DEXTROSE ciprofloxacin hcl 124 25% 214 ciprofloxacin hcl (ophth) 218 CLIMARA PRO 123 CLINIMIX E 2.75%/DEXTROSE ciprofloxacin in d5w 124 CLIN SINGLE USE KIT 16 10% 214 ciprofloxacin-ciprofloxacin CLINDACIN ETZ 77 CLINIMIX E 2.75%/DEXTROSE hcl 124 CLINDACIN PAC 77 5% 214 CLINIMIX E 4.25%/DEXTROSE cisatracurium besylate 212 CLINDAGEL 77 10% 214 CISATRACURIUM clindamycin hcl 16 CLINIMIX E 4.25%/DEXTROSE BESYLATE 212 clindamycin palmitate 25% 214 CISPLATIN 46 hydrochloride 16 CLINIMIX E 4.25%/DEXTROSE cisplatin 46 clindamycin phosphate 16 5% 214 citalopram hydrobromide 26 CLINDAMYCIN CLINIMIX E 5%/DEXTROSE CITANEST FORTE PHOSPHATE 78 15% 215 clindamycin phosphate CLINIMIX E 5%/DEXTROSE DENTAL 135 20% 215 CITANEST PLAIN DENTAL136 (topical) 77 clindamycin phosphate in CLINIMIX E 5%/DEXTROSE CITRANATAL 90 DHA 202 d5w 16 25% 215 CITRANATAL ASSURE 202 clindamycin phosphate CLINIMIX N14G30E 215 CITRANATAL B-CALM 202 vaginal 238 CLINIMIX N9G20E 215 CITRANATAL BLOOM 202 clindamycin phosphate-benzoyl CLINOIN 78 peroxide 78 CITRANATAL BLOOM clindamycin phosphate-benzoyl CLN FACIAL MOISTURIZER DHA 202 peroxide (refrigerate) 78 NOURISHING 91 CITRANATAL DHA 202 clobetasol propionate 85

Index 11 clobetasol propionate emollient codeine sulfate 7 CONFORMANT 2 WOUND VEIL base 85 CODEINE SULFATE 7 12"X12" 104 clobetasol propionate CONFORMANT 2 WOUND VEIL emulsion 85 codeine sulfate 7 12"X24" 104 CLOBEX 85 CODEINE SULFATE 7 CONFORMANT 2 WOUND VEIL CLOCORTOLONE CODITUSSIN AC 74 24"X36" 104 CONFORMANT 2 WOUND VEIL PIVALATE 85 COGENTIN 53 CLOCORTOLONE PIVALATE 3"X5YD 104 PUMP 85 COLAZAL 125 CONFORMANT 2 WOUND VEIL CLODAN KIT 85 COLCHICINE 128 4"X12" 104 colchicine w/ probenecid 128 CONFORMANT 2 WOUND VEIL CLODERM 85 4"X4" 104 CLODERM PUMP 85 COLCRYS 128 CONFORMANT 2 WOUND VEIL clofarabine 47 colesevelam hcl 38 6"X2YD 104 CLOLAR 47 COLESTID 38 CONGESTAC 74 COLESTID FLAVORED 38 CONTOUR NEXT CONTROL clomiphene citrate 120 LEVEL 1 143 CLOMIPHENE CITRATE 120 colestipol hcl 38 CONTOUR NEXT CONTROL clomipramine hcl 27 COLLADERM 99 LEVEL 2 143 clonazepam 22 COLLAGEN ULTRA 207 CONTREET FOAM 104 clonidine hcl 42 COLY-MYCIN S 222 CONTREET FOAM CAVITY 104 clonidine hcl (adhd) 1 COLYTE-FLAVOR PACKS 135 CONTREET FOAM HEEL 104 clonidine hcl (analgesia) 6 COMBIGAN 217 CONTREET FOAM clopidogrel bisulfate 129 COMBIPATCH 123 SACRAL 104 clorazepate dipotassium 18 CONTREET COMBIVENT RESPIMAT 20 HYDROCOLLOID 104 CLORPRES 42 COMBIVIR 57 CONTROL SOLUTION clotrimazole 156 COMETRIQ 49 NORMAL 143 clotrimazole (topical) 81 COMFEEL FILM 104 CONVENIENCE PAK 227 clotrimazole w/ COMFEEL PLUS CONZIP 7 betamethasone 81 CLEARDRESSING 104 COOL CONTROL SOLUTION clozapine 55 COMFEEL PLUS A 143 CLOZAPINE ODT 55 CONTOURDRESSING 104 COOL CONTROL SOLUTION CLOZARIL 55 COMFEEL PLUS B 143 DRESSING 104 COOLMAGIC 104 CMX PATCH 96 COMFEEL PLUS COOLMAGIC TUBE SITE CNL8 NAIL KIT 81 TRIANGLEDRESSING 104 DRESSING 104 CO-BALAMIN 2 COMFEEL PLUS ULCER COPA ISLAND BORDERED CO-NATAL FA 202 DRESSING 104 FOAM DRESSING 4"X4" 138 COMFEEL PLUS COPA PLUS HYDROPHILIC CO-VERATROL 2 ULCERDRESSING 104 FOAM DRESSING 4"X4" 138 COAL TAR 102 COMFEEL ULCER COPASIL 91 COARTEM 44 CAREDRESSING 104 COPAXONE 227 COMFORT-AID 1.5"X2.5"104 COCA COLA SYRUP 35 COPEGUS 59 COMPLERA 57 COCAINE HCL 96 COPPER TRACE METAL 153 COMPLETE NATAL DHA202 COCOA BUTTER 91 CORDRAN 85,86 COMPLETENATE 202 COCOA BUTTER HAND & CORDRAN TAPE 86 BODYLOTION 91 COMTAN 53 COREG 61 COCOA BUTTER PETROLEUM CONCEPT DHA 202 JELLY 91 COREG CR 61 CONCEPT OB 202 COCONUT OIL BEAUTY 91 CONCEPTIONXR MOTILITY CORGARD 62 COD LIVER OIL 209 SUPPORT FORMULA 162 CORLANOR 64 COD LIVER OIL FOR KIDS209 CONCERTA 1 CORLOPAM 44 CODAR AR 74 CONDYLOX 95

Index 12 CORNWALL METAL cromolyn sodium 19 CURITY GAUZE PADS PIPETTINGHOLDER (FOR cromolyn sodium 3"X3" 139 1240S) 149 (mastocytosis) 125 CURITY GAUZE PADS 4"X4" 12 CORNWALL METAL cromolyn sodium (ophth) 221 PLY 139 PIPETTINGHOLDER (FOR CURITY GAUZE SPONGE 2"X2" 1250S) 149 crotamiton 101 8 PLY 139 CORNWALL METAL CRYSVITA 121 CURITY GAUZE SPONGE PIPETTINGHOLDER (FOR CU-PLUS 207 2"X2"12 PLY 139 1260S) 149 CURITY GAUZE SPONGE 3"X3" CORNWALL METAL CUBICIN 16 12 PLY 139 PIPETTINGHOLDER (FOR CUBICIN RF 16 CURITY GAUZE SPONGE 4"X4" 1270S) 149 CULTURELLE ADVANCED 12 PLY 139 CORTANE-B 86 IMMUNE DEFENSE 31 CURITY GAUZE SPONGE 4"X4" 16 PLY 139 CORTANE-B AQUEOUS 222 CULTURELLE PRO-WELL31 CUPRIMINE 154 CURITY GAUZE SPONGE 4"X4" CORTEF 70 8 PLY 139 CURAFIL GEL WOUND CURITY GAUZE SPONGE CORTENEMA 13 DRESSING 104 CORTIFOAM 13 4"X4"16 PLY 139 CURE-ALL 99 CURITY GAUZE SPONGES CORTISONE ACETATE 70 CUREX ALL-PURPOSE 4"X4" 12 PLY 139 CORTISPORIN 81 SPONGES 4"X4" 4 PLY 138 CURITY GAUZE SPONGES CORVERT 18 CURITY ALCOHOL 4"X4" 8 PLY 139 PREPS/MEDIUM 2 PLY 148 CURITY HEAVY DRAINAGE CORVITE 162 CURITY ALCOHOL PACK 104 CORVITE 150 130,131 SWABS 148 CURITY HYPERTONIC CORVITE FE 131 CURITY ALL PURPOSE SODIUMCHLORIDE PACKING SPONGES 2"X2" 139 CORZIDE 42 STRIP 1/2"X15' 104 CURITY ALL PURPOSE CURITY NON-ADHERENT COSENTYX 83 SPONGES 2"X2" 4PLY 139 STRIPS 3"X3" 139 COSENTYX SENSOREADY CURITY ALL PURPOSE CURITY SALINE DRESSING PEN 83 SPONGES 3"X3" 4PLY 139 8"X4" 104 COSMEGEN 49 CURITY ALL PURPOSE CURITY SODIUM CHLORIDE COSOPT 217 SPONGES 4 PLY 139 DRESSING 6"X6-3/4" 105 CURITY ALL PURPOSE CURITY COSOPT PF 217 SPONGES 4"X4" 139 SPONGES/CELLULOSEFILLED/ COTELLIC 49 CURITY ALL PURPOSE 2"X2" 139 COTEMPLA XR-ODT 1 SPONGES 4"X4" 4PLY 139 CURITY CURITY ALL PURPOSE COUMADIN 21 SPONGES/CELLULOSEFILLED/ SPONGES 4"X4" 4PLY/SOFT 4"X4" 139 COVRSITE COVER POUCH 139 CURITY UNNA BOOT DRESSING 138 CURITY AMD 3"X10YD 105 COVRSITE PLUS COMPOSITE ANTIMICROBIALGAUZE CURITY UNNA BOOT DRESSING 138 SPONGES 2"X2" 8 PLY 139 4"X10YD 105 COZAAR 41 CURITY AMD CUROSURF 229 CRAMP RELEAF 155 ANTIMICROBIALGAUZE CUSHINGS SYNDROME CRAN-B-OTC 155 SPONGES 4"X4" 12 PLY 139 DIAGNOSTIC 116 CURITY COVER SPONGE CRANBLADDER RELEAF 155 4"X4" 139 CUTICERIN 3"X16" 105 CREAM BASE NIOSOMES225 CURITY COVER SPONGES CUTICERIN 3"X3" 105 CREAM-HEAVY BASE 3"X3" 139 CUTICERIN 3"X8" 105 NIOSOME 225 CURITY COVER SPONGES CUTICERIN 4"X4" 105 CREON 118 4"X4" 139 CURITY DRESSING CUTICERIN 8"X16" 105 CRESEMBA 36 SPONGES 4"X4" 6 PLY 139 CUTINOVA HYDRO 2"X2- CRESTOR 39 CURITY GAUZE PADS 3/8" 105 CRINONE 238 2"X2" 139 CUTINOVA HYDRO 4"X4" 105 CRIXIVAN 57 CURITY GAUZE PADS 2"X2" CUTINOVA HYDRO 6"X8" 105 12 PLY 139 CROFAB 223 CUTIVATE 86

Index 13 CUVITRU 223 CVS WHEY PROTEIN 215 DAILY PAK MAXIMUM CUVPOSA 231 CYANOCOBALAMIN 129 MULTIVITAMIN/ASIAN GINSENG EXTRACT 163 CVS ADULT 50+ cyanocobalamin 129 DAILY PROBIOTIC 32 PROBIOTIC 31 CYANOKIT 34 CVS ADULT PROBIOTIC 32 DAKLINZA 59 CYCLESSA 67 CVS ALCOHOL PREP DALIRESP 19 PADS 148 CYCLO/GABA10/300 PACK 210 DALVANCE 14 CVS ALCOHOL PREP danazol 13 SWABS 148 cyclobenzaprine hcl 209 CVS COD LIVER OIL 209 CYCLOGYL 218 DANTRIUM 210 CVS DAILY ULTRA CYCLOMYDRIL 218 DANTRIUM IV 210 MOISTURELOTION 91 cyclopentolate hcl 218 dantrolene sodium 210 CVS DIABETES HEALTH CYCLOPHENE dapsone 16 SUPPORT 162 RAPIDPAQ 209 CVS DIGESTIVE dapsone (topical) 78 PROBIOTIC 32 cyclophosphamide 46 DAPTACEL 230 CVS DRY MOUTH SPRAY 157 CYCLOPHOSPHAMIDE 46 daptomycin 16 CVS GAUZE PAD 3"X3" 139 cyclophosphamide 46 DARAPRIM 44 CVS GAUZE PADS 2"X2" 12- CYCLOSERINE 45 darifenacin hydrobromide 235 PLY 139 CYCLOSET 29 DARZALEX 47 CVS GAUZE PADS 4"X4" 12- cyclosporine 154 PLY 139 daunorubicin hcl 49 CVS GAUZE PADS STERILE CYCLOSPORINE DAXBIA 65 4"X4" 12-PLY 139 MODIFIED 154 cyclosporine modified (for DAYPRO 4 CVS HAIR/SKIN/NAILS 207 microemulsion) 154 DAYTRANA 1 CVS ISOPROPYL ALCOHOL CYFOLEX 131 WIPES 100 DDAVP 122 CVS MANUKA HONEY WOUND CYKLOKAPRON 133 DEBACTEROL 157 GEL 105 CYMBALTA 27 decitabine 47 CVS MOISTURIZING cyproheptadine hcl 38 CREAM 91 DECON-A 74 CVS ONE DAILY MENS 50+ CYRAMZA 47 DECON-G 74 ADVANCED 162 CYSTADANE 121 DECUBI-VITE 163 CVS PREP PADS 148 CYSTAGON 127 DEEP HEALTH 155 CVS PROBIOTIC 32 CYSTARAN 221 DEEP SLEEP 155 CVS PROBIOTIC MAXIMUM cytarabine 47 deferoxamine mesylate 34 STRENGTH 32 CVS PROBIOTIC PEARLS CYTARABINEAQUEOUS 47 DEFITELIO 21 EXTRA STRENGTH 32 CYTO CARN 215 DEKAS ESSENTIAL 199 CVS SENIOR PROBIOTIC 32 CYTO RALA 2 DEKAS PLUS 163 CVS SILVER GEL 105 CYTOGAM 223 DELESTROGEN 123 CVS SPECTRAVITE ADULT CYTOMEL 230 DELZICOL 125 50+ 163 CYTOTEC 234 CVS SPECTRAVITE ULTRA DEMADEX 118 MEN50+ 163 CYTOVENE 59 demeclocycline hcl 229 CVS SPECTRAVITE ULTRA CYTRA-3 127 DEMEROL 7 MENS HEALTH 163 D-VI-SOL 240 DEMSER 41 CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR 163 D.H.E. 45 149 DENAVIR 84 CVS SPECTRAVITE ULTRA DACARBAZINE 51 DEPACON 25 WOMEN 163 dacarbazine 51 DEPAKENE 25,26 CVS SPECTRAVITE ULTRA DACOGEN 47 WOMENS HEALTH 163 DEPAKOTE 26 CVS SPECTRAVITE ULTRA dactinomycin 49 DEPAKOTE ER 26 WOMENS HEALTH DAILY HEART HEALTH DEPAKOTE SPRINKLES 26 SUPPORT 163 SENIOR 163 DEPEN TITRATABS 154

Index 14 DEPO-ESTRADIOL 123 DERMACEA TYPE VII GAUZE DERMAGRAN-B HYDROPHILIC DEPO-MEDROL 70 3"X3" 12 PLY 140 WOUND DRESSING 105 DERMACEA TYPE VII GAUZE DERMAIDE ALOE 91 DEPO-PROVERA 48 3"X3" 12PLY 140 DERMAL THERAPY EXTRA DEPO-PROVERA DERMACEA TYPE VII GAUZE STRENGTH BODY LOTION 91 CONTRACEPTIVE 69 4"X4" 12 PLY 140 DERMAL THERAPY FACE DEPO-SUBQ PROVERA DERMACEA TYPE VII GAUZE CAREMOISTURIZING 104 69 4"X4" 16 PLY 140 LOTION 91 DEPO-TESTOSTERONE 13 DERMACEA TYPE VII GAUZE DERMAL THERAPY FOOT DEPOCYT 47 4"X4" 8 PLY 140 MASSAGE 91 DERMACEA X-RAY DEPRIZINE FUSEPAQ 232 DERMAL THERAPY HAND SPONGES 4"X4" 16 PLY 140 ELBOW & KNEE CREAM 91 DEPRIZINE RAPIDPAQ 232 DERMACINRX ANALGESIC DERMAL THERAPY HEEL DERMA PAK-ITS IODOFORM COMBOPAK 4 CARE 91 PACKING STRIPS 105 DERMACINRX AZENASE DERMALEVIN ADHESIVE DERMA SILKRX ANODYNEXA PAK 210 FOAMDRESSING 4"X4" 140 PAK 4 DERMACINRX CINLONE-I DERMAPLEX 105 DERMA SILKRX DICLOPAK 4 CPI 70 DERMASORB AF 81 DERMA-GEL 4" X 4" 105 DERMACINRX CLORHEXACIN 100 DERMASORB HC 86 DERMA-SMOOTHE/FS BODY 86 DERMACINRX DPN PAK227 DERMASORB TA 86 DERMA-SMOOTHE/FS DERMACINRX DUOPATCH DERMASORB XM 89 PHARMAPAK 96 SCALP 86 DERMASYN 105 DERMABASEOIL IN DERMACINRX INFLAMMATRAL PAK 4 dermatological products, WATER 91 misc. 99 DERMACEA DRAIN SPONGES DERMACINRX LEXITRAL 4"X4" 139 PHARMAPAK 80 DERMATOP 86 DERMACEA GAUZE SPONGE DERMACINRX NEUROTRAL DERMAVITE 163 2"X2" 12 PLY 139 PHARMAPAK 97 DERMAWERX SURGICAL PLUS DERMACEA GAUZE SPONGE DERMACINRX PHN PAK 97 PAK 100 2"X2" 8 PLY 139 DERMACINRX DERMAZINC CREAM 84 DERMACEA GAUZE SPONGE PUREFOLIX 131 DERMAZONE 86 3"X3" 12 PLY 139 DERMACINRX SILAPAK 86 DERMACEA GAUZE SPONGE DERMACINRX SURGICAL DERMAZYL 97 3"X3" 8 PLY 139 COMBOPAK 100 DERMEND MOISTURIZING DERMACEA GAUZE SPONGE DERMACINRX SURGICAL BRUISE FORMULA 91 4"X4" 12 PLY 140 PHARMAPAK 100 DERMOTIC 222 DERMACEA GAUZE SPONGE DERMACINRX THERAZOLE DERMOVIX 101 4"X4" 16 PLY 140 PAK 81 DESCOVY 57 DERMACEA GAUZE SPONGE DERMACINRX TICANASE 4"X4" 8 PLY 140 PAK 210 DESFERAL 34 DERMACEA I.V. DRAIN DERMACINRX ZRM PAK 97 DESGEN DM 74 SPONGES 2"X2" 140 DERMACEA I.V. DRAIN DERMAGAUZE desipramine hcl 27 140 DRESSING 105 desloratadine 37 SPONGES 4"X4" DERMAGAUZE HYDROGEL DERMACEA I.V. SPONGES DESLORATADINE ODT 37 2"X2" 140 WOUNDDRESSING 4" X 4" 105 desmopressin acetate 122 DERMACEA NON-WOVEN desmopressin acetate SPONGES 2"X2" 4 PLY 140 DERMAGRAN HYDROGEL WOUNDDRESSING 105 spray 122 DERMACEA NON-WOVEN desmopressin acetate spray SPONGES 3"X3" 4 PLY 140 DERMAGRAN HYDROPHILIC DERMACEA NON-WOVEN WOUND DRESSING refrigerated 122 SPONGES 4"X4" 4 PLY 140 2"X2" 105 DESOGEN 67 DERMACEA NON-WOVEN DERMAGRAN HYDROPHILIC desogestrel & ethinyl SPONGES 4"X4" 6 PLY 140 WOUND DRESSING estradiol 67 DERMACEA TYPE VII GAUZE 4"X4" 105 desogestrel-ethinyl estradiol 2"X2" 12 PLY 140 DERMAGRAN HYDROPHILIC (biphasic) 67 DERMACEA TYPE VII GAUZE WOUND DRESSING desogestrel-ethinyl estradiol 2"X2" 8 PLY 140 8"X4" 105 (triphasic) 67

Index 15 DESONATE 86 DEXTROSE 10%/NACL DIATRUE GLUCOSE CONTROL desonide 86 0.45% 151 SOLUTION LEVEL 2 143 DEXTROSE DIATRUE GLUCOSE CONTROL DESOWEN 86 5%/ELECTROLYTE #48 SOLUTION LEVEL 3 143 desoximetasone 86 VIAFLEX 151 diazepam 18 DESOXYN 1 DEXTROSE 10%/NACL DIAZEPAM 18 0.2% 151 DESQUAM-X WASH 78 DEXTROSE 10%/NACL diazepam 18 DESVENLAFAXINE ER 27 0.225% 151 DIAZEPAM 22 desvenlafaxine succinate 27 DEXTROSE 2.5%/NACL DIAZEPAM RECTAL DETROL 235 0.45% 151 GEL 22,23 DEXTROSE 20% 212 DETROL LA 235 DIBENZYLINE 41 DEXTROSE 25% 212 DEX COMBO 70 DICLEGIS 35 DEXTROSE 30% 212 DEX LA 16 70 DICLO GEL PAK 80 DEXTROSE 40% 212 DICLO GEL/XRYLIX dexamethasone 70 DEXTROSE 5%/NACL SHEETS 80 DEXAMETHASONE 70 0.225% 151 diclofenac potassium 4 dexamethasone 70 DEXTROSE 5%/NACL diclofenac sodium 4 DEXAMETHASONE 70 0.3% 151 DEXTROSE DICLOFENAC SODIUM 80 dexamethasone 70 ANHYDROUS 212 diclofenac sodium (actinic DEXAMETHASONE (LA) 70 dextrose in lactated keratoses) 83 DEXAMETHASONE ringers 151 diclofenac sodium (ophth) 221 ACETATE/DEXAMETHASONE DEXTROSE diclofenac sodium (topical) 80 PHOSPHATE 70 MONOHYDRATE 212 diclofenac sodium-capsaicin 4 DEXAMETHASONE dextrose w/ sodium chloride 151 diclofenac sodium-capsaicin INTENSOL 70 (topical) 80 DEXAMETHASONE SODIUM DHEA 91 diclofenac w/ misoprostol 4 PHOSPHATE 70 DIAB 105 dexamethasone sodium dicloxacillin sodium 225 DIAB DAILY CARE 105 phosphate 70 DICLOZOR 80 DEXAMETHASONE SODIUM DIAB F.D.G. FREEZE- PHOSPHATE 220 DRIED 105 DICOPANOL FUSEPAQ 37 DEXAMETHASONE SODIUM DIABETES HEALTH DICOPANOL RAPIDPAQ 37 PHOSPHATE/SODIUM PACK 163 dicyclomine hcl 231 CHLORIDE 70 DIABETES SUPPORT PACK 163 didanosine 57 DEXEDRINE 1 DIFF-STAT 32 DEXERYL 99 DIABETIDERM 91 DIABETIDERM FOOT DIFFERIN 78 DEXILANT 233 REJUVENATING 91 DIFICID 138 DEXLIDO 70 DIABETIDERM HAND & DIFLORASONE DEXLIDO-M 70 BODY 91 DIACETATE 86 DIABETIDERM MASSAGE DIFLUCAN 36 dexmedetomidine hcl 134 STIMULATOR 99 DEXMEDETOMIDINE HCL 134 DIALYVITE 3000 158 diflunisal 7 dexmethylphenidate hcl 1 DIALYVITE 5000 158 DIGESTIVE ADVANTAGE 32 DIGESTIVE ADVANTAGE DEXPAK 10 DAY 70 DIALYVITE SUPREME D 163 DEXPAK 13 DAY 70 LACTOSE DEFENSE DIALYVITE/ZINC 158 FORMULA 32 DEXPAK 6 DAY 70 DIAMOX 118 DIGIFAB 34 dexrazoxane 51 DIANEAL PD-2/1.5% digoxin 63 dextroamphetamine sulfate 1 DEXTROSE 156 DIGOXIN 63 dextromethorphan-guaifenesin DIASTAT ACUDIAL 22 digoxin 63 74 DIASTAT PEDIATRIC 22 DEXTROSE 212 dihydroergotamine DIATRUE GLUCOSE mesylate 149 dextrose 212 CONTROL SOLUTION LEVEL DIHYDROERGOTAMINE 1 143 MESYLATE 149

Index 16 DILANTIN 25 dobutamine in d5w 239 DOXIL 49 DILANTIN INFATABS 25 DOCEFREZ 52 doxorubicin hcl 49 DILANTIN-125 25 docetaxel 52 DOXORUBICIN HCL 49 DILATRATE SR 17 DOCETAXEL 52 doxorubicin hcl liposomal 49 DILAUDID 7 docetaxel 52 DOXYCYCLINE 101 DILAUDID-HP 7 DOCETAXEL (NON-ALCOHOL doxycycline (monohydrate) 229 diltiazem hcl 63 FORMULA) 52 doxycycline hyclate 229 DOCTORS CHOICE DILTIAZEM HCL 63 BURNS/SCALDS/ABRASIONS DOXYCYCLINE HYCLATE 229 diltiazem hcl 63 105 doxycycline hyclate 229 diltiazem hcl coated beads 62 DOCTORS CHOICE DIABETIC DRAWTEX ADVANCED WOUND diltiazem hcl extended release SLOW HEALING CARE 2"X2" 105 beads 63 BANDAGES 105 DRAWTEX ADVANCED WOUND DILTIAZEM DOCTORS CHOICE SKIN CARE 3"X3" 105 HYDROCHLORIDE/DEXTROSE CLOSURE 105 DRAWTEX ADVANCED WOUND 63 DOCTORS CHOICE SLOW CARE 3"X39" 105 DILTIAZEM HEALING BANDAGES 105 DRAWTEX ADVANCED WOUND HYDROCHLORIDE/SODIUM DOCTORS CHOICE ULTRA- CARE 4"X39" 105 CHLORIDE 63 FLEX 105 DRAWTEX ADVANCED WOUND DIMENHYDRINATE 35 dofetilide 19 CARE 4"X4" 105 DOLOPHINE 7 DRAWTEX ADVANCED WOUND DIOVAN 41 CARE 6"X8" 106 DOME-PASTE DRAWTEX ADVANCED WOUND DIOVAN HCT 42 BANDAGE 105 DIPENTOCAINE 80 CARE 8"X39" 106 DOMETUSS-DMX 74 DRAWTEX ADVANCED WOUND DIPENTUM 125 donepezil hydrochloride 226 CARE 8"X8" 106 diphenhydramine hcl 37 DONNATAL 231 DRIHEP ARTERIAL LINE diphenoxylate w/ atropine 33 dopamine hcl 239 SAMPLING SYR/1ML LS/3ML WASTE SYR/2-CAP 116 DIPHENOXYLATE/ATROPINE DOPAMINE HCL 239 33 DRIHEP ARTERIAL LINE DIPHTHERIA/TETANUS dopamine in d5w 239 SAMPLING SYR/1ML LS/SELF- TOXOIDS ADSORBED DOPRAM 1 VENT TIP CAP 116 DRIHEP ARTERIAL LINE PEDIATRIC 230 DORAL 134 DIPRIVAN 126 SAMPLING SYR/3ML LL/5ML DORIBAX 15 WASTE SYR/2-CAP 116 DIPROLENE 86 DORIPENEM 15 DRIHEP ARTERIAL LINE DIPROLENE AF 86 DORYX 229 SAMPLING SYR/3ML LL/SELF- dipyridamole 129 VENT TIP CAP 116 DORYX MPC 229 DRIHEP ARTERIAL LINE DISALCID 7 dorzolamide hcl 221 SAMPLING SYR/3ML LS/5ML disopyramide phosphate 18 DORZOLAMIDE HCL 221 WASTE SYR/2-CAP 116 disulfiram 226 dorzolamide hcl-timolol DRIHEP ARTERIAL LINE DITROPAN XL 235 maleate 217 SAMPLING SYR/3ML LS/SELF- VENT TIP CAP 116 DIURIL 119 DORZOLAMIDE HCL/TIMOLOL DRIHEP ARTERIAL LINE divalproex sodium 26 MALEATE 217 SAMPLING SYR/5ML LL/SELF- DIVIGEL 123 VENT TIP CAP 116 DOTHELLE DHA 202 DRIHEP PLUS 3ML LL DIVISTA 131 DOUBLE PM 220 PREFILLED DL-ALANINE 215 DOUBLEDEX 70 SYR/GZ/PREP/LABEL/CAP/NDL DL-LEUCINE 215 DOVONEX 83 STOP 116 DL-METHIONINE 215 DRIHEP PLUS 3ML LL doxazosin mesylate 42 PREFILLED DL-PHENYLALANINE 215 doxepin hcl 27 SYR/GZ/PREP/LABEL/CAP/SAF DMAE 91 DOXEPIN TYCONE 116 DML FORTE 91 HYDROCHLORIDE 83 dobutamine hcl 239 doxercalciferol 122

Index 17 DRIHEP PLUS 3ML LL DURAFIBER 2"X2" 106 EASY STEP CONTROL PREFILLED SYR/NEEDLE DURAFIBER 3/4"X18" 106 SOLUTION NORMAL 144 STOPPER/SAFETYCONE 116 EASY TALK CONTROL DRIHEP PLUS 3ML LL DURAFIBER 4"X4" 106 SOLUTION HIGH 144 PREFILLED SYR/TIP CAP/NDL DURAFIBER 6"X6" 106 EASY TALK CONTROL STOP/SAFETYCONE 116 DURAFLU 74 SOLUTION LOW 144 DRIHEP PLUS 3ML LL EASY TALK CONTROL PREFILLED SYR/TIP DURAGESIC 7 SOLUTION NORMAL 144 CAP/NEEDLE DURASAFE EASY TOUCH ALCOHOL PREP STOPPER/22X1 116 SPINAL/EPIDURALTRAY/1% PADS/MEDIUM 148 DRIHEP PLUS 3ML XYLOCAINE/19GX36"CLOSE EASY TOUCH CONTROL PREFILLEDSYR/GZ/SWAB/TIP CATH 136 SOLUTION/HIGH & LOW 144 CAP/NDL ST/ICE BAG 117 DURASAFE EASY TOUCH HEALTHPRO DRISDOL 240 SPINAL/EPIDURALTRAY/1% CONTROL SOLUTION/HIGH & XYLOCAINE/19GX36"OPEN LOW 144 DRITHO-CREME HP 83 CATH 136 EASY TRAK GLUCOSE DRIXORAL DURASAFE CONTROLSOLUTION COLD/ALLERGY 74 SPINAL/EPIDURALTRAY/1% HIGH 144 dronabinol 35 XYLOCAINE/20GX36"CLOSE EASY TRAK GLUCOSE droperidol 17 CATH 136 CONTROLSOLUTION drospirenone-ethinyl DURASAFE LOW 144 estradiol 67 SPINAL/EPIDURALTRAY/1% EASY TRAK GLUCOSE drospirenone-ethinyl estradiol- XYLOCAINE/20GX36"OPEN CONTROLSOLUTION levomefolate calcium 67 CATH 136 NORMAL 144 DROXIA 129 DURAXIN 6 EASYGLUCO CONTROL DUREZOL 220 SOLUTION HIGH 144 DROXY CREAM 91 EASYGLUCO CONTROL DRYMAX EXTRA 140 DURLAZA 129 SOLUTION LOW 144 DRYSOL 100 dutasteride 127 EASYGLUCO CONTROL DS PREP PAK 80 dutasteride-tamsulosin SOLUTION NORMAL 144 hcl 127 EASYGLUCO PLUS CONTROL DST PLUS PAK 80 DUTOPROL 42 SOLUTION LEVEL 1 144 DUAC 78 DUZALLO 128 EASYMAX 15 GLUCOSE DUAL COMPLEX FORMULA 1 CONTROL SOLUTION LEVEL KIT 80 DYANAVEL XR 1 1/LEVEL 2 144 DUAVEE 123 DYAZIDE 118 EASYMAX 15 LEVEL 1 DUDRESS ISLAND DRESSING DYLOJECT 4 GLUCOSE CONTROL 4"X4" 106 SOLUTION 144 DYMISTA 210 EASYMAX 15 LEVEL 2 DUDRESS ISLAND DRESSING dyphylline-guaifenesin 19 6"X6" 106 GLUCOSE CONTROL SOLUTION 144 DUET DHA 400 202 DYRENIUM 119 DYSPORT 211 EASYMAX CONTROL DUET DHA BALANCED 202 SOLUTIONHIGH 144 DUETACT 28 DYURAL-40 70 EASYMAX CONTROL DUEXIS 4 DYURAL-80 70 SOLUTIONLOW 144 DYURAL-L 71 EASYMAX CONTROL DULERA 20 SOLUTIONNORMAL 144 duloxetine hcl 27 DYURAL-LM 71 EASYMAX GLUCOSE DUO-CARE CONTROL E.E.S. 400 138 CONTROL SOLUTION SOLUTION 143 E.E.S. GRANULES 138 NORMAL/LOW 144 DUODERM EARLY ALERT 155 EC-NAPROSYN 4 HYDROACTIVE 106 EASY PLUS II CONTROL EC-RX PROGESTERONE DUODOTE 33 SOLUTION HIGH 144 10% 225 DUOPA 53 EASY PLUS II CONTROL ECHINACEA COMPOUND 155 DUPIXENT 89 SOLUTION LOW 144 econazole nitrate 81 EASY STEP CONTROL DURACHOL 131 ECOTRIN REGULAR SOLUTION HIGH 144 STRENGTH 7 DURACLON 7 EASY STEP CONTROL ECOZA 81 SOLUTION LOW 144

Index 18 ECZEMA & PSORIASIS ELESTAT 221 EMPLICITI 47 SPRAY 155 ELESTRIN 123 EMSAM 26 ED A-HIST 74 ELETONE 99 EMTRIVA 57 EDARBI 41 ELETONE TWINPACK 99 EMULSION SB 99 EDARBYCLOR 42 eletriptan hydrobromide 150 EMVERM 14 EDECRIN 118 ELIDEL 95 ENABLEX 235 EDLUAR 134 ELIGARD 48 enalapril maleate 40 EDURANT 57 ELIMITE 101 enalapril maleate & efavirenz 57 ELIPHOS 126 hydrochlorothiazide 42 EFFER-K 153 enalaprilat 40 ELIQUIS 21 EFFEXOR XR 27 ENBRACE HR 202 ELIQUIS STARTER PACK 21 EFFIENT 129 ENBREL 6 ELITE-OB 202 EFUDEX 83 ENBREL MINI 6 ELITEK 51 EGRIFTA 120 ENBREL SURECLICK 6 ELIXOPHYLLIN 21 EHA LOTION 97 ENCARE 237 ELLA 69 EHA LOTION 4% 97 ENDARI 129 ELLENCE 49 ELAPRASE 122 ENDOMETRIN 238 ELLIOTTS B 151 ELASTO-GEL 12"X12" 106 ENDUR-VM 163 ELMIRON 127 ELASTO-GEL 2"X3" 106 ENDUR-VM WITH IRON 163 ELOCON 86 ELASTO-GEL 3" ROUND 106 ENGERIX-B 236 ELON MATRIX 5000 207 ELASTO-GEL 4"X4" 106 ENLON 45 ELON MATRIX PLUS 207 ELASTO-GEL 5"X5" 106 ELON MATRIX 5000 ENOVARX-BACLOFEN 80 ELASTO-GEL 6"X8" 106 COMPLETE 207 ENOVARX- ELASTO-GEL 8"X16" 106 ELON MATRIX CYCLOBENZAPRINE HCL 209 COMPLETE 207 ENOVARX-DICLOFENAC ELASTO-GEL CAST/SPLINT SODIUM 80 12"X12" 106 ELON R3 207 ELASTO-GEL CAST/SPLINT ELON SKIN REPAIR ENOVARX-IBUPROFEN 80 4"X4" 106 SYSTEM 91 ENOVARX-LIDOCAINE HCL97 ELASTO-GEL CAST/SPLINT EMADINE 221 ENOVARX-NAPROXEN 80 6"X8" 106 EMBEDA 7 ENOVARX-TRAMADOL 80 ELASTO-GEL CAST/SPLINT 8"X16" 106 EMBRACE CONTROL enoxaparin sodium 21 SOLUTIONLOW 144 ENSTILAR 86 ELASTO-GEL FACE MASK106 EMBRACE EVO GLUCOSE ELASTO-GEL PLUS 2"X3" 106 CONTROL SOLUTION LEVEL entacapone 53 ELASTO-GEL PLUS 4"X4" 106 1 144 entecavir 59 ELASTO-GEL PLUS 8"X8" 106 EMBRACE EVO GLUCOSE ENTEREG 126 CONTROL SOLUTION LEVEL ELAVIL 28 2 144 ENTOCORT EC 71 ELDEPRYL 54 EMBRACE GLUCOSE ENTRE-B 74 ELELYSO 129 CONTROL SOLUTION ENTRE-HIST PSE 74 ELEMENT COMPACT HIGH 144 ENTRESTO 64 EMBRACE PRO GLUCOSE CONTROL SOLUTION LEVEL ENTTY SPRAY EMULSION 99 2 144 CONTROL SOLUTION 144 ELEMENT COMPACT EMCYT 48 ENTYVIO 125 CONTROL SOLUTION LEVEL EMEND 35 ENVARSUS XR 154 3 144 EMEND TRIPACK 35 EPANED 40 ELEMENT HIGH EPCLUSA 59 CONTROL 144 EMFLAZA 71 ELEMENT LOW EMOLLIA-CREME 91 EPHEDRINE SULFATE 239 CONTROL 144 EMOLLIA-LOTION 91 ephedrine sulfate (pressors) 239 ELEMENT NORMAL emollient 91 CONTROL 144

Index 19 EPHEDRINE EQL ALCOHOL SWABS 148 erythromycin (ophth) 218 SULFATE/SODIUMCHLORIDE EQL CENTURY MATURE erythromycin base 138 239 ADULTS50+ 163 erythromycin EPICERAM 99 EQL CENTURY MENS 163 ethylsuccinate 138 EPIDUO 78 EQL CENTURY ERYTHROMYCIN EPIDUO FORTE 78 WOMENS 163 ETHYLSUCCINATE 138 EPIFOAM 86 EQL DAILY PROBIOTIC 32 ESBRIET 228 EPILYT 91 EQL DRY MOUTH ORAL ESCAVITE 201 RINSE 157 ESCAVITE D 201 EPIMIDE 99 EQL GAUZE PADS epinastine hcl (ophth) 221 2"X2"/SMALL 140 ESCAVITE LQ 201 EPINEPHRINE 238 EQL GAUZE PADS escitalopram oxalate 26 4"X4"/LARGE 140 ESGIC 6 epinephrine 239 EQL GAUZE STERILE PADS epinephrine (anaphylaxis) 238 3"X3" 140 esmolol hcl 61 EPINEPHRINE HCL 239 EQL MOISTURIZING ESMOLOL HYDROCHLORIDE 61 EPINEPHRINE/DEXTROSE CREAM 91 239 EQL ONE DAILY MENS 163 esomeprazole magnesium 233 EPINEPHRINE/SODIUM EQL PROBIOTIC COLON ESOMEPRAZOLE CHLORIDE 239 SUPPORT 32 SODIUM 233 EPINEPHRINESNAP-V 239 EQL ULTRA MOISTURIZING esomeprazole sodium 233 EPIPEN 2-PAK 239 DAILY LOTION 91 ESOMEPRAZOLE EQUAPAX/ATORVASTATIN STRONTIUM 233 epirubicin hcl 49 CALCIUM/COQ10 39 ESSENTRA WIPES 9X9" EPISIL 157 EQUAPAX/IBUPROFEN/MINR CLEANROOM EPISNAP 239 EX 3 SUPPLIES/PRESATURATED 100 EPIVIR 57 EQUETRO 54 ESSIAC TONIC 155 EPIVIR HBV 59 EQUIPTO-BACLOFEN 80 estazolam 134 eplerenone 44 EQUIPTO-NAPROXEN 80 ESTER-C 159 EPOGEN 130 ERAXIS 35 ESTRACE 123,238 epoprostenol sodium 64 ERBITUX 47 estradiol 123,124 eprosartan mesylate 41 ERGOCAL 240 ergocalciferol 240 estradiol & norethindrone eptifibatide 129 acetate 123 EPY II KIT 239 ERGOCALCIFEROL 240 estradiol vaginal 238 ERGOLOID EPY KIT 239 MESYLATES 228 estradiol valerate 124 EPZICOM 57 ERGOMAR 149 ESTRING 238 EQ COMPLETE ergotamine w/ caffeine 149 ESTROGEL 124 MULTIVITAMINADULTS UNDER estropipate 124 50 163 ERIVEDGE 48 EQ ONE DAILY MENS 50+ 163 ERLEADA 48 ESTROSTEP FE 67 EQ ONE DAILY MENS ERTACZO 81 eszopiclone 134 HEALTH 163 ertapenem sodium 15 ethacrynate sodium 118 EQ ONE DAILY WOMENS ERWINAZE 51 ethacrynic acid 118 50+ 163 EQ ONE DAILY WOMENS ERY-TAB 138 ethambutol hcl 45 HEALTH 163 ERYGEL 78 ETHAMOLIN 156 EQ PROBIOTIC DIGESTIVE ERYPED 200 138 ethosuximide 25 SYSTEM SUPPORT 32 ETHYL CHLORIDE 97 EQ THERAPEUTIC DRY ERYPED 400 138 SKIN 91 ERYTHROCIN ETHYL CHLORIDE/FINE EQ THERAPEUTIC LACTOBIONATE 138 PINPOINT 97 MOISTURIZING CREAM 91 ERYTHROCIN ETHYL CHLORIDE/FINE EQL ADVANCED RECOVERY STEARATE 138 STREAM 97 SKIN CARE 91 erythromycin (acne aid) 78 ETHYL CHLORIDE/MEDIUM JET STREAM 97

Index 20 ETHYL CHLORIDE/MEDIUM EVOLUTION CONTROL EXU-DRY BURN JACKET CHILD STREAM 97 SOLUTION NORMAL 145 17"X20" 106 ETHYL CHLORIDE/MIST 97 EVOMELA 46 EXU-DRY BURN VEST ethynodiol diacet & eth EVOTAZ 57 26"X38" 106 EXU-DRY BURN VEST CHILD estrad 67 EVOXAC 157 ETIDRONATE DISODIUM 119 15"X20" 106 EVZIO 34 EXU-DRY BUTTOCKS etodolac 4 EXACTUSS 74 23"X53" 106 etomidate 126 EXACTUSS TR 74 EXU-DRY DISC 3" 106 ETOPOPHOS 52 EXU-DRY ELBOW/KNEE/HEEL EXALGO 7 ETOPOSIDE 52 10"X17" 107 EXAPHEX TR 74 etoposide 52 EXU-DRY FACE 9"X14" 107 EXCEL-GEL 106 EUCERIN 92 EXU-DRY INCISION 3"X9" 107 EXCILON AMD EXU-DRY LEG 34"X37" 107 EUCERIN BABY 91 ANTIMICROBIALDRAIN EUCERIN CALMING DAILY SPONGES 4"X4" 6 PLY 140 EXU-DRY NON-PERMEABLE MOISTURIZER 91 EXCILON AMD PAD 24"X36" 107 EUCERIN DAILY ANTIMICROBIALNON-WOVEN EXU-DRY NON-PERMEABLE PROTECTION/SPF 30 91 SPONGES 4"X4" 6 PLY 140 SHEET 36"X72" 107 EUCERIN INTENSIVE EXCILON DRAIN SPONGE EXU-DRY PADDED HAND REPAIR 91 4"X4" 140 12"X13" 107 EUCERIN INTENSIVE EXCILON DRAIN SPONGES EXU-DRY PADDED HAND REPAIRHAND 92 4"X4" 6 PLY 140 CHILD 8"X8" 107 EUCERIN ORIGINAL EXCILON I.V. SPONGES 2"X2" EXU-DRY PADDED NECK HEALINGSOOTHING 6 PLY 140 6"X25" 107 REPAIR 92 EXU-DRY PERMEABLE PAD EXELDERM 81 24"X36" 107 EUCERIN PLUS 92 EXELON 226 EXU-DRY PERMEABLE EUCERIN PLUS INTENSIVE exemestane 48 QUILTED 36"X72" 107 REPAIR 92 EXU-DRY SCALP 3"X14" 107 EUCERIN PROFESSIONAL EXFORGE 43 REPAIR RICH FEEL 92 EXFORGE HCT 43 EXU-DRY SLIT DISC 3" 107 EXU-DRY SLIT TUBE EUCERIN SKIN CALMING EXJADE 33 DAILY MOISTURIZING 92 2"X3" 107 EUCERIN SMOOTHING EXODERM 81 EXU-DRY SLIT TUBE REPAIRADVANCED EXONDYS 51 211 3"X4" 107 FORMULA 92 EXPAREL 136 EXU-DRY SLIT TUBE EUCRISA 101 4"X6" 107 EXTAVIA 227 EXUDERM LP 4" X 4" 107 EUFLEXXA 210 EXTINA 81 EURAX 101 EXUDERM LP 6" X 6" 107 EXTRA-VIRT PLUS DHA 202 EXUDERM RCD 4" X 4" 107 EVAMIST 124 EXU-DRY 15"X18" 106 EVEKEO 1 EXUDERM RCD 6" X 6" 107 EXU-DRY 15"X24" 106 EXUDERM RCD 8" X 8" 107 EVENCARE CONTROL EXU-DRY 20"X28" 106 SOLUTION 144 EXUDERM SACRUM 4" X EVENCARE G2 GLUCOSE EXU-DRY 3"X4" 106 3.6" 107 CONTROL SOLUTION/LOW- EXU-DRY 4"X6" 106 EXUDERM SATIN 2" X 2" 107 HIGH 145 EXU-DRY 6"X9" 106 EXUDERM SATIN 4" X 4" 107 EVENCARE G3 GLUCOSE EXUDERM SATIN 6" X 6" 107 CONTROL SOLUTION/LOW- EXU-DRY 9"X15" 106 HIGH 145 EXU-DRY ARM 27"X31" 106 EXUDERM SATIN 8" X 8" 107 EVENCARE MINI GLUCOSE EXU-DRY ARM/SHOULDER EXUDERM ULTRA 4" X 4" 107 CONTROL SOLUTION TIES 27"X31" 106 EXUDERM ULTRA NORMAL 145 EXU-DRY BOOT/FOOT HYDROCOLLOID WOUND EVICEL 133 DRESSING/CHILD 106 DRESSING 4" X 4" 107 EVISTA 121 EXU-DRY BURN JACKET EYE HEALTH 163 31"X32" 106 EVITHROM 133 EXU-DRY BURN JACKET EYEAID IRRIGATING SOLUTION 221 EVOCLIN 78 36"X40" 106

Index 21 EYLEA 218 fentanyl citrate 7 FERROUS SULFATE 133 ezetimibe 40 FENTANYL CITRATE 7,8 FERROUS SULFATE ezetimibe-simvastatin 38 fentanyl citrate 8 ANHYDROUS 132 FERROUS SULFATE FABIOR 78 FENTANYL CITRATE 8 HEPTAHYDRATE 132 FABRAZYME 122 FENTANYL FETZIMA 27 FACTIVE 124 CITRATE/BUPIVACAINE HCL/SODIUM CHLORIDE 11 FETZIMA TITRATION PACK27 FALESSA 67 FENTANYL FEXMID 209 famciclovir 60 CITRATE/BUPIVACAINE fexofenadine hcl 37 famotidine 232 HYDROCHLORIDE 11 fexofenadine-pseudoephedrine FENTANYL FAMOTIDINE PREMIXED 232 74 CITRATE/BUPIVACAINE FIASP 30 FAMVIR 60 HYDROCHLORIDE/SODIUM FANAPT 54 CHLORIDE 11 FIASP FLEXTOUCH 30 FIBRACOL COLLAGEN- FANAPT TITRATION PACK 54 FENTANYL CITRATE/BUPIVICAINE ALGINATE WOUND DRESSING FANATREX FUSEPAQ 23 HYDROCHLORIDE/SODIUM 4" X 4 & 3/8" 107 FARESTON 48 CHLORIDE 11 FIBRACOL COLLAGEN- FARXIGA 31 FENTANYL ALGINATE WOUND DRESSING/2" X 2" 107 FARYDAK 49 CITRATE/NACL 8 FENTANYL FIBRACOL COLLAGEN- FASENRA 19 CITRATE/ROPIVACAINE ALGINATE WOUND FASLODEX 48 HYDROCHLORIDE 11 DRESSING/4" X 8-3/4" 107 FIBRACOL COLLAGEN- fat emulsion 212 FENTANYL CITRATE/ROPIVACAINE ALGINATE WOUND FAZACLO 55 HYDROCHLORIDE/SODIUM PACKING/3/8"X3/8"X15-3/4" FBL KIT 80 CHLORIDE 11 107 FC FEMALE CONDOM 142 FENTANYL CITRATE/SODIUM FIBRICOR 39 FC2 FEMALE CONDOM 142 CHLORIDE 8 FIFTY50 ALCOHOL PREP fe fum-iron polysacch complex-fa- FENTORA 8 PADS 148 b complex-c-zn-mn-cu 131 FER-IN-SOL 132 FIFTY50 CONTROL fe fumarate-vitamin c-vitamin SOLUTION2.0 145 FERAHEME 132 FINACEA 101 b12-folic acid 131 FERIVA 131 FE PLUS PROTEIN 131 finasteride 127 FERIVA 21/7 131 felbamate 25 FIORICET 6 FERIVAFA 131 FELBATOL 25 FIORICET/CODEINE 11 FERRALET 90 131 FELDENE 4 FIORINAL 6 FERRAPLUS 90 131 FIORINAL/CODEINE #3 11 felodipine 63 FERREX 150 FORTE FEM PH 237 PLUS 131 FIRAZYR 128 FEMARA 48 FERREX 28 131 FIRMAGON 48 FEMCON FE 67 FERRIPROX 33 FIRST-BACLOFEN 1 209 FEMHRT LOW DOSE 123 FERRLECIT 132 FIRST-BACLOFEN 5 209 FEMRING 238 FERRO-PLEX FIRST-BXN MOUTHWASH 156 FENOFIBRATE 38 HEMATINIC 131 FIRST-DUKES 131 MOUTHWASH 156 fenofibrate 39 FERROTRIN ferrous fumarate w/ b12-vit c-fa- FIRST-HYDROCORTISONE fenofibrate micronized 39 ifc 131 86 FENOFIBRIC ACID 39 ferrous fumarate-fa-b complex- FIRST-LANSOPRAZOLE 233 FENOGLIDE 39 c-zn-mg-mn-cu 131 FIRST-MARYS ferrous fumarate-folic MOUTHWASH 156 FENOPROFEN CALCIUM 4 acid 131 FIRST-METRONIDAZOLE fenoprofen calcium 4 ferrous sulfate 132 100 14 FENORTHO 4 FERROUS SULFATE 132 FIRST-METRONIDAZOLE 50 14 fentanyl 8 ferrous sulfate 133

Index 22 FIRST-MOUTHWASH BLM156 FLUAD 2018-2019 236 FLUOXETINE 227 FIRST-OMEPRAZOLE 233 FLUARIX QUADRIVALENT fluoxetine hcl 26 FIRST-PROGESTERONE VGS 2016-2017 236 fluoxetine hcl (pmdd) 228 FLUARIX QUADRIVALENT 100 COMPOUNDING KIT 238 FLUOXETINE FIRST-PROGESTERONE VGS 2017-2018 236 FLUARIX QUADRIVALENT HYDROCHLORIDE 26 200 COMPOUNDING KIT 238 fluphenazine decanoate 55 FIRST-PROGESTERONE VGS 2018-2019 236 400 COMPOUNDING KIT 238 FLUBLOK 2015-2016 236 FLUPHENAZINE HCL 55 FIRST-PROGESTERONE VGS FLUBLOK 2016-2017 236 fluphenazine hcl 55 50 COMPOUNDING KIT 238 FLUBLOK 2017-2018 236 FLURA-DROPS 152 FIRST-TESTOSTERONE 13 FLUBLOK QUADRIVALENT flurandrenolide 86 FIRST-TESTOSTERONE MC 2017-2018 236 FLURAZEPAM HCL 134 COMPOUNDING KIT 13 FLUBLOK QUADRIVALENT FIRST-VANCOMYCIN 25 14 2018-2019 236 flurbiprofen 4 FIRST-VANCOMYCIN 50 14 FLUCELVAX 2015-2016 236 flurbiprofen sodium 221 FITNESS TABS FOR MEN FLUCELVAX QUADRIVALENT flutamide 48 AM/PM/LYCOPENE 163 2016-2017 236 fluticasone propionate 87 FITNESS TABS FOR WOMEN FLUCELVAX QUADRIVALENT fluticasone propionate AM/PM/LYCOPENE 163 2017-2018 236 (nasal) 211 FLAGYL 14 FLUCELVAX QUADRIVALENT fluticasone-salmeterol 20 FLANAX PAIN RELIEF KIT 4 2018-2019 236 fluconazole 36 fluvastatin sodium 39 FLAREX 220 fluconazole in dextrose 36 FLUVIRIN 2015-2016 236 flavoxate hcl 235 FLUCONAZOLE IN NACL 36 FLUVIRIN 2016-2017 236 FLEBOGAMMA DIF 223 fluconazole in nacl 36 FLUVIRIN 2017-2018 236 flecainide acetate 18 flucytosine 36 fluvoxamine maleate 26 FLECTOR 80 FLUZONE HIGH-DOSE PF 2016- fludarabine phosphate 47 FLEXIN 97 2017 236 fludrocortisone acetate 73 FLEXIZOL COMBIPAK 4 FLUZONE HIGH-DOSE PF 2017- FLULAVAL QUADRIVALENT 2018 236 FLEXZAN 4 X 4 140 2014-2015 236 FLUZONE HIGH-DOSE PF 2018- FLOLAN 64 FLULAVAL QUADRIVALENT 2019 236 FLOLIPID 39 2016-2017 236 FLUZONE INTRADERMAL FLULAVAL QUADRIVALENT QUADRIVALENT 2016- FLOMAX 128 2017-2018 236 2017 237 FLONASE ALLERGY FLULAVAL QUADRIVALENT FLUZONE INTRADERMAL RELIEF 211 2018-2019 236 QUADRIVALENT 2017- FLONASE ALLERGY RELIEF FLUMADINE 60 2018 237 CHILDRENS 211 flumazenil 34 FLUZONE QUADRIVALENT FLONASE SENSIMIST 211 2016-2017 237 FLORA VANCE 32 FLUNISOLIDE 211 FLUZONE QUADRIVALENT FLORAJEN BIFIDOBLEND 32 fluocinolone acetonide 86 2017-2018 237 fluocinolone acetonide FLUZONE QUADRIVALENT FLORAJEN3 32 (otic) 222 2018-2019 237 FLORAJEN4KIDS 32 fluocinonide 86 FML 220 FLORIVA 152,201 fluocinonide emulsified FML FORTE 220 FLORIVA PLUS 199 base 86 FML LIQUIFILM 220 FLOVENT DISKUS 20 FLUOR-A-DAY 152 FOAM DRESSING FLOVENT HFA 20 FLUORABON 152 BORDERED 107 fluorometholone (ophth) 220 FOAM DRESSING CIRCULAR FLOWTUSS 74 BORDERED 107 FLOXIN OTIC 222 FLUOROPLEX 83 FOAM DRESSING NON- FLOXURIDINE 47 fluorouracil 47 BORDERED 107 FLUAD 2016-2017 236 FLUOROURACIL 83 FOCALGIN 90 DHA 202 FLUAD 2017-2018 236 fluorouracil (topical) 83 FOCALGIN CA 202

Index 23 FOCALGIN DSS 131 FORMULA 405 LIGHT FUZEON 57 FOCALIN 1 TEXTURED FYCOMPA 22 MOISTURIZER 92 FOCALIN XR 1 FORMULA 405 G-MYCO NAIL 82 FOLBEE PLUS CZ 158 MOISTURIZING 92 gabapentin 23 FOLCAL DHA 202 FORTAMET 29 GABITRIL 25 FOLCAPS OMEGA 3 202 FORTAVIT 163 GABLOFEN 209 FOLET DHA 202 FORTAZ 66 galantamine hydrobromide 226 FOLET ONE 202 FORTEO 119 GALANTAMINE FOLGARD OS 160 FORTESTA 13 HYDROBROMIDE 226 galantamine hydrobromide 226 FOLGARD RX 131 FORTICAL 119 GALZIN 154 FOLI-D 131 FORTIFY DAILY PROBIOTIC 32 GAMASTAN 223 FOLIC + B12 131 FORTISCARE CONTROL GAMASTAN S/D 223 FOLIC ACID 130 SOLUTIONS HIGH 145 GAMMAGARD LIQUID 223 folic acid 130 FORTISCARE CONTROL SOLUTIONS LOW 145 GAMMAGARD S/D IGA LESS folic acid-vitamin b6-vitamin THAN 1MCG/ML 223 b12 131 FORTISCARE CONTROL GAMMAKED 223 FOLIKA-D 131 SOLUTIONS NORMAL 145 FOSAMAX 119 GAMMAPLEX 223 FOLIKA-V 199 FOSAMAX PLUS D 119 GAMUNEX-C 223 FOLITAB 500 131 fosamprenavir calcium 57 ganciclovir sodium 59 FOLIVANE-F 131 FOSCAVIR 59 GANIRELIX ACETATE 120 FOLIVANE-OB 202 FOSFREE 163 GARDASIL 237 FOLIVANE-PLUS 131 fosinopril sodium 40 GARDASIL 9 237 FOLIXAPURE 131 fosinopril sodium & GASTROCROM 125 FOLLISTIM AQ 120 hydrochlorothiazide 43 gatifloxacin (ophth) 219 FOLOTYN 47 fosphenytoin sodium 25 GATTEX 126 FOLTRATE 131 FOSRENOL 126 GAUZE DRESSING 4"X4" 140 fomepizole 34 FRAGMIN 21 GAUZE PADS 2"X2" 140 fondaparinux sodium 21 FREAMINE HBC 6.9% 215 GAUZE PADS 3"X3" 140 FORA CONTROL SOLUTION FREAMINE III 215 HIGH 145 GAUZE PADS 4"X4" 140 FORA CONTROL SOLUTION FREEDAVITE 163 GAUZE PADS 4"X4" 12 LOW 145 FREESTYLE CONTROL PLY 140 FORA CONTROL SOLUTION SOLUTION 145 GAUZE SPONGE TYPE VII NORMAL 145 FREESTYLE CONTROL MEDI-PAK 2"X2" 8PLY 140 FORACARE GDH CONTROL SOLUTION HIGH/LOW 145 GAUZE SPONGES 4"X4" 12 SOLUTION HIGH 145 FROVA 150 PLY 140 FORACARE GDH CONTROL frovatriptan succinate 150 GAZYVA 47 SOLUTION LOW 145 FRUCTOSE 212 GE100 CONTROL SOLUTION FORACARE GDH CONTROL FULPHILA 130 NORMAL 145 SOLUTION NORMAL 145 GEBAUERS INSTANT ICE 97 FORANE 126 FULYZAQ 31 GEBAUERS PAIN EASE 97 FUNGIMEZ 81 FORFIVO XL 26 GEBAUERS SPRAY AND FORMA-RAY 56 FURADANTIN 234 STRETCH 97 formaldehyde 56 furosemide 118 GEL-ONE 210 FORMALDEHYDE 56 FUROSEMIDE 118 GELCLAIR 157 FORMULA 405 ENRICHED furosemide 119 GELFILM OP 221 EYE 92 FUSILEV 51 GELNIQUE 235 FORMULA 405 FACE CREAM 92 FUSION PLUS 131 GELNIQUE PUMP 235 FUSION SPRINKLES 131 GELOCAST UNNAS BOOT107

Index 24 GELSYN-3 210 GLUCOCARD 01 CONTROL GLYSET 28 gemcitabine hcl 47 SOLUTION GLYXAMBI 28 NORMAL/HIGH 145 gemfibrozil 39 GLUCOCARD 01 CONTROL GNP ACIDOPHILUS HIGH GEMZAR 47 145 POTENCY 32 SOLUTION/NORMAL GNP ADVANCED GENADUR 99 GLUCOCARD EXPRESSION CONTROL SOLUTION LEVEL RECOVERY 92 GENADUR KIT 99 1 145 GNP ALCOHOL SWABS 148 GENERESS FE 67 GLUCOCARD SHINE GNP EASY TOUCH CONTROL GENOTROPIN 120 CONTROL SOLUTION LEVEL SOLUTION HIGH/LOW 145 GENOTROPIN MINIQUICK120 1 145 GNP GENTIAN VIOLET 82 GLUCOCARD X-METER GENTAK 219 GNP IODIDES TINCTURE 56 CONTROLSOLUTION/NORMA GNP IODINE TINCTURE 56 gentamicin in saline 2 L 145 GNP ISOPROPYL ALCOHOL gentamicin sulfate 2 GLUCOCOM HIGH CONTROL 145 WIPES 100 gentamicin sulfate (ophth) 219 GLUCOCOM NORMAL GNP PROBIOTIC COLON gentamicin sulfate (topical) 81 CONTROL 145 SUPPORT 32 GNP STERILE PADS GENTAMICIN SULFATE/0.9% GLUCOPHAGE 29 SODIUM CHLORIDE 2,3 3"X3" 141 GLUCOPHAGE XR 29 GOCOVRI 53 GENTIAN VIOLET 82 GLUCOSE CONTROL GENTLE 92 GOLD BOND MEDICATED NORMAL 145 BODYLOTION 92 GENVISC 850 210 GLUCOSE CONTROL GOLD BOND MEDICATED GENVOYA 57 SOLUTION 145 BODYLOTION EXTRA 31 GEODON 54 GLUCOTROL STRENGTH 92 GERI-FREEDA SENIOR GLUCOTROL XL 31 GOLD BOND ULTIMATE 92 FORMULA 163 GLUCOVANCE 28 GOLD BOND ULTIMATE GERITOL COMPLETE 159 GLUMETZA 29 DIABETICS DRY SKIN RELIEF 92 GIALAX 135 GLUTAMINE 215 GOLD BOND ULTIMATE GIAZO 125 GLUTARALDEHYDE 56 DIABETICS' DRY RELIEF 92 GILENYA 227 GLUTATHIONE 215 GOLD BOND ULTIMATE GILOTRIF 49 HEALING 92 GLUTATHIONE-L 215 GOLD BOND ULTIMATE GILPHEX TR 74 GLUTATHIONE-L PROTECTION 92 GILTUSS 74 REDUCED 215 GOLD BOND ULTIMATE GILTUSS COUGH & COLD 74 glyburide 31 RESTORING 92 GILTUSS SINUS & glyburide micronized 31 GOLD BOND ULTIMATE CONGESTION 74 glyburide-metformin 28 SHEERRIBBONS PEARLRADIANCE 92 GILTUSS TR 74 GLYCATE 231 GOLD BOND ULTIMATE GLASSIA 228 glycine (gu irrigant) 127 SHEERRIBBONS glatiramer acetate 227 glycine diluent 225 SILKSOFTNESS 92 GLEEVEC 49 GLYCOLIC ACID 84 GOLD BOND ULTIMATE SOFTENING 92 GLEOSTINE 46 GLYCOLIC ACID 70% HIGH GOLD BOND ULTIMATE GLIADEL WAFER 46 PURITY 84 SOOTHING 92 glimepiride 31 GLYCOPHOS 153 GOLYTELY 135 glipizide 31 glycopyrrolate 231 GONAL-F 120 231 glipizide-metformin hcl 28 GLYCOPYRROLATE GONAL-F RFF 120 GLOBAL ALCOHOL PREP glycopyrrolate 231 GONAL-F RFF REDIJECT 120 EASEPADS 148 GLYCOPYRROLATE 231 GONITRO 17 GLUCAGEN HYPOKIT 29 GLYCOTROL 207 GORDOFILM 95 GLUCAGON EMERGENCY GLYCOTROL KIT 29 COMPLETE 207 GORDONS UREA 89 GLUCO COR 207 GLYNASE 31 GRALISE 227

Index 25 GRALISE STARTER 227 HEALTHWISE ALCOHOL HM COMPLETE 50+ WOMENS GRANISETRON HCL 34 PREP PADS 148 ULTIMATE 164 HEALTHY HEART HM ESTROPLUS 208 granisetron hcl 34 COMPLEX 208 HM HAIR/SKIN/NAILS 164 GRANIX 130 HEART 208 HM IODIDES TINCTURE 56 GREEN SOAP 100 HEART SAVIOR 208 HM IODINE TINCTURE 56 GREEN SOURCE 208 HECTOROL 122 HM ONE DAILY MENS 164 GRIS-PEG 36 HEMANGEOL 62 HM ONE DAILY WOMENS 164 griseofulvin microsize 36 HEMATOGEN FA 131 HM STERILE ALCOHOL PREP griseofulvin ultramicrosize 36 HEMATRON-AF 131 PADS 148 GRX HYDROGEL GAUZE HEMENATAL OB 202 HM STERILE PADS 141 2X2 107 GRX HYDROGEL GAUZE HEMENATAL OB + DHA 202 HM STERILE PADS 2"X2" 141 4X4 107 HEMETAB 131 homatropine hbr 218 GRX VITAMIN E 92 HEMOCYTE PLUS 131 HORIZANT 228 GRX WOUND 107 HEPAGAM B 223 HORMONE CREAM BASE guaifenesin 76 heparin (porcine) in sodium NIOSOMES 225 HORMONE CREAM-HEAVY guaifenesin-codeine 74 chloride 21 HEPARIN LOCK FLUSH 21 BASENIOSOMES 225 guanfacine hcl 42 heparin sod (porcine) in HPR 99 guanfacine hcl (adhd) 1 d5w 21 HPR PLUS 99 GUANIDINE HCL 45 HEPARIN SODIUM 21 HPR PLUS HYDROGEL KIT 99 GYNAZOLE-1 238 heparin sodium (porcine) 21 HPR PLUS/MB HYDROGEL 92 H-E-B INCONTROL ALCOHOL heparin sodium (porcine) lock HUMALOG 30 PADS 148 flush 21 HUMALOG JUNIOR H.P. ACTHAR 120 heparin sodium (porcine) lock KWIKPEN 30 HAEGARDA 128 flush & nacl lock flush 21 HUMALOG KWIKPEN 30 HEPARIN SODIUM/D5W 21 HAIR FARE 208 HUMALOG MIX 50/50 30 HEPARIN HAIR NOURISHING HUMALOG MIX 50/50 SUPPLEMENT 208 SODIUM/DEXTROSE 22 HEPARIN SODIUM/NACL KWIKPEN 30 HAIR-VITES 163 0.45% 22 HUMALOG MIX 75/25 30 HAIR/SKIN/NAILS 164 HEPARIN SODIUM/SODIUM HUMALOG MIX 75/25 HALAC 87 CHLORIDE 22 KWIKPEN 30 HALAVEN 52 HEPARIN SODIUM/SODIUM HUMATROPE 121 CHLORIDE 0.9% 22 HUMATROPE COMBO HALCION 134 HEPATAMINE 215 PACK 121 HALDOL 55 HEPLISAV-B 237 HUMATROPEN FOR 12MG 149 HALDOL DECANOATE 100 55 HEPSERA 59 HALDOL DECANOATE 50 55 HUMATROPEN FOR HERBAPROFEN 155 24MG 149 halobetasol propionate 87 HERCEPTIN 47 HUMATROPEN FOR 6MG 149 HALOG 87 HETLIOZ 134 HUMIRA 3 haloperidol 55 HEXALEN 46 HUMIRA PEDIATRIC CROHNS haloperidol decanoate 55 HIMALAYAN GOJI 155 DISEASE STARTER PACK 3 HUMIRA PEN 3 haloperidol lactate 55 HIPREX 234 HALOTIN 82 HUMIRA PEN-CD/UC/HS HISTEX-PE 75 STARTER 3 HARVONI 59 HIZENTRA 223 HUMIRA PEN-PS/UV HAVRIX 237 HM ACIDOPHILUS 32 STARTER 3 HEAL AID PLUS 99 HM COMPLETE 164 HUMULIN 70/30 30 HEALON 221 HM COMPLETE 50+ MENS HUMULIN 70/30 KWIKPEN 30 HEALON GV 221 ULTIMATE 164 HUMULIN N 30 HEALON5 221 HUMULIN N KWIKPEN 30

Index 26 HUMULIN R 30 HYDROFERA BLUE HYDROMORPHONE HUMULIN R U-500 4"X4" 108 HYDROCHLORIDE/BUPIVACAI (CONCENTRATED) 30 HYDROFERA BLUE FOAM NE HYDROCHLORIDE/SODIUM HUMULIN R U-500 DRESSING 108 11 KWIKPEN 30 HYDROFERA BLUE FOAM HYDROMORPHONE HURRICAINE 156 DRESSING 2"X2" 108 HYDROCHLORIDE/ROPIVACAI HYDROFERA BLUE FOAM NE HYDROCHLORIDE 11 HYALEX 164 DRESSING 4"X4" 108 HYDROMORPHONE HYALGAN 210 HYDROFERA BLUE FOAM HYDROCHLORIDE/SODIUM HYALUCIL-4 83 DRESSING 6"X6" 108 CHLORIDE 8 hyaluronate sodium HYDROFERA BLUE FOAM HYDROMORPHONE/SODIUM (emollient) 92 DRESSING/MOISTURE CHLORIDE 8 RETENTIVE FILM 108 HYDROXOCOBALAMIN 129 HYCAMTIN 52 HYDROFERA BLUE FOAM HYCOFENIX 75 DRESSING/MOISTURE hydroxychloroquine sulfate 45 HYCOLOID-GRX 107 RETENTIVE FILM/2- HYDROXYPROGESTERONE CAPROATE 48 hydralazine hcl 44 1/4X8 108 HYDROFERA BLUE FOAM hydroxyprogesterone HYDRASYN25 92 DRESSING/MOISTURE caproate 225 HYDRAZONE LOTION 92 RETENTIVE FILM/4"X4" 108 hydroxyurea 51 HYDREA 51 HYDROFERA BLUE FOAM HYDROXYZINE HCL 17 HYDRO 35 89 DRESSING/MOISTURE hydroxyzine hcl 17 RETENTIVE HYDRO 40 FOAM 89 FILM/ISLAND 108 HYDROXYZINE PAMOATE 17 HYDRO-LAN 92 HYDROFERA BLUE FOAM hydroxyzine pamoate 17 HYDROCELL ADHESIVE DRESSING/MOISTURE HYLATOPIC PLUS 99 DRESSING 4"X4" 141 RETENTIVE/OSTOMY/2.5" HYLENEX 154 HYDROCELL DRESSING 108 4"X4" 141 HYDROFERA BLUE FOAM HYLIRA 92 HYDROCERIN 100 DRESSING/TUNNELING/9MM HYMOVIS 210 hydrochlorothiazide 119 108 HYOPHEN 234 HYDROFERA BLUE HEAVY hyoscyamine sulfate 231 HYDROCODONE DRAINAGE 4"X4" 108 BITARTRATE/CHLORPHENIRA HYDROFERA BLUE HEAVY HYPAFIX/5 CM X 10M/2" X11 MINE MALEATE/PSE 75 DRAINAGE 6"X6" 108 YDS 108 hydrocodone polistirex- HYDROFERA BLUE READY HYPER-SAL 76 chlorpheniramine polistirex 75 FOAMDRESSING HYPERHEP B S/D 223 hydrocodone w/ 2.5"X2.5" 108 HYPERLYTE-CR 151 homatropine 73 HYDROFERA BLUE READY hydrocodone- FOAMDRESSING 4"X5" 108 HYPERRHO S/D 223 acetaminophen 11 HYDROFERA BLUE READY HYPERRHO S/D MINI- hydrocodone-ibuprofen 11 FOAMDRESSING 8"X8" 108 DOSE 223 HYDROCOL II 108 HYDROGEL 108 HYPERSAL 76 HYDROCOL II SACRAL 108 HYDROGEL AG 108 HYPERTET S/D 223 HYDROCOL II THIN 108 HYDROGEN PEROXIDE 56 hypromellose (intraocular) 221 hydrocortisone 71 hydromorphone hcl 8 HYQVIA 223 hydrocortisone (intrarectal) 13 HYDROMORPHONE HCL 8 HYSINGLA ER 8 hydrocortisone (rectal) 14 hydromorphone hcl 8 HYZAAR 43 hydrocortisone (topical) 87 HYDROMORPHONE I.L.X. B-12 131 hydrocortisone acetate w/ HCL/SODIUMCHLORIDE 8 ibandronate sodium 119,120 pramoxine 14 HYDROMORPHONE IBRANCE 49 HYDROCHLORIDE 8 hydrocortisone butyrate 87 IBUDONE 11 hydrocortisone butyrate HYDROMORPHONE hydrophilic lipo base 87 HYDROCHLORIDE/ SODIUM ibuprofen 4 CHLORIDE 8 hydrocortisone valerate 87 IBUPROFEN COMFORT PAC 4 hydrocortisone w/acetic acid 222 ibuprofen lysine 4

Index 27 ibutilide fumarate 19 INFANRIX 231 INVANZ 15 IC 400 5 INFASURF 229 INVEGA 54 IC 800 5 INFED 133 INVEGA SUSTENNA 54 ICAPS AREDS FORMULA 164 INFINITY CONTROL INVEGA TRINZA 54 ICAPS PLUS 164 SOLUTION HIGH 145 INVIRASE 57 INFINITY CONTROL ICAR PEDIATRIC 133 SOLUTION LOW 145 INVOKAMET 28 ICAR-C PLUS 131 INFINITY CONTROL INVOKAMET XR 28 ICLUSIG 50 SOLUTION NORMAL 145 INVOKANA 31 ICY HOT LIDOCAINE PLUS INFINITY VOICE LEVEL 2 145 IODIDES TINCTURE 56 MENTHOL 97 IODINE STRONG 67 ICY HOT PM 97 INFLAMMA-K KIT 80 INFLAMMATION REDUCTION IODINE TINCTURE 56 IDAMYCIN PFS 49 PACK 5 IODINE TINCTURE MILD 56 idarubicin hcl 49 INFLECTRA 125 IODOPEN 152 IDHIFA 50 INFUMORPH 200 8 iodoquinol-hydrocortisone-aloe IFEX 46 INFUMORPH 500 8 polysaccharide 82 ifosfamide 46 INFUVITE ADULT 199 IONOSOL-B/DEXTROSE IFOSFAMIDE 46 5% 151 INFUVITE PEDIATRIC 201 IONOSOL-MB/DEXTROSE ILARIS 3 INGREZZA 227 5% 151 ILEVRO 221 INJECT-EASE 149 IONSYS 8 ILUVIEN 220 INJECT-EASE AUTOMATIC IOPIDINE 218 imatinib mesylate 50 INJECTOR 149 IPOL INACTIVATED IPV 237 IMBRUVICA 50 INJECTAFER 133 ipratropium bromide 19 imipenem-cilastatin 15 INLYTA 50 ipratropium bromide (nasal)211 imipramine hcl 28 INNOPRAN XL 62 ipratropium-albuterol 20 imipramine pamoate 28 INOVA 78 IPRIVASK 22 imiquimod 95 INOVA 4/1 ACNE CONTROL THERAPY 78 irbesartan 41 IMITREX 150 INOVA 8/2 ACNE CONTROL irbesartan-hydrochlorothiazide IMITREX STATDOSE THERAPY 78 43 REFILL 150 INSPRA 44 IRESSA 50 IMITREX STATDOSE INSULIN SYRINGES AND PEN IRINOTECAN 52 SYSTEM 150 NEEDLES 149 irinotecan hcl 52 IMLYGIC 52 INTEGRA F 131 iron combinations 132 IMODIUM A-D 33 INTEGRA PLUS 132 iron polysaccharide complex-vit IMPAVIDO 14 INTEGRILIN 129 b12-folic acid 132 IMPOYZ 87 INTELENCE 57 iron w/ vitamins 159 IMURAN 154 INTERARTICULAR JOINT iron-docusate-b12-folic acid-vit c- IN TOUCH GLUCOSE KIT 71 vit e-copper-biotin 132 CONTROLSOLUTION 145 INTERDRY AG TEXTILE iron-folic acid-vitamin c-vitamin INATAL GT 202 10"X12' ROLL 108 b6-vitamin b12-zinc 132 INTERMEZZO 134 iron-vitamin c-vitamin b12-folic INCRELEX 121 acid 132 INCRUSE ELLIPTA 19 INTRALIPID 212 IROSPAN 24/6 132 indapamide 119 INTRAROSA 237 irrigation solutions, INDERAL LA 62 INTRASITE GEL physiological 155 APPLIPAK 108 INDERAL XL 62 IS 24/6 132 INTRON A 51 INDOCIN 5 ISCAR MALI 2 INTRON A W/DILUENT 51 indomethacin 5 ISENTRESS 57 INTUNIV 1 ISENTRESS HD 57 indomethacin sodium 5 INULOSE BLOOD SUGAR INFANATE BALANCE 202 SUPPORT 208 isoflurane 127

Index 28 ISOLYTE-P/DEXTROSE JENTADUETO 28 KELARX 101 5% 151 JENTADUETO XR 28 KENALOG 87 ISOLYTE-S 151 JETREA 221 KENALOG-10 71 ISOLYTE-S PH 7.4 151 JEVTANA 52 KENALOG-40 71 ISONIAZID 45 JOBST IT STAYS/ROLL- KENDALL ALGINATE isoniazid 45 ON 99 HYDROCOLLOID DRESSING ISOPROPYL ALCOHOL JOINT LUBE 155 4"X4" 108 WIPES 100 JTT PHYSICIANS KIT 71 KENDALL ALGINATE isoproterenol hcl 20 HYDROCOLLOID DRESSING JUBLIA 82 ISOPTO ATROPINE 218 4"X5" 108 JULUCA 57 KENDALL ALGINATE ISOPTO CARPINE 218 JUXTAPID 40 HYDROCOLLOID DRESSING ISORDIL TITRADOSE 17 K-PAX IMMUNE SUPPORT 6"X6" 108 isosorbide dinitrate 17 FORMULA DOUBLE KENDALL ALGINATE ISOSORBIDE DINITRATE STRENGTH 164 HYDROCOLLOID DRESSING ER 17 K-PAX IMMUNE SUPPORT 6"X7" 108 isosorbide mononitrate 17 FORMULA PROFESSIONAL KENDALL ALGINATE HYDROCOLLOID DRESSING ISOTONIC GENTAMICIN 3 STRENGTH 164 K-PAX IMMUNE SUPPORT 8"X8" 108 isotretinoin 78 FORMULA SINGLE KENDALL AMORPHOUS isradipine 63 STRENGTH 164 HYDROGEL WOUND DRESSING 109 ISTALOL 217 K-PHOS 153 KENDALL ANTIMICROBIAL ISTODAX 50 K-PHOS NEUTRAL 153 BANDAGE 4-1/2"X4-1/8YD 109 ISTODAX (OVERFILL) 50 K-PHOS NO 2 127 KENDALL HYDROGEL ISUPREL 20 K-TAB 153 IMPREGNATED GAUZE 2"X2" 109 ITCH-ENDER! 99 K.B.G.L. IN TERODERM CREAM 80 KENDALL HYDROGEL itraconazole 36 IMPREGNATED GAUZE KABIVEN 212 IV INFUSION CPI 97 4"X4" 109 KADCYLA 47 KENDALL HYDROGEL IV NOVICE PACK 97 KADIAN 8 IMPREGNATED GAUZE ivermectin 14 KALBITOR 128 4"X8" 109 IXEMPRA KIT 52 KENDALL HYDROGEL WOUND KALETRA 57 J & J BURN CREAM 92 DRESSING 3" DISK 109 KALTOSTAT 108 KENDALL HYDROGEL WOUND J & J GAUZE 2"X2" 8 PLY 141 KALTOSTAT FORTEX 108 DRESSING 4-3/4" DISK 109 J & J GAUZE 4"X4" 12 PLY141 KENDALL HYDROPHILIC KALTOSTAT ROPE 108 J & J GAUZE 4"X4" 8 PLY 141 FOAMDRESSING 2"X2" 141 KALTOSTAT WOUND KENDALL HYDROPHILIC J & J GAUZE SPONGES 12-PLY DRESSING 108 4" X 4" 141 FOAMDRESSING 3"X3" 141 J & J GAUZE SPONGES 16-PLY KALYDECO 228 KENDALL HYDROPHILIC 4" X 4" 141 KAMDOY 99 FOAMDRESSING 4"X4" 141 J & J GAUZE SPONGES 8- KANUMA 122 KENDALL HYDROPHILIC FOAMPLUS DRESSING PLY4" X 4" 141 KAPSPARGO SPRINKLE 61 J-TIP KIT W/VIAL 2"X2" 141 ADAPTERS 149 KAPVAY 1 KENDALL HYDROPHILIC JADENU 34 KARBINAL ER 37 FOAMPLUS DRESSING 3"X3" 141 JADENU SPRINKLE 33 KARBOZYME EC 118 KENDALL ZINC CALCIUM JAKAFI 50 KAYEXALATE 156 ALGINATE DRESSING JALYN 128 KAZANO 28 2"X2" 109 KENDALL ZINC CALCIUM JANUMET 28 KCL 0.15%/D5W/NACL 0.225% 151 ALGINATE DRESSING JANUMET XR 28 KCL 0.3%/D5W/NACL 4"X4" 109 JANUVIA 29 0.9% 151 KENDALL ZINC CALCIUM JARDIANCE 31 KEFLEX 65 ALGINATE DRESSING 4"X8" 109

Index 29 KENDALL ZINC CALCIUM KETOPROFEN ER 5 L-HISTIDINE 215 ALGINATE DRESSING ROPE KETOROCAINE-L 5 L-HISTIDINE 12" 109 KETOROCAINE-LM 5 MONOHYDROCHLORIDE 215 KENGREAL 129 L-HISTIDINE KEPIVANCE 51 KETOROLAC 2% GEL 80 MONOHYDROCHLORIDE KEPPRA 23 ketorolac tromethamine 5 MONOHYDRATE 215 ketorolac tromethamine L-ISOLEUCINE 215 KEPPRA XR 23 (ophth) 221 L-LEUCINE 215 KERADAN 92 KETOSTIX 118 L-METHIONINE 215 KERAGEL 109 ketotifen fumarate (ophth)221 L-PHENYLALANINE 215 KERAGELT 109 KEVEYIS 118 L-PROLINE 215 KERALAC 89 KEVZARA 4 L-TAURINE 215 KERALYT 95 KEYTRUDA 47 L-THREONINE 215 KERALYT SCALP 95 KHEDEZLA 27 L-TRYPTOPHAN 215 KERAMATRIX REPLICINE KIDNEY 208 10CMX10CM 109 L-TYROSINE 215 KERAMATRIX REPLICINE KINERET 3 L-VALINE 215 5CMX5CM 109 KINRIX 231 labetalol hcl 61 KERASAL FUNGAL NAIL KISQALI 50 LAC-HYDRIN 93 RENEWAL 99 KISQALI FEMARA 200 KERI ADVANCED MOISTURE DOSE 49 LAC-HYDRIN TWELVE 93 THERAPY 92 KISQALI FEMARA 400 LACRISERT 217 KERI BASIC ESSENTIALS 93 DOSE 49 lactated ringer's 151 KERI LONG LASTING 93 KISQALI FEMARA 600 lactated ringer's (irrigation) 155 DOSE 49 KERI NOURISHING SHEA lactic acid (ammonium BUTTER 93 KITABIS PAK 3 lactate) 93 KERI ORIGINAL 93 KLARON 78 lactic acid w/ vitamin e 93 KERI OVERNIGHT 93 KLONOPIN 23 LACTINOL HX 93 KERI RENEWAL MILK KLOR-CON M15 153 BODY 93 LACTO-PECTIN 32 KERI RENEWAL SKIN KLOR-CON/25 153 lactulose 135 FIRMING 93 KOMBIGLYZE XR 28 lactulose (encephalopathy) 126 KERI RENEWAL STRETCH KORLYM 29 LADY ESTHER 4 PURPOSE MARK MINIMIZER 93 KOSHER PRENATAL PLUS FACE CREAM 93 KERI SENSITIVE SKIN 93 IRON 202 LAMICTAL 23 KERLIX SPONGES 4" X 4" 12 KP MENS DAILY PACK 164 LAMICTAL CHEWABLE PLY 141 KP WOMENS DAILY DISPERSIBLE 23 KERLIX SPONGES 4" X 4" 16 PACK 164 LAMICTAL ODT 23 PLY 141 KRISTALOSE 135 KERLIX SUPER SPONGE LAMICTAL STARTER/NOT SALINE DRESSING 109 KRYSTEXXA 128 TAKING CARBAMAZEPINE 23 KUVAN 122 LAMICTAL STARTER/TAKING KERYDIN 82 CARBAMAZEPINE/NOT TAKING KETALAR 126 KYLEENA 69 VALPROATE 23 ketamine hcl 126 KYNAMRO 38 LAMICTAL STARTER/TAKING KETEK 16 KYPROLIS 50 VALPROATE 23 LAMICTAL XR 23 KETOCARE 117 L-ALANINE 215 LAMISIL 36 ketoconazole 36 L-ARGININE 215 LAMISIL AT SPRAY 82 ketoconazole (topical) 82 L-ARGININE BASE 215 lamivudine 57 KETODAN KIT 82 L-CYSTEINE HCL 215 lamivudine (hbv) 59 KETONE TEST STRIPS 117 L-CYSTINE 215 lamivudine-zidovudine 57 KETOPHENE RAPIDPAQ 80 L-GLUTAMIC ACID 215 lamotrigine 24 KETOPROFEN 5 L-GLUTAMINE 215 LANCET DEVICES 145 ketoprofen 5 L-GLUTATHIONE 215

Index 30 LANCETS 145 LEVALBUTEROL TARTRATE LIBERTY CONTROL lanolin 225 HFA 20 SOLUTIONNORMAL 146 LEVAQUIN 124 LIBERTY GLUCOSE CONTROL LANOLOR 93 LEVATIO PATCH 97 LEVEL 1 146 LANOXIN 63,64 LIBERTY GLUCOSE CONTROL LEVBID 231 LANOXIN PEDIATRIC 63 LEVEL 2 146 LEVEMIR 30 LIBERTY GLUCOSE CONTROL lansoprazole 233 LEVEMIR FLEXTOUCH 30 MID 146 lanthanum carbonate 126 LIBERTY GLUCOSE CONTROL levetiracetam 24 LANTUS 30 NORMAL 146 LEVETIRACETAM 24 LANTUS SOLOSTAR 30 LIBRAX 232 levetiracetam 24 LARTRUVO 47 LIDO-RX 4.1 97 levetiracetam in sodium lidocaine 97 LASIX 119 chloride 24 LASTACAFT 221 LIDOCAINE AND LEVICYN 99 TETRACAINECREAM 97 LATANOPROST 222 LEVIGOLT 97 LIDOCAINE HCL 18 latanoprost 222 levobunolol hcl 217 lidocaine hcl 97 LATRIX XM 89 levocarnitine (metabolic LIDOCAINE HCL 136 LATUDA 54 modifiers) 122 levocetirizine lidocaine hcl (cardiac) 18 LAVARE WOUND WASH 109 dihydrochloride 37 lidocaine hcl (local anesth.) 136 LAZANDA 9 levofloxacin 124 lidocaine hcl (mouth-throat) 156 LDO PLUS 97 levofloxacin (ophth) 219 LIDOCAINE HCL- LEADER FINGER CREAM 93 levofloxacin in d5w 124 HYDROCORTISONE ACETATE LECITHIN 212 WITH ALOE 14 LEVOLEUCOVORIN 51 LIDOCAINE leflunomide 6 levoleucovorin calcium 51 HCL/DEXTROSE 136 LEMTRADA 227 LEVOMEFOLATE DHA 202 LIDOCAINE LENVIMA 10 MG DAILY levonorgestrel & eth HYDROCHLORIDE 136 DOSE 50 estradiol 67 LIDOCAINE LENVIMA 14 MG DAILY levonorgestrel (emergency HYDROCHLORIDE/SODIUM DOSE 50 oc) 69 BICARBONATE 136 LENVIMA 18 MG DAILY levonorgestrel-eth estradiol lidocaine in d5w 18 DOSE 50 (triphasic) 67 lidocaine w/ epinephrine 136 LENVIMA 20 MG DAILY levonorgestrel-ethinyl estradiol lidocaine-hydrocortisone acetate DOSE 50 (91-day) 67 LENVIMA 24 MG DAILY (rectal) 14 levonorgestrel-ethinyl estradiol lidocaine-menthol 97 DOSE 50 (continuous) 67 LENVIMA 8 MG DAILY LEVOPHED 239 lidocaine-prilocaine 97 DOSE 50 LEVORPHANOL LIDOCARE LENZAPATCH 97 TARTRATE 9 ARM/NECK/LEG 97 LESCOL XL 39 LEVOTHYROXINE LIDOCARE BACK/SHOULDER 97 LETAIRIS 64 SODIUM 230 LIDODERM 97 letrozole 48 levothyroxine sodium 230 LIDODOSE 97 LETS KIT 135 LEVSIN 232 LIDOLOG KIT 71 LEUCINE 215 LEVSIN/SL 232 LIDOPAC 97 leucovorin calcium 51 LEVULAN KERASTICK 83 LIDOPIN 97 LEUCOVORIN CALCIUM 51 LEXAPRO 27 LIDOPROFEN 80 leucovorin calcium 51 LEXIVA 57,58 LIDORX 98 LEUKERAN 46 LEXIXRYL 80 LIDOTHOL 98 LEUKINE 130 LEXUSS 210 75 LIDOTRAL 98 leuprolide acetate 48 LIALDA 125 LIDOTRANS 5 PAK 98 LEVACET 6 LIBERTY CONTROL SOLUTION HIGH 146 LIDOTREX 109 levalbuterol hcl 20

Index 31 LIDOVEX 98 LITHIUM 54 LOTENSIN HCT 43 LIDOVIN 98 lithium carbonate 54 LOTREL 43 LIDOXIB KIT 5 LITHIUM CARBONATE 54 LOTRIMIN AF 82 LIDOZOL 98 lithium carbonate 54 LOTRIMIN AF FOR HER 82 LIDTOPIC MAX 98 LITHOBID 54 LOTRIMIN AF JOCK ITCH 82 LIFE PACK MENS 164 LITHOSTAT 128 LOTRIMIN ULTRA 82 LIFE PACK WOMENS 164 LIVALO 39 LOTRISONE 82 LILETTA 69 LO LOESTRIN FE 67 LOTRONEX 126 LINCOCIN 16 LOCOID 87 LOUTREX 84 lincomycin hcl 16 LOCOID LIPOCREAM 87 lovastatin 39 LINDANE 101 LODINE 5 LOVAZA 38 lindane 101 LODOSYN 53 LOVENOX 22 linezolid 16 LOESTRIN 1.5/30-21 67 LOVIRAL 155 LINEZOLID 16 LOESTRIN 1/20-21 67 loxapine succinate 55 linezolid 16 LOESTRIN FE 1.5/30 68 LOYON 99 LINZESS 126 LOESTRIN FE 1/20 68 LOZI-FLUR 152 LIORESAL INTRATHECAL 209 LOFIBRA 39 LT INJECTION KIT 71 liothyronine sodium 230 LOHIST-D 75 LUBRIDERM 93 LIPIDSHIELD PLUS 208 LOHIST-DM 75 LUBRIDERM ADVANCED LIPITOR 39 LOMOTIL 33 THERAPY 93 LUBRIDERM DAILY LIPOFEN 39 LONGEVITY 208 MOISTURE/NORMAL TO DRY LIPOTRIAD VISION LONGEVITY PLUS 208 SKIN 93 SUPPORT 208 LONHALA MAGNAIR REFILL LUBRIDERM DAILY LIPOTRIAD VISION KIT 19 MOISTURESHEA + CALMING SUPPORTPLUS 208 LONHALA MAGNAIR LAVENDER JASMINE 93 LIPOTRIAD VISIONARY 208 STARTER KIT 19 LUBRIDERM INTENSE SKIN LIQUIHEP BD 3ML PREFIL LONSURF 49 REPAIR 93 SYR/SWAB/GAUZE/CAP/NDL loperamide hcl 33 LUBRIDERM MENS 3-IN-1 93 STOP/LBL/NDLS 117 LUBRIDERM SERIOUSLY LIQUIHEP BD 3ML PREFILLED LOPID 39 SENSITIVE 93 SYR/TIP CAP/NDL lopinavir-ritonavir 58 LUBRIDERM SKIN STOP/LABEL/23GX1" 117 LOPRESSOR 61 NOURISHINGWITH SHEA AND LIQUIHEP BD 3ML PREFILLED LOPRESSOR HCT 43 COCOA BUTTERS 93 SYRINGE/TIP CAP/NEEDLE LUBRISOFT 93 STOPPER 117 LOPROX 82 LIQUIHEP II BD 3ML LL LOPROX SHAMPOO 82 LUCEMYRA 226 SYR/LL/SWAB/GZ/CAP/NDL lorazepam 18 LUCENTIS 218 ST/SAFETYCONE 117 LORAZEPAM/DEXTROSE18 LUGOLS 67 LIQUIHEP II BD 3ML PREFILL LUGOLS STRONG IODINE 56 SYR/LL/SWAB/GZ/CAP/NDL LORAZEPAM/SODIUM ST/ICE BG 117 CHLORIDE 18 LULICONAZOLE 82 LIQUIHEP II BD 3ML PREFILL LORTAB 12 LUMIGAN 222 SYR/SWAB/GAUZE/CAP/NDL LORVATUS LUMIZYME 122 ST/ICE BG 117 PHARMAPAK 210 LUNESTA 134 LIQUIHEP II BD 3ML PREFILL LORZONE 209 LUNG 208 SYR/TIP CAP/NDL losartan potassium 41 STOP/LABEL/23GX1 117 losartan potassium & LUNG TONIC 155 LIQUIHEP II BD 3ML LUPANETA PACK 121 PREFILLED SYRINGE/TIP hydrochlorothiazide 43 LOSEASONIQUE 68 LUPRON DEPOT (1- CAP/NEEDLE STOPPER 117 MONTH) 48 lisinopril 41 LOTEMAX 220 LUPRON DEPOT (3- lisinopril & LOTENSIN 41 MONTH) 48 hydrochlorothiazide 43

Index 32 LUPRON DEPOT (4- MAL PATCH 98 MEDERMA AG FACE MONTH) 48 MALARONE 44 CREAM 93 LUPRON DEPOT (6- MEDERMA AG HAND & BODY MONTH) 48 malathion 101 LOTION 93 LUPRON DEPOT-PED (1- MAMMARY 208 MEDERMA FOR KIDS 102 MONTH) 121 MANGANESE SULFATE 152 MEDERMA STRETCH MARKS LUPRON DEPOT-PED (3- MANGANESE TRACE THERAPY 93 MONTH) 121 METAL 152 MEDFIX EZ 109 LURIDE 152 mannitol 119 MEDI-DERM 96 LUXAMEND 109 maprotiline hcl 26 MEDI-DERM-RX 96 LUXIQ 87 MARBETA-25 71 MEDI-DERM/L 98 LUZU 82 MARBETA-L 71 MEDI-DERM/L-RX 98 LYCELLE 101 MARCAINE 136 MEDI-PAK PERFORMANCE LYDIA PINKHAM 155 MARCAINE SPINAL 136 PLUSCOMBINE ABD PAD/8" X LYMPH 208 MARCAINE/EPINEPHRINE 7.5" 109 LYMPHATONIC 155 136 MEDI-PATCH RX 98 LYNPARZA 50 MARDEX-25 71 MEDI-PATCH/LIDOCAINE 98 LYRICA 24 MARINOL 35 MEDICAL PROVIDER EZ FLU SHOT 2015-2016 237 LYRICA CR 227 MARLIDO KIT 136 MEDICAL PROVIDER SINGLE LYSODREN 48 MARLIDO-25 136 USE EZ FLU SHOT 237 LYSTEDA 133 MARNATAL-F 203 MEDIHONEY CALCIUM MARPLAN 26 ALGINATE DRESSING M-M-R II 237 4"X5" 109 M-VIT 203 MARQIBO 52 MEDIHONEY CALCIUM M.V.I. ADULT 199 MARVONA SUIK 136 ALGINATE M.V.I. PEDIATRIC 201 MAS CARE-PAK 71 DRESSING/2"X2" 109 M.V.I.-12 WITHOUT VITAMIN MEDIHONEY WOUND & BURN MATULANE 51 DRESSING 3/4"X12" 109 K 199 MAVIK 41 MEDIHONEY M2 B-60 164 MAVYRET 59 WOUND/BURNDRESSING109 M2 CALCIUM 208 MAXALT 150 MEDIHONEY M2 CHROMIUM 208 WOUND/BURNDRESSING MAXALT-MLT 150 4"X5" 109 MAC PATCH 98 MAXAM 93 MEDISENSE GLUCOSE MACI 209 MAXFE 132 KETONECONTROL SOLUTION MACNATAL CN DHA 203 MAXIDEX 220 1-LOW,1-MED,1 HIGH 146 MACRILEN 116 MEDISENSE GLUCOSE MAXIMA CONTROL KETONECONTROL SOLUTION MACROBID 234 SOLUTION 146 1-NORMAL 146 MACRODANTIN 234 MAXIMA CONTROL MEDISENSE HIGH/LOW SOLUTION/NORMAL 146 MACUGEN 218 CONTROL SOLUTION 146 MAXIPIME 66 MACULAR VITAMIN MEDISENSE HIGH/MID/LOW BENEFIT 164 MAXITROL 220 CONTROL SOLUTION 146 mafenide acetate 84 MAXORB EXTRA AG+ 109 MEDISENSE MID CONTROL SOLUTION 146 MAXZIDE 118 MAGNEBIND 400 152 MEDROL 71 MAGNESIUM SULFATE IN MAXZIDE-25 118 MEDROL DOSEPAK 71 D5W 152 MB HYDROGEL 99 magnesium sulfate in MEDROLOAN II SUIK 71 meclizine hcl 35 dextrose 152 MEDROLOAN SUIK 71 MECLOFENAMATE MAGNESIUM MEDROX 98 SULFATE/DEXTROSE 152 SODIUM 5 MAGNESIUM MEDELA TENDER CARE MEDROX-RX 96 SULFATE/SODIUMCHLORIDE LANOLIN 93 medroxyprogesterone 152 MEDERMA 102 acetate 225 MAKENA 225

Index 33 medroxyprogesterone acetate MEPERIDINE HCL 9 methenamine-hyosc-methylene (contraceptive) 69 meperidine hcl 9 blue-sod phos-phenyl sal 234 methenamine-hyoscamine- mefenamic acid 5 MEPERIDINE mefloquine hcl 45 methylene blue-sodium HCL/PROMETHAZINE phosphate 234 HCL 12 MEFLOQUINE HCL 45 methimazole 230 MEGA MULTI FOR MEPERIDINE WOMEN 164 HYDROCHLORIDE/SODIUM METHIONINE 215 MEGA MULTIVITAMIN FOR CHLORIDE 9 METHIONINE/INOSITOL/CHOLI MEN 164 MEPHYTON 240 NE/CYANOCOBALAMIN 132 MEGA MULTIVITAMIN FOR mepivacaine hcl 136 METHITEST 13 WOMEN 164 meprobamate 17 methocarbamol 209 MEGA PROBIOTIC 32 MEPRON 15 methotrexate sodium 47 MEGACE ES 225 mercaptopurine 47 METHOTREXATE SODIUM 47 MEGACE ORAL 48 meropenem 15 methotrexate sodium 47 MEGAVITE FRUITS & methoxsalen rapid 83 VEGGIES 164 MEROPENEM/SODIUM MEGAVITE GOLDEN YEARS CHLORIDE 15 methscopolamine bromide 232 55+ 164 MERREM 15 methyclothiazide 119 megestrol acetate 48 mesalamine 125 METHYL SALICYLATE 96 megestrol acetate mesalamine w/ cleanser 125 methyldopa 42 (appetite) 225 mesna 51 methyldopa & MEIJER ALCOHOL SWABS hydrochlorothiazide 43 EXTRA-THICK 148 MESNEX 51 METHYLDOPATE HCL 42 MEKINIST 50 MESTINON 45 METHYLENE BLUE 34 MEKTOVI 50 MESTINON TIMESPAN 45 methylergonovine maleate 222 meloxicam 5 META BIOTIC/BIO-ACTIVE MELOXICAM COMFORT 12 32 METHYLIN 1 PAC 5 METADATE CD 1 methylphenidate hcl 2 melphalan 46 METAPROTERENOL METHYLPHENIDATE HCL SULFATE 20 melphalan hcl 46 ER 2 METASTRON 51 METHYLPHENIDATE memantine hcl 226 METAXALL CP 210 HYDROCHLORIDE ER 2 MENACTRA 235 METAXALONE 209 METHYLPHENIDATE MENEST 124 HYDROCHLORIDE ER (LA) 2 metaxalone 209 MENHIBRIX 235 METHYLPREDNISOLONE 71 metformin hcl 29 MENOMUNE-A/C/Y/W-135 methylprednisolone 71 235 methadone hcl 9 METHYLPREDNISOLONE MENOPAUSE RELIEF 208 METHADONE HCL 9 ACETATE 71 MENOPAUTONIC 155 methadone hcl 9 methylprednisolone acetate 71 METHADONE HCL 9 METHYLPREDNISOLONE MENOPUR 120 ACETATE 71 MENOSTAR 124 methadone hcl 9 METHYLPREDNISOLONE MENS 50+ ADVANCED 164 METHADONE HCL 9 ACETATE/BUPIVACAINE MENS 50+ MULTI VITAMIN methadone hcl 9 HYDROCHLORIDE 71 &MINERAL FORMULA 164 METHADOSE 9 methylprednisolone sod MENS MULTI VITAMIN & succ 71 METHADOSE SUGAR- METHYLPREDNISOLONE/LIDO MINERAL FORMULA 164 FREE 9 MENS PACK 164 CAINE 71 methamphetamine hcl 1 METHYLTESTOSTERONE 13 MENTAX 82 methazolamide 118 217 MENTHO-CAINE KIT 98 METIPRANOLOL methenamine hippurate 234 metoclopramide hcl 125 MENVEO 235 methenamine mandelate 234 METOCLOPRAMIDE ODT 125 MEPERIDINE HCL 9 methenamine-hyosc-methylene 119 meperidine hcl 9 blue-benzoic acid-phenyl metolazone sal 234

Index 34 metoprolol & MIDAZOLAM MIRODERM FENESTRATED hydrochlorothiazide 43 HYDROCHLORIDE/SODIUM BIOLOGIC WOUND MATRIX metoprolol succinate 61 CHLORIDE 134 5X5CM 110 METOPROLOL SUCCINATE midodrine hcl 239 MIRODERM FENESTRATED ER/HYDROCHLOROTHIAZIDE MIGERGOT 149 BIOLOGIC WOUND MATRIX 8X15CM 110 43 miglitol 28 METOPROLOL TARTRATE 61 MIRODERM FENESTRATED miglustat 129 BIOLOGIC WOUND MATRIX metoprolol tartrate 61 MIGRAINE PACK 149 8X8CM 110 METOPROLOL TARTRATE 61 MIRODERM FENESTRATED MIGRANAL 149 METOPROLOL/HYDROCHLOR PLUSBIOLOGIC WOUND OTHIAZIDE 43 MIGRANOW 149 MATRIX 3X3CM/MESHED 110 METOZOLV ODT 125 MIL ADREGEN 208 MIRODERM FENESTRATED METRO IV 14 MILADRENE FORTE 208 PLUSBIOLOGIC WOUND MATRIX 4X4CM/MESHED 110 METROCREAM 101 MILCO-B-FORTE 159 MIRODERM FENESTRATED METROGEL 101 MILLIPRED 71 PLUSBIOLOGIC WOUND METROGEL-VAGINAL 238 MILLIPRED DP 71 MATRIX 5X5CM/MESHED 110 MILPAN 208 MIRODERM FENESTRATED METROLOTION 101 PLUSBIOLOGIC WOUND metronidazole 14 milrinone lactate 64 MATRIX metronidazole (topical) 101 milrinone lactate in 8X15CM/MESHED 110 METRONIDAZOLE dextrose 64 MIRODERM FENESTRATED BENZOATE/SYRSPEND SF mineral oil 135 PLUSBIOLOGIC WOUND PH4 14 MINIPRESS 42 MATRIX 8X8CM/MESHED 110 metronidazole in nacl 14 MIRODERM MESHED MINIVELLE 124 BIOLOGICWOUND MATRIX metronidazole vaginal 238 MINOCIN 229 3X3CM 110 MEVACOR 39 minocycline hcl 229 MIRODERM MESHED mexiletine hcl 18 minoxidil 44 BIOLOGICWOUND MATRIX 3X7CM 110 MG-PLUS PROTEIN 208 MIOCHOL-E 218 MIRODERM MESHED MH MACULAR HEALTH 164 MIOSTAT 218 BIOLOGICWOUND MATRIX MIACALCIN 120 MIRALAX 135 4X4CM 110 MIADERM RADIATION MIRAPEX 53 MIRODERM MESHED RELIEF 99 BIOLOGICWOUND MATRIX MIRAPEX ER 53 MICARDIS 41 5X5CM 110 MIRASORB SPONGES 2" X MIRODERM MESHED MICARDIS HCT 43 2" 141 BIOLOGICWOUND MATRIX MICATIN 82 MIRASORB SPONGES 4" X 8X15CM 110 MICONAZOLE 3 238 4" 141 MIRODERM MESHED miconazole nitrate (topical) 82 MIRCERA 130 BIOLOGICWOUND MATRIX 8X8CM 110 miconazole nitrate vaginal 238 MIRCETTE 68 MIRENA 69 mirtazapine 26 MICORT-HC 87 MIRVASO 101 MICRHOGAM ULTRA- MIRODERM FENESTRATED FILTEREDPLUS 223 BIOLOGIC WOUND MATRIX misoprostol 234 2X2CM 109 MITIGARE 128 MICRO-K 153 MIRODERM FENESTRATED MICROCYN 109 BIOLOGIC WOUND MATRIX mitomycin 49 MICROCYN SKIN AND WOUND 2X3CM 110 MITOSOL 219 HYDROGEL 109 MIRODERM FENESTRATED mitoxantrone hcl 49 MICRODOT CONTROL BIOLOGIC WOUND MATRIX MIVACRON 212 SOLUTIONHIGH/LOW 146 3X3CM 110 MICROKLENZ ANTISEPTIC MIRODERM FENESTRATED MLD KIT 136 WOUND CLEANSER 109 BIOLOGIC WOUND MATRIX MLK F1 KIT 71 MICROZIDE 119 4X4CM 110 MLK F2 KIT 71 midazolam hcl 134 MLK F3 KIT 71

Index 35 MLK F4 KIT 71 morphine sulfate 9 multiple vitamins w/ minerals & MLP A-1 71 MORPHINE SULFATE 9 folic acid 164 MULTITRACE-4 153 MLP A-2 71 morphine sulfate 9 MULTITRACE-4 MM BIOTIN/KERATIN 208 MORPHINE SULFATE ER 9 NEONATAL 153 MOBIC 5 MORPHINE MULTITRACE-4 modafinil 2 SULFATE/SODIUM PEDIATRIC 153 CHLORIDE 9 MULTITRACE-5 153 MODERIBA 59 MOSQUITO EXTRACT 116 MODERIBA 1200 DOSE MULTIVITAMIN ADULTS 195 PACK 59 MOTHERS FRIEND 93 MULTIVITAMIN MEN 195 MODERIBA 800 DOSE MOTOFEN 33 MULTIVITAMIN WITH PACK 59 MOUTH TONIC 155 FLUORIDE 159 MODICON 68 MOUTHKOTE 157 MULTIVITAMIN+ 199 moexipril hcl 41 MOVANTIK 126 MULTIVITAMIN/FLUORIDE 199 moexipril-hydrochlorothiazide MOVIPREP 135 43 mupirocin 81 MOXATAG 224 MOI-STIR 157 mupirocin calcium (topical) 81 MOXEZA 219 MOISTURE CREAM 99 MUSTARGEN 46 MOISTURIZING CREAM 93 MOXIFLOXACIN HCL 124 MVW COMPLETE MOLINDONE moxifloxacin hcl 124 FORMULATION 195 HYDROCHLORIDE 55 moxifloxacin hcl (ophth) 219 MVW COMPLETE mometasone furoate 87 moxifloxacin hcl in sodium FORMULATIOND3000 195 mometasone furoate chloride 124 MVW COMPLETE (nasal) 211 MOXIFLOXACIN FORMULATIOND500 195 MOMMYS BLISS HYDROCHLORDIE/SODIUM MVW COMPLETE MULTIVITAMINORGANIC CHLORIDE 219 FORMULATIONMINIS 195 DROPS 199 MOZOBIL 133 MYALEPT 122 MONISTAT 3 COMBINATION MPS 208 MYAMBUTOL 45 PACK 238 MYCAMINE 35 MONISTAT SOOTHING CARE MS CONTIN 9 ITCH RELIEF 87 MSM SKIN LOTION 93 MYCO NAIL 82 MONODOX 229 MTX SUPPORT 132 MYCO-NAIL 82 MONOJECT BONE MARROW MUCINEX 76 MYCOBUTIN 45 BIOPSY PREPPING TRAY 136 MUCINEX D 75 mycophenolate mofetil 154 MONOJECT BONE MARROW mycophenolate mofetil hcl 154 BIOPSY TRAY/BIOP ASPIR MUCINEX D MAXIMUM NEEDLE 11GX4" 137 STRENGTH 75 mycophenolate sodium 154 MONOJECT BONE MARROW MUCINEX DM 75 MYDAYIS 1 BIOPSY TRAY/BIOP ASPIR MUCINEX DM MAXIMUM MYFORTIC 154 NEEDLE 8GX4" 137 STRENGTH 75 MYGLUCOHEALTH CONTROL MONOJECT BONE MARROW MUGARD 157 LOW/NORMAL/HIGH 146 BIOPSY TRAY/STERNAL-ILIAC MULTAQ 19 MYKIDZ IRON FL 201 NEEDLE 16G 137 MULTI PRENATAL 203 MONOVISC 210 MYLERAN 46 MONSELS FERRIC MULTI-BETIC DIABETES164 MYLOTARG 47 SUBSULFATE 133 MULTI-GLAN 208 MYNATAL 203 montelukast sodium 19 MULTI-SPECIALTY KIT 71 MYNATAL ADVANCE 203 MONUROL 234 MULTI-VITAMIN MYNATAL PLUS 203 MORGIDOX 1X100MG 229 MONOCAPS 164 MULTIGEN 132 MYNATAL ULTRACAPLET 203 MORGIDOX 1X50MG KIT 229 MULTIGEN FOLIC 132 MYNATAL-Z 203 MORGIDOX 2X100MG 229 MULTIGEN PLUS 132 MYNATE 90 PLUS 203 MORPHABOND ER 9 multiple vitamins w/ MYOBLOC 211 morphine sulfate 9 minerals 168,195 MYRBETRIQ 235 MORPHINE SULFATE 9

Index 36 MYSOLINE 24 NAT-RUL THERAVITE- NEOSALUS CP 99 MYTESI 31 M/HIGHPOTENCY 195 NEOSPORIN 219 NATACHEW 203 NABI-HB 223 NEOSPORIN GU NATACYN 219 nabumetone 5 IRRIGANT 127 NATALVIT 203 NEOSTIGMINE nadolol 62 NATAZIA 68 METHYLSULFATE 45 nadolol & neostigmine methylsulfate 45 nateglinide 31 bendroflumethiazide 43 NEOSTIGMINE NAFCILLIN 225 NATELLE ONE 203 METHYLSULFATE 45 nafcillin sodium 225 NATESTO 13 NEOTUSS PLUS 75 NAFCILLIN SODIUM 225 NATPARA 120 NEPHPLEX RX 159 naftifine hcl 82 NATRECOR 65 NEPHRAMINE 216 NAFTIN 82 NATROBA 101 NEPHRO-VITE RX 159 NAGLAZYME 122 NATRUL PROBIOTIC 32 NEPHROCAPS 159 NAIL SCRUB 99 NATRUL-100 195 NEPHRON FA 132 nalbuphine hcl 12 NATRUL-MEGA-75 195 NEPTAZANE 118 NALFON 5 NATRUL-VITES 195 NERLYNX 50 NALOXONE HCL 34 NATURAL WHEY 215 NESACAINE 137 naloxone hcl 34 NATURE-THROID 230 NESACAINE-MPF 137 NALOXONE HCL 34 NATURE-THROID NT- NESINA 29 2.5 230 NALOXONE HYDROCHLORIDE NESTABS 203 DIHYDRATE 67 NAVELBINE 52 NESTABS ABC 203 NALTREXONE 34 NEBUPENT 14 NESTABS DHA 203 naltrexone hcl 34 NEBUSAL 76 NESTABS ONE 203 NAMENDA 226 NECON 1/50-28 68 NEUAC KIT 78 NAMENDA TITRATION NECON 10/11-28 68 NEULASTA 130 PAK 226 NEEVO DHA 203 NAMENDA XR 226 NEULASTA ONPRO KIT 130 nefazodone hcl 27 NAMENDA XR TITRATION NEUPOGEN 130 NEMBUTAL SODIUM 133 PACK 226 NEUPRO 53 NAMZARIC 226 NEO-SYNALAR 81 NEURCAINE 98 NAPRELAN 5 NEO-SYNALAR KIT 81 NEURIN-SL 132 NAPRO 15% COMPOUNDING NEOCERA 99 NEURONTIN 24 KIT 80 NEOKE ALCAR 216 NEUT 151 NAPROSYN 5 NEOKE MCT70 212 naproxen 5 NEUTEK 2TEK CONTROL NEOKE RA LIPOIC 2 SOLUTIONS 146 NAPROXEN COMFORT PAC 5 neomycin sulfate 3 NEUTRASAL 157 naproxen sodium 5 neomycin-bacitracin zn- NEUTROGENA BODY LIGHT naratriptan hcl 150 polymyxin 219 SESAME FORMULA 93 NARCAN 34 neomycin-polymy- NEUTROGENA CLEAR PORE dexameth 220 NARDIL 26 CLEANSER/MASK 78 neomycin-polymyxin-gramicidin NEUTROGENA HAND 93 NAROPIN 137 219 NEUTROGENA NASACORT ALLERGY neomycin-polymyxin-hc HAND/NORWEGIANFORMULA/ 24HR 211 (otic) 222 FAST ABSORBING 94 NASACORT ALLERGY 24HR neomycin/polymyxin b gu 127 NEUTROGENA HEALTHY CHILDRENS 211 NEOMYCIN/POLYMYXIN/HYD SKIN 94 NASALGUARD 99 ROCORTISONE 220 NEUTROGENA HEALTHY SKIN NASCOBAL 129 NEOPROFEN 5 FACE SPF 15 94 NASONEX 211 NEORAL 155 NEUTROGENA MOISTURE SENSITIVE SKIN 94 NAT-RUL C-COMPLEX 159 NEOSALUS 93 NEVANAC 221

Index 37 nevirapine 58 nimodipine 63 NIZATIDINE 232 NEW LIFE HAIR 208 NINLARO 50 NIZORAL 82 NEWGEN 203 NIPENT 51 NO IRON MULTIPLE NEXA PLUS 203 NIPRIDE RTU 44 VITAMIN/MINERALS 196 NOCTIVA 123 NEXAVAR 50 NISEKO HYDRATING FACIAL NEXCARE WOUND MOISTURIZER 94 nonoxynol-9 237 CLEANSER 110 nisoldipine 63 NONYX 99 NEXGEN NORMAL NISOLDIPINE ER 63 NOR-QD 69 CONTROL 146 nit remover 101 NORCO 12 NEXIUM 233 NITHIODOTE 33 NORDIPEN 5 INJECTION NEXIUM 24HR 233 NITRO-BID 17 DEVICE 149 NEXIUM 24HR CLEAR NORDIPEN DELIVERY MINIS 233 NITRO-DUR 17 SYSTEM 149 NEXIUM I.V. 233 nitrofurantoin 235 NORDITROPIN FLEXPRO 121 NEXPLANON 69 nitrofurantoin norepinephrine bitartrate 239 macrocrystal 234 NOREPINEPHRINE NEXTERONE 19 nitrofurantoin monohyd NF FORMULAS CALCIUM BITARTRATE/DEXTROSE 239 macro 234 NOREPINEPHRINE MAGNESIUM/BOTANICALS nitroglycerin 17 156 BITARTRATE/SODIUM NIACIN 240 NITROGLYCERIN 17 CHLORIDE 239 nitroglycerin 17 NOREPINEPHRINE/DEXTROSE niacin (antihyperlipidemic) 40 239 NIACINAMIDE 240 nitroglycerin in d5w 17 NOREPINEPHRINE/SODIUM NITROGLYCERIN IN NIACOR 40 CHLORIDE 239 DEXTROSE 5% 17 norethin acet & estrad-fe 68 NIASPAN 40 NITROGLYCERIN NICADAN 195 LINGUAL 17 norethindrone & eth estradiol68 norethindrone & ethinyl estradiol- NICADAN ZX 195 NITROLINGUAL PUMPSPRAY 17 fe 68 nicardipine hcl 63 NITROMIST 17 norethindrone NICARDIPINE (contraceptive) 69 HYDROCHLORIDE/DEXTROSE NITROPRESS 44 norethindrone acet & eth 63 nitroprusside sodium 44 estra 68 NICAZEL 195 NITROSTAT 17 norethindrone acetate 225 NICAZEL FORTE 195 NITYR 122 norethindrone acetate-ethinyl NIVA-PLUS 203 estradiol 123 NICODERM CQ 228 norethindrone acetate-ethinyl NICOMIDE 209 NIVATOPIC PLUS 99 estradiol-fe 68 NICORETTE 228 NIVEA 94 norethindrone-eth estradiol NICORETTE MINI 228 NIVEA EXTRA (triphasic) 68 NICORETTE STARTER ENRICHED 94 norgestimate-ethinyl KIT 228 NIVEA EXTRA ENRICHED estradiol 68 LOTION 94 norgestimate-ethinyl estradiol NICOTINAMIDE 240 NIVEA GENTLE BODY (triphasic) 68 nicotine 228 EXFOLIATOR 94 norgestrel & ethinyl estradiol 68 nicotine polacrilex 228 NIVEA LIGHT 94 NORINYL 1+35 68 NICOTINE TRANSDERMAL NIVEA ORIGINAL 94 NORITATE 101 SYSTEM 228 NIVEA ORIGINAL NORMOSOL -R 151 NICOTROL INHALER 228 MOISTURE 94 NORMOSOL-M IN D5W 151 NICOTROL NS 228 NIVEA SOFT 94 NORMOSOL-R 152 nifedipine 63 NIVEA VISAGE 94 NIFEREX 132 NIVEA VISAGE INNER NORMOSOL-R IN D5W 151 NILANDRON 48 BEAUTY NIGHTTIME NORPACE 18 RENEWAL 94 nilutamide 48 NORPACE CR 18 nizatidine 232 NIMBEX 212 NORPRAMIN 28

Index 38 NORTHERA 239 NUPLAZID 54 OCUFEN 221 nortriptyline hcl 28 NUSRUGEPAK SURGICAL OCUFLOX 219 NORTUSS-EX 75 PREP/CAREPAK 100 OCULAR VITAMINS 196 NUTRADERM 94 NORVASC 63 OCUSOFT HYPOCHLOR 100 NUTRADERM ADVANCED NORVIR 58 FORMULA 94 OCUSOFT LID SCRUB FOAMING 100 NORWEGIAN COD LIVER NUTRASEB 94 OIL 209 OCUSOFT LID SCRUB NOVA MAX PLUS GLU/KET NUTRESTORE 216 ORIGINAL 100 CONTROL SOLUTION- NUTRICAP 196 OCUVEL 196 MID 146 NUTRIDOX 229 OCUVITE ADULT 50+ 196 NOVACORT 87 NUTRIVIT 159 OCUVITE ADULT NOVAREL 120 NUTROPIN AQ NUSPIN FORMULA 196 NOVOLIN 70/30 30 10 121 OCUVITE LUTEIN 196 NOVOLIN 70/30 RELION 30 NUTROPIN AQ NUSPIN ODEFSEY 58 20 121 ODOMZO 48 NOVOLIN N 30 NUTROPIN AQ NUSPIN NOVOLIN N RELION 30 5 121 OFEV 229 NOVOLIN R 30 NUVAIL 99 OFIRMEV 7 NOVOLIN R RELION 30 NUVARING 69 OFLOXACIN 124 NOVOLOG 30 NUVESSA 238 ofloxacin 124 NOVOLOG FLEXPEN 30 NUVIGIL 2 ofloxacin (ophth) 219 NOVOLOG MIX 70/30 30 NYATA 82 ofloxacin (otic) 222 NOVOLOG MIX 70/30 NYMALIZE 63 OGESTREL 68 PREFILLED FLEXPEN 30 nystatin 36 olanzapine 55 NOVOLOG PENFILL 30 nystatin (mouth-throat) 156 olanzapine-fluoxetine hcl 227 NOXAFIL 36 nystatin (topical) 82 olmesartan medoxomil 41 NOXIFOL-D 132 nystatin-triamcinolone 82 olmesartan medoxomil- amlodipine-hydrochlorothiazide NOXIPAK 87 O-CAL FA 203 NP #2 DRUG PREPARATION 43 KIT 80 O-CAL PRENATAL 203 olmesartan medoxomil- NPLATE 130 OB COMPLETE 203 hydrochlorothiazide 43 olopatadine hcl 221 NU GAUZE 4PLY 4"X4" 141 OB COMPLETE ADVANCED 203 NU GAUZE GENERAL-USE olopatadine hcl (nasal) 211 SPONGES 4"X4" 4 PLY 141 OB COMPLETE GOLD 203 OLUX 87 NU-GEL COLLAGEN WOUND OB COMPLETE ONE 203 OLUX-E 87 DRESSING 110 OB COMPLETE PETITE 203 OLYSIO 59 NU-GEL WOUND DRESSING/3- OB COMPLETE OMECLAMOX-PAK 234 3/4" X 3-3/4" 110 PREMIER 203 NU-GEL WOUND OB COMPLETE/DHA 203 omega-3-acid ethyl esters 38 DRESSING/6"X 8" 110 OMEGA-3/D-3 WELLNESS NUCALA 19 OBREDON 75 PACK 38 NUCORT 87 OBSTETRIX DHA 203 omeprazole 233 NUCYNTA 10 OBSTETRIX EC 203 OMEPRAZOLE + SYRSPEND SFALKA 233 NUCYNTA ER 10 OBSTETRIX ONE 203 OBTREX 203 omeprazole-sodium NUEDEXTA 228 bicarbonate 234 NUFERA 132 OBTREX DHA 203 OMNARIS 211 NULOJIX 155 OC8 78 OMNIPRED 220 NULYTELY/FLAVOR OCALIVA 125 OMNITROPE 121 PACKS 135 OCREVUS 227 OMNITROPE PEN 10 NUMBONEX 98 OCTAGAM 223 INJECTION DEVICE 149 NUMOISYN 157 octreotide acetate 123 OMNITROPE PEN 5 INJECTION DEVICE 149

Index 39 ON CALL EXPRESS GLUCOSE OPDIVO 47 OSENI 28 CONTROL SOLUTION 146 ophthalmic irrigation OSMITROL VIAFLEX 119 ON CALL PLUS GLUCOSE solution 222 OSMOLEX ER 53 CONTROL LEVEL 1/2 146 ophthalmic irrigation solution - ON CALL VIVID GLUCOSE intraocular 222 OSMOPREP 135 CONTROL LEVEL 1/2 146 opium tincture 33 OSPHENA 121 ONCASPAR 51 OPSUMIT 64 OTEZLA 6 ONCOVITE 196 OPTI-WOMAN 196 OTIPRIO 222 ondansetron 35 OPTIFOAM 141 OTOVEL 222 ondansetron hcl 34,35 OPTIONS CONCEPTROL OTREXUP 3 ONDANSETRON VAGINAL OVACE PLUS 84 HYDROCHLORIDE/SODIUM CONTRACEPTIVE 237 CHLORIDE 35 OPTIONS GYNOL II OVACE PLUS WASH 84 ONE DAILY MENS FORMULA VAGINALCONTRACEPTIVE OVACE WASH 84 W/O IRON 196 237 OVARY 208 ONE DAILY PLUS IRON 196 OPTIVITE P.M.T. 196 OVCON-35 68 ONE DAILY WOMENS 196 OPTUMRX GLUCOSE OVIDE 101 ONE-A-DAY ENERGY 196 CONTROL LEVEL 1/2 146 OVIDREL 120 ONE-A-DAY MENOPAUSE OPURITY 196 FORMULA 196 OPURITY B12/FOLIC oxacillin sodium 225 ONE-A-DAY MENS 50+ ACID 132 oxaliplatin 46 ADVANTAGE 196 ORABLOC 136 oxaprozin 5 ONE-A-DAY MENS HEALTH ORACEA 101 FORMULA 196 OXAYDO 10 ONE-A-DAY MENS PRO ORACIT 127 oxazepam 18 EDGE 196 ORAFATE 157 OXAZEPAM 18 ONE-A-DAY PROACTIVE ORAL RELIEF SPRAY FOR oxcarbazepine 24 65+ 196 DRYMOUTH & ONE-A-DAY TEEN DISCOMFORT 157 oxiconazole nitrate 82 ADVANTAGEFOR HIM 196 ORAP 228 OXISTAT 82 ONE-A-DAY WEIGHT SMART OXSORALEN ULTRA 83 ADVANCED 196 ORAPRED ODT 71 ONE-A-DAY WOMENS 50+ ORAVIG 157 OXTELLAR XR 24 ADVANTAGE 196 ORBACTIV 14 oxybutynin chloride 235 ONE-A-DAY WOMENS ACTIVE oxycodone hcl 10 MIND & BODY 196 ORCHIC 208 ONE-A-DAY WOMENS ORENCIA 6 OXYCODONE HCL ER 10 PETITES 196 ORENCIA CLICKJECT 6 oxycodone w/ acetaminophen 12 ONE-A-DAY WOMENS PLUS ORENITRAM 64 HEALTHY SKIN SUPPORT196 oxycodone-aspirin 12 ONETOUCH ULTRA ORFADIN 122 OXYCODONE/ACETAMINOPHE CONTROL 146 ORILISSA 120 N 12 ONETOUCH VERIO CONTROL ORKAMBI 228 OXYCODONE/IBUPROFEN 12 SOLUTION HIGH 146 OXYCONTIN 10 ONETOUCH VERIO MID orphenadrine citrate 209 CONTROL SOLUTION 146 ORTHO D 132 oxymorphone hcl 10 ONEXTON 78 ORTHO DF 132 OXYMORPHONE HYDROCHLORIDE ER 10 ONFI 23 ORTHO MICRONOR 69 oxytocin 222 ONGLYZA 29 ORTHO TRI-CYCLEN 68 OXYTOCIN/DEXTROSE 222 ONIVYDE 52 ORTHO TRI-CYCLEN LO 68 OXYTOCIN/DEXTROSE/LACTA ONMEL 36 ORTHO-CYCLEN 68 TED RINGERS 223 ONZETRA XSAIL 150 ORTHO-NOVUM 1/35 68 OXYTOCIN/LACTATED RINGERS 223 OPANA 10 ORTHO-NOVUM 7/7/7 68 OXYTOCIN/SODIUM OPANA ER (CRUSH ORTHOVISC 210 CHLORDIE 223 RESISTANT) 10 oseltamivir phosphate 60

Index 40 OXYTOCIN/SODIUM PAPAVERINE HCL 64 PEN NEEDLES 30GX5MM 149 CHLORIDE 223 PARA-AMINOBENZOIC PEN-KERA 94 OXYTROL 235 ACID 240 penicillin g potassium 224 OXYTROL FOR WOMEN 235 PARAFON FORTE DSC 209 PENICILLIN G POTASSIUM IN OZEMPIC 29 PARAGARD INTRAUTERINE ISO-OSMOTIC OZURDEX 220 COPPER CONTRACEPTIVE DEXTROSE 224 T380A 69 PENICILLIN G PROCAINE 224 P-CARE 100MX 136 PARATHYROID 208 PENICILLIN G SODIUM 224 P-CARE D40G 71 PAREGORIC 33 penicillin v potassium 224 P-CARE D40MX 71 parenteral electrolytes 152 P-CARE D80G 71 PENICILLIN V paricalcitol 122 POTASSIUM 224 P-CARE D80MX 72 PARLODEL 53 penicillin v potassium 224 P-CARE K40 72 PARNATE 26 PENLAC NAIL LACQUER 82 P-CARE K40G 72 paromomycin sulfate 3 PENNSAID 80 P-CARE K40MX 72 paroxetine hcl 27 PENTACEL 231 P-CARE K80 72 paroxetine mesylate PENTAM 300 15 P-CARE K80G 72 (vasomotor) 228 PENTASA 125 PARVLEX 196 P-CARE K80MX 72 pentazocine w/ naloxone 12 P-CARE MG 136 PASER 45 PENTETATE CALCIUM P-CARE X 137 PATADAY 222 TRISODIUM 34 PA MENS 50 PLUS PATANASE 211 PENTETATE ZINC VITAPAK 196 PATANOL 222 TRISODIUM 34 pentobarbital sodium 133 PA MENS VITAPAK 196 PAXIL 27 PA WOMENS 50 PLUS pentoxifylline 128 PAXIL CR 27 VITAPAK 196 PENTRAVAN 94 PAZEO 222 PA WOMENS VITAPAK 196 PENTRAVAN PLUS 94 PCE 138 PACLITAXEL 52 PEPCID 232 PCP 100 135 paclitaxel 52 PEPCID AC MAXIMUM paliperidone 54 PEARLS IC 32 STRENGTH 232 palonosetron hcl 35 ped multivitamins w/fl & PERCOCET 12 iron 201 PALONOSETRON PERFOROMIST 20 PEDIAPRED 72 HYDROCHLORIDE 35 PERIDEX 157 PEDIARIX 231 PAMELOR 28 PERIDIN-C 159 pamidronate disodium 120 pediatric multiple vitamin w/ minerals & c 201 PERIKABIVEN 212 PAMIDRONATE pediatric multivitamins DISODIUM 120 perindopril erbumine 41 w/fl 199,200 PERJETA 47 pamidronate disodium 120 pediatric vitamins acd w/ PANCREAZE 118 fluoride 200 PERMAVAN EXTERNAL PATCH 98 PANCURONIUM peg 3350-kcl-sod bicarb-sod BROMIDE 212 chloride-sod sulfate 135 permethrin 101 pancuronium bromide 212 peg 3350-potassium chloride- perphenazine 55 sod bicarbonate-sod PANDEL 87 PERPHENAZINE/AMITRIPTYLIN chloride 135 E 227 PANHEMATIN 128 PEG-INTRON REDIPEN 59 PERTZYE 118 PANOXYL 78 PEG-INTRON REDIPEN PAK PEXEVA 27 PANOXYL-4 CREAMY 4 59 PFIZERPEN 224 WASH 78 PEGANONE 25 PANRETIN 83 PH 12 STERILE DILUENT PEGASYS 60 FORFLOLAN 225 PANTOPRAZOLE SODIUM 67 PEGASYS PROCLICK 59 PHARMACIST CHOICE pantoprazole sodium 233 PEGINTRON 60 ALCOHOL PRED PADS 100 papaverine hcl 64 PHARMACIST CHOICE PELEVERUS 110 ALCOHOLPREP PADS 148

Index 41 PHARMACIST CHOICE TSX PHYTOMULTI 196 PNV PRENATAL PLUS PATCH 98 phytonadione 240 MULTIVITAMIN + DHA 203 phenazopyridine hcl 128 PNV TABS 29-1 204 PICATO 83 phenelzine sulfate 26 PICO SINGLE USE PNV-DHA 204 PHENERGAN 38 NEGATIVEPRESSURE PNV-DHA+DOCUSATE 204 phenobarbital 133 WOUND THERAPY PNV-OMEGA 204 PHENOBARBITAL 134 SYSTEM 110 PNV-SELECT 204 pilocarpine hcl 218 phenobarbital 134 PNV-TOTAL 204 157 PHENOBARBITAL pilocarpine hcl (oral) PNV-VP-U 204 SODIUM 134 pimozide 228 POCKETCHEM EZ CONTROL phenobarbital-hyoscyamine- pindolol 62 LEVEL 1 146 atropine-scopolamine 232 pioglitazone hcl 30 POD-CARE 100C 72 phenoxybenzamine hcl 41 pioglitazone hcl- POD-CARE 100CG 72 phentolamine mesylate 41 glimepiride 28 POD-CARE 100CMX 72 PHENYLEPHRINE HCL 239 pioglitazone hcl-metformin POD-CARE 100K 72 phenylephrine hcl (ophth) 219 hcl 28 piperacillin sodium-tazobactam POD-CARE 100KG 72 phenylephrine hcl sodium 224 (pressors) 239 POD-CARE 100KMX 72 PHENYLEPHRINE piroxicam 5 PODOCON 25 IN BENZOIN HYDROCHLORIDE/DEXTROSE PITOCIN 223 TINCTURE 95 239 PITUITARY 208 podofilox 95 PHENYLEPHRINE PLAN B ONE-STEP 69 POLY-VI-FLOR 200 HYDROCHLORIDE/SODIUM CHLORIDE 239 PLAQUENIL 45 POLY-VI-FLOR FS 200 phenylephrine w/ dm-gg 75 PLASMA-LYTE A 152 POLY-VI-FLOR/IRON 201 phenylephrine-brompheniramine- PLASMA-LYTE-148 152 polyethylene glycol 3350 135 dm 75 PLASMA-LYTE-56/D5W 152 POLYMEM ALGINATE phenylephrine-chlorphen-dm DRESSING/3" X 3" 110 PLASTIC ADAPTER FOR POLYMEM ALGINATE 75 BUSHINJECTOR 149 PHENYLEPHRINE/GUAIFENESI PLASTIC ADAPTER FOR DRESSING/4" X 2" 110 N 75 POLYMEM ALGINATE BUSHINJECTOR B-D DRESSING/4" X 4" 110 PHENYLEPHRINE/SODIUM PLASTIPAK 149 CHLORIDE 239 POLYMEM ALGINATE PLAVIX 129 PHENYLHISTINE DH 75 DRESSING/5" X 5" 110 PLEGISOL 64 PHENYTEK 25 POLYMEM ALGINATE PLEGRIDY 227 DRESSING/6.5" X 7.5" 110 phenytoin 25 PLEGRIDY STARTER POLYMEM DRESSING/3" X phenytoin sodium 25 PACK 227 3" 141 phenytoin sodium extended 25 POLYMEM DRESSING/4" X PLEXION 78 4" 141 PHILLIPS COLON HEALTH 32 PLEXION CLEANSER 78 POLYMEM SILVER PHLAG SPRAY 99 PLEXION CLEANSING DRESSING/4.25" X 4.25" 110 PHLEXY-10 216 CLOTHS 78 POLYMEM SILVER ISLAND PHOSLYRA 126 PLIAGLIS 98 DRESSING/6" X 6" 111 polymyxin b sulfate 16 PHOSPHOLINE IODIDE 218 PNEUMOVAX 23 235 PNEUMOVAX 23/1 polymyxin b-trimethoprim 219 PHOTOFRIN 51 DOSE 235 polysaccharide iron PHYSICIANS EZ USE B-12 PNV FERROUS complex 133 COMPLIANCE KIT 129 FUMARATE/DOCUSATE/FOLI PHYSICIANS EZ USE JOINT POLYTRIM 219 C ACID 203 POLYWIC SILVER WOUND TUNNEL AND TRIGGER 72 PNV FOLIC ACID + IRON PHYSICIANS EZ USE M- FILLER/3" X 3" 111 MULTIVITAMIN 203 POMALYST 49 PRED 72 PNV OB+DHA 203 PHYSOSTIGMINE PONSTEL 5 PNV PRENATAL PLUS SALICYLATE 34 PORTRAZZA 48 PHYTOCILLIN 156 MULTIVITAMIN 203

Index 42 pot & sod citrates w/citric PR NATAL 430 204 PREDNISOLONE ACETATE P- ac 127 PR NATAL 430 EC 204 F 220 pot phosphate monobasic w/ sod prednisolone sodium phosphate dibasic & PRADAXA 22 phosphate 72 monobasic 153 PRALIDOXIME PREDNISOLONE SODIUM POTABA 240 CHLORIDE 34 PHOSPHATE 72 potassium acetate 153 PRALUENT 40 prednisolone sodium pramipexole phosphate 72 potassium bicarb & chloride153 dihydrochloride 53 PREDNISOLONE SODIUM potassium bicarbonate 153 PRAMLYTE 26 PHOSPHATE 220 potassium chloride 153 PREDNISOLONE/MOXIFLOXAC PRAMOSONE 87,88 IN 220 POTASSIUM CHLORIDE 153 PRAMOSONE E 87 PREDNISOLONE/MOXIFLOXAC potassium chloride 153 PRAMOTIC 222 IN/BROMFENAC 220 POTASSIUM CHLORIDE pramoxine hcl 98 PREDNISOLONE/MOXIFLOXAC ER 153 IN/KETOROLAC 220 potassium chloride in pramoxine-hc 88 PREDNISONE 72 dextrose 152 PRANDIN 31 prednisone 72 potassium chloride in dextrose & PRASTERA 3 sodium chloride 152 PREDNISONE 72 potassium chloride prasugrel hcl 129 PREDNISONE INTENSOL 72 microencapsulated crystals PRAVACHOL 40 PREFERA OB 204 er 153 pravastatin sodium 40 PREFERAOB +DHA 204 POTASSIUM PRAXBIND 34 CHLORIDE/DEXTROSE 152 PREFERAOB ONE 204 POTASSIUM praziquantel 14 PREFEST 123 CHLORIDE/DEXTROSE/LACTA prazosin hcl 42 PREGNYL W/DILUENT TED RINGERS 152 PRE PROTEIN 216 BENZYLALCOHOL/NACL 120 POTASSIUM PREMARIN 124,238 CHLORIDE/LIDOCAINE PRE-FOLIC 132 HYDROCHLORIDE 152 PRE-NATAL FORMULA 204 PREMASOL 216 POTASSIUM PRECEDEX 134 PREMESISRX 204 CHLORIDE/LIDOCAINE PRECISION GLUCOSE PREMIUM PACKETS 196 HYDROCHLORIDE/DEXTROSE CONTROL 146 PREMIUM SCAR PATCH 98 152 PRECISION GLUCOSE POTASSIUM CONTROLSOLUTION (TRI- PREMPHASE 123 CHLORIDE/LIDOCAINE LEVEL/HI/LO/NORMAL) 146 PREMPRO 123 HYDROCHLORIDE/SODIUM PRECISION GLUCOSE PRENA 1 TRUE 204 CHLORIDE 152 KETONECONTROL PRENA1 CHEW 204 potassium citrate SOLUTION 1-LOW, 1- (alkalinizer) 127 HIGH 146 PRENA1 PEARL 204 potassium citrate-citric acid 127 PRECISION PRENAISSANCE 204 POTASSIUM GLUCOSE/KETONECONTROL PRENAISSANCE CITRATE/SODIUMCITRATE/CIT SOLUTIONS 1-HI 1-LO 146 BALANCE 204 RIC ACID 127 PRECOSE 28 PRENAISSANCE HARMONY POTASSIUM P- PRED FORTE 220 DHA 204 AMINOBENZOATE 240 PRENAISSANCE NEXT 204 PRED MILD 220 POTASSIUM PRENAISSANCE NEXT-B 204 PHOSPHATE/SODIUM PRED-G 220 PRENAISSANCE PLUS 204 CHLORIDE 153 PRED-G S.O.P. 220 PRENATA 204 potassium phosphates 153 PREDNICARBATE 88 PRENATABS FA 204 POTASSIUM prednicarbate 88 PHOSPHATES 153 PRENATABS RX 204 prednisolone 72 POTIGA 24 PRENATAL 204,205 PR CREAM 99 PREDNISOLONE 72 prednisolone acetate PRENATAL + DHA 204 PR NATAL 400 204 (ophth) 220 PRENATAL 19 204 PR NATAL 400 EC 204 PRENATAL AND IRON 204

Index 43 PRENATAL FORTE 204 PRESET 3ML LL PRIMACOL DRESSING PRENATAL LOW IRON 204 SYR/PREFILLLYOPH LITH 8"X8" 111 HEP/CAP/PREP/GZ/LABEL PRIMACOL SPECIALTY PRENATAL ONE DAILY 204 117 DRESSING 111 PRENATAL PLUS 204 PRESET 3ML LL PRIMACOL THIN DRESSING PRENATAL PLUS IRON 204 SYR/PREFILLLYOPH LITH 4"X4" 111 PRIMACOL THIN DRESSING PRENATAL VITAMIN 205 HEP/CAP/PREP/GZ/SFTYCON E 117 6"X6" 111 PRENATAL VITAMINS PLUS PRESET 3ML LL PRIMAQUINE PHOSPHATE45 LOW IRON 205 SYR/PREFILLLYOPHIL LITH PRIMARY DRESSING PRENATAL-U 205 HEP/TIP CAP/NDL STOP117 TRAY 111 PRENATE 205 PRESET 3ML LL PRIMAXIN IV 15 PRENATE AM 205 SYR/PREFILLLYOPHIL LITH PRIMER MODIFIED UNNA HEP/TIP BOOT/4"X10YD 111 PRENATE DHA 205 CAP/SAFETYCONE 117 PRENATE ELITE 205 PRESET 3ML SYR/PREFILL primidone 24 PRENATE ENHANCE 205 LYOPH LITH PRIMLEV 12 PRENATE ESSENTIAL 205 HEP/SWAB/GZ/CAP/NDL PRIMSOL 15 STOP 117 PRINIVIL 41 PRENATE MINI 205 PRESET 3ML SYR/PREFILL PRENATE PIXIE 205 LYOPH LITH PRISTIQ 27 PRENATE RESTORE 205 HEP/SWAB/GZ/CAP/SAFETYC PRIVIGEN 223 PRENATE STAR 205 ONE 117 PRO COMFORT ALCOHOL PRESET 3ML PADS 148 PREORBOTIC 32 SYR/PREFILLEDLYOPHIL PRO NUTRIENTS PREPIV SUPPLY 98 LITH HEP/TIP CAP/NDL PROBIOTIC 32 PREPLUS 205 STOP 117 PRO-BIOTIC BLEND 32 PREPOPIK 135 PRESTALIA 43 PRO-C-DURE 1 KIT 72 PREQUE 10 205 PRETAB 205 PRO-C-DURE 2 KIT 72 PRESCRIPTIVE FORMULAS PRETTY FEET & HANDS 94 PRO-C-DURE 3 KIT 72 OPTIMAL VITAMIN PACKS PREVACID 233 PRO-C-DURE 4 KIT 72 MENS 196 PREVACID 24HR 233 PRESCRIPTIVE FORMULAS PRO-C-DURE 5 KIT 72 OPTIMAL VITAMIN PACKS PREVACID SOLUTAB 233 PRO-C-DURE 6 KIT 72 WOMENS 196 PREVIDOLRX ANALGESIC PRO-CAL 197 PAK 5 PRESERA 100 32 PREVNAR 13 235 PRO-FLORA IMMUNE PRESERVISION AREDS 197 PROAIR HFA 20 PREVPAC 234 PRESERVISION AREDS 2 197 PROAIR RESPICLICK 20 PREVYMIS 59 PRESERVISION AREDS 2 + probenecid 128 MULTI VITAMIN 196 PREZCOBIX 58 PROBIOMAX DAILY DF 32 PRESERVISION/LUTEIN 197 PREZISTA 58 32 PRESET 1ML LS PRIALT 7 PROBIOMAX PLUS DF PROBIOTIC 32 SYR/PREFILLLYOPH LITH PRIFTIN 45 HEP/CAP/PREP/GZ/LABEL PROBIOTIC & ACIDOPHILUS 117 PRILOSEC 233 FORMULA EXTRA PRESET 1ML LS PRIMACARE 205 STRENGTH 32 SYR/PREFILLLYOPH LITH PRIMACOL BORDERED PROBIOTIC + HEP/CAP/PREP/GZ/SFTYCONE DRESSING 2"X2" 111 COLOSTRUM 32 117 PRIMACOL BORDERED PROBIOTIC + OMEGA-3 32 PRESET 1ML LS DRESSING 4"X4" 111 PROBIOTIC ACIDOPHILUS 32 SYR/PREFILLLYOPHIL LITH PRIMACOL BORDERED HEP/TIP CAP/NDL STOP 117 DRESSING 6"X6" 111 PROBIOTIC ACIDOPHILUS PRESET 1ML LS PRIMACOL DRESSING BEADS 32 SYR/PREFILLLYOPHIL LITH 111 PROBIOTIC ADVANCED 4"X4" ULTRAPOTENCY 32 HEP/TIP PRIMACOL DRESSING 6"X6" 111 PROBIOTIC COLON CAP/SAFETYCONE 117 SUPPORT 32

Index 44 PROBIOTIC promethazine w/codeine 75 PROVIDA DHA 205 COMPLEX/ACIDOPHILUS 32 promethazine-dm 75 PROVIDA OB 205 PROBIOTIC DAILY 32 promethazine-phenylephrine- PROVIGIL 2 PROBIOTIC MATURE codeine 75 PROVISC 221 ADULT 33 PROMETHAZINE/PHENYLEP PROBIOTIC PEARLS 33 HRINE 75 PROVIT 197 PROBIOTIC PEARLS PROMETRIUM 226 PROZAC 27 ADVANTAGE 33 PROMISEB 84 PROZAC WEEKLY 27 probiotic product 33 PROMISEB COMPLETE 84 PRUCLAIR 100 PROBIOTIC-10 33 propafenone hcl 18 PRUDOXIN 83 PROBIOTIC-10 ULTIMATE 33 PROPANTHELINE PRUMYX 100 PROBUPHINE IMPLANT BROMIDE 232 pseudoephed-bromphen-dm 75 KIT 12 proparacaine hcl 219 procainamide hcl 18 pseudoephed-cpm w/ propofol 126 hydrocod 75 PROCALAMINE 216 propranolol & pseudoephedrine w/ codeine- PROCARDIA 63 hydrochlorothiazide 43 gg 75 PROCARDIA XL 63 propranolol hcl 62 pseudoephedrine-guaifenesin 75 PROCEL 216 PROPRANOLOL HCL 62 PSORCON 88 PROCEL 100 216 propranolol hcl 62 PULMICORT 20 PROCENTRA 1 propylthiouracil 230 PULMICORT FLEXHALER 20 PROCERV HP 197 PROQUAD 237 PULMOZYME 228 prochlorperazine 56 PRORENAL+D 197 PURACYN PLUS DUO- prochlorperazine edisylate 55 PRORENAL+D/OMEGA- CARE 111 prochlorperazine maleate 55 3 197 PURAPLY 2CM X 4CM 111 PROSCAR 128 PROCORT 14 PURAPLY 5CM X 5 CM 111 PROSOL 216 PROCRIT 130 PURAPLY 6CM X 9CM 111 PROSTATE 208 PROCTOCORT 14 PUREFE OB PLUS 205 PROSTIN VR PROCTOFOAM HC 14 PEDIATRIC 156 PUREFE PLUS 132 PROCYSBI 127 PROSYNMINIC 216 PURILON 111 PRODIGEN 33 PROTAMINE SULFATE 129 PURIXAN 47 PRODIGY CONTROL PROTECT CARDIO AF 197 PYLERA 234 SOLUTIONHIGH 146 pyrazinamide 45 PRODIGY CONTROL PROTECT PLUS 197 SOLUTIONLOW 146 PROTECT PLUS NF 197 PYRIDIUM 128 PROFERRIN-FORTE 132 PROTECT PLUS SO 197 pyridostigmine bromide 45 progesterone 225 PROTECTIRON 132 PYRIDOXINE HCL 240 PROGESTERONE 10% PROTEGRA 197 pyridoxine hcl 240 KIT 225 PROTEIN 216 PYROGALLIC ACID 96 progesterone micronized 225 PROTEOLYTIC ENZYMES QBRELIS 41 PROGLYCEM 29 EC 118 QC ALCOHOL SWABS 148 PROGRAF 155 PROTHELIAL 157 QC ALL PURPOSE PROLASTIN-C 228 PROTONIX 233,234 DRESSINGS4"X4" 141 PROLENSA 222 PROTOPAM CHLORIDE 34 QC BORDER ISLAND GAUZE PAD 2"X2" 141 PROLEUKIN 51 PROTOPIC 95 QC COD LIVER OIL 209 PROLIA 120 protriptyline hcl 28 QC IODIDES TINCTURE 56 PROLINE 216 PROVAYBLUE 34 QC IODINE TINCTURE 56 PROMACTA 130 PROVENGE 48 QC STERILE PADS 141 promethazine & PROVENTIL HFA 20 QNASL 211 phenylephrine 75 PROVERA 226 promethazine hcl 38 QNASL CHILDRENS 211

Index 45 QTERN 29 RA DRY MOUTH 157 RAYALDEE 122 QUADRACEL 231 RA EAR CARE 208 RAYOS 72 QUADRAMET 51 RA FIRST AID IODINE 56 RAZADYNE 226 QUALAQUIN 45 RA GAUZE SPONGES RAZADYNE ER 226 QUARTETTE 68 4"X4" 141 RE:IIMMUNE 33 RA GENTLE SKIN QUAZEPAM 134 CREAM 94 READYSHARP ANESTHETICS QUDEXY XR 24 RA ISOPROPYL ALCOHOL +BETAMETHASONE 72 READYSHARP ANESTHETICS QUELICIN 211 WIPES 100 RA PROBIOTIC COLON +DEXAMETHASONE 72 QUENCH 197 CARE 33 READYSHARP ANESTHETICS QUESTRAN 38 RA PROBIOTIC +KETOROLAC 5 COMPLEX 33 READYSHARP ANESTHETICS QUESTRAN LIGHT 38 +METHYLPREDNISOLONE quetiapine fumarate 55 RA PROBIOTIC DIGESTIVE SUPPORT 33 80 72 QUFLORA FE 160 RA PROBIOTIC MAXIMUM READYSHARP QUFLORA FE PEDIATRIC 201 STRENGTH 33 BETAMETHASONE 72 READYSHARP QUFLORA GUMMIES 200 RA RENEWAL DRY SKIN THERAPY 94 BUPIVACAINE 137 QUFLORA PEDIATRIC 200 RA STERILE PADS READYSHARP QUICKTEK CONTROL 2"X2" 141 DEXAMETHASONE 72 SOLUTION 146 RA STERILE PADS READYSHARP KETOROLAC5 QUILLICHEW ER 2 3"X3" 141 READYSHARP QUILLIVANT XR 2 RA STERILE PADS LIDOCAINE 137 READYSHARP QUIN B STRONG 197 4"X4" 141 rabeprazole sodium 234 METHYLPREDNISOLONE quinapril hcl 41 RADIACARE POST 80 72 quinapril-hydrochlorothiazide HEALING 111 READYSHARP 43 RADIADERM SYSTEM TRIAMCINOLONE 72 QUINIDINE GLUCONATE 18 R1+R2 100 READYSHARP-A 136 quinidine gluconate 18 RADIADERM SYSTEM READYSHARP-K 73 QUINIDINE SULFATE 18 R2 100 READYSHARP-P40 73 RADIADRES GEL quinine sulfate 45 SHEET 111 READYSHARP-P80 73 QUINJA 82 RADIAGEL 111 REALITY SWABS 148 QUINTABS-M 197 RADIAGUARD REBETOL 60 QUINTET GLUCOSE ADVANCED 94 REBIF 227 CONTROL/HIGH/NORMAL RADIAPLEXRX 111 REBIF REBIDOSE 227 147 RADIOGARDASE 34 REBIF REBIDOSE QUTENZA 98 RAGUS 197 TITRATIONPACK 227 QVAR 20 raloxifene hcl 121 REBIF TITRATION PACK 227 QVAR REDIHALER 20 ramipril 41 RECEDO 102 R-NATAL OB 205 RANEXA 16,17 RECLAST 120 RA ALCOHOL SWABS 148 ranitidine hcl 232 RECOMBIVAX HB 237 RA ALL PURPOSE RECOTHROM 133 DRESSINGS4"X4" 141 RAPAFLO 128 RA CENTRAL-VITE 197 RAPAMUNE 155 RECOTHROM SPRAY KIT 133 RA CENTRAL-VITE UNDER RAPIVAB 60 RECTIV 14 50MENS 197 RAPLIXA 133 RECURA 82 RA CENTRAL-VITE UNDER rasagiline mesylate 54 RED YEAST RICE 2 50WOMENS 197 RASUVO 3 REFUAH PLUS GLUCOSE RA COD LIVER OIL 209 CONTROL SOLUTION 147 RA DAYLOGIC HEALING DRY RAVICTI 122 REGENECARE 111 SKIN THERAPY 94 RAY-TEC X-RAY RA DRESSING SPONGES DETECTABLESPONGES 4" X REGLAN 125 4"X4" 141 4" 16 PLY 141 REGONOL 45

Index 46 REGRANEX 111 REPLICARE 1-1/2"X2- RESTORE HYDROGEL RELAGARD 237 1/2" 111 DRESSING 111 REPLICARE 4"X4" 111 RESTORE HYDROGEL GAUZE RELEEVIA 98 REPLICARE 6"X6" 111 PAD 4"X4" 111 RELEEVIA MC 98 RESTORE HYDROGEL GAUZE REPLICARE 8"X8" 111 RELENZA DISKHALER 60 STRIP 2"X3.5YD 112 REPLICARE THIN RESTORE ODOR ABSORBING RELHIST 75 2"X2.75" 111 DRESSING 4"X4" 141 RELION ALCOHOL REPLICARE THIN RESTORE PLUS WOUND CARE SWABS 148 3.5"X5.5" 111 DRESSING 4"X4" 112 RELION KETONE 118 REPLICARE THIN 6"X8" 111 RESTORE PLUS WOUND CARE RELION KETONE TEST REPLICARE ULTRA DRESSING 4"X4" TAPERED STRIPS 118 4"X4" 111 EDGE 112 RELISTOR 126 REPLICARE ULTRA RESTORE PLUS WOUND CARE RELNATE DHA 205 6"X6" 111 DRESSING 6"X6" TAPERED REPLICARE ULTRA SACRUM EDGE 112 RELPAX 150 7"X8" 111 RESTORE PLUS WOUND CARE REMATEX 96 REPREXAIN 12 DRESSING 6"X8" 112 RESTORE PLUS WOUND CARE REMAXAZON EXTERNAL REQ 49+ 197 PATCH 98 DRESSING 6"X8" TAPERED REMEDY 4-IN-1 BODY REQUIP 53 EDGE 112 CLEANSER/FOAMER 111 REQUIP XL 53 RESTORE PLUS WOUND CARE REMERON 26 RESCRIPTOR 58 DRESSING 8"X8" 112 RESTORE PLUS WOUND CARE REMERON SOLTAB 26 RESCULA 222 DRESSING 8"X8" TAPERED REMICADE 125 RESERVAPAK KIT 2 EDGE 112 remifentanil hcl 10 RESERVAPAK PLUS KIT 2 RESTORE PLUS WOUND CARE REMIFENTANIL resorcinol-sulfur 78 DRESSING TRIANGLE 112 HYDROCHLORIDE/SODIUM RESTORE SILVER DRESSING CHLORIDE 10 RESPA-BR 37 2"X2" 112 REMIGEN CREAM 94 RESPIRATONIC 156 RESTORE SILVER DRESSING RESTA 94 4"X4" NON-ADHESIVE 112 REMODULIN 64 RESTORE SILVER DRESSING REMOVE ADHESIVE RESTA LITE 94 4"X4.75" 112 REMOVER 100 RESTA WOUND RESTORE SILVER DRESSING RENACIDIN 127 CLEANSER 111 4"X5" CONTACT LAYER 112 RENAGEL 126 RESTASIS 219 RESTORE SILVER DRESSING RESTASIS MULTIDOSE 219 6"X8" CONTACT LAYER 112 RENAMENT 216 RESTORE SILVER DRESSING RENAPLEX-D 197 RESTORA 33 6"X8" NON-ADHESIVE 112 RENATABS 159 RESTORA RX 33 RESTORE SILVER DRESSING RENATABS WITH IRON 159 RESTORA SPRINKLES 33 ROPE 12" 112 RESTORE TRIO ABSORBENT RENFLEXIS 126 RESTORE CONTACT LAYER/NON-ADHERENT DRESSING 3"X3" 142 RENOVO 98 2"X2" 141 RESTORE WOUND CARE RENUU NL 102 RESTORE CX WOUND CARE DRESSING 4"X4" 112 RESTORE WOUND CARE RENUU PATCH 98 DRESSING-STERILE 111 RESTORE DRESSING FOR DRESSING 4"X4" RENVELA 126 PSORIASIS-STERILE 111 ADHESIVE 112 REOPRO 129 RESTORE EXTRA THIN RESTORE WOUND CARE repaglinide 31 DRESSING 4"X4" 111 DRESSING 4"X4" NON- ADHESIVE 112 repaglinide-metformin hcl 29 RESTORE EXTRA THIN DRESSING 6"X8" 111 RESTORE WOUND CARE REPATHA 40 RESTORE EXTRA THIN DRESSING 4"X5" CONTACT REPATHA PUSHTRONEX DRESSING 8"X8" 111 LAYER 112 SYSTEM 40 RESTORE FOAM DRESSING RESTORE WOUND CARE REPATHA SURECLICK 40 BORDERED 4"X4" 141 DRESSING 6"X6" REPLACE 197 RESTORE FOAM DRESSING ADHESIVE 112 NON-BORDERED 4"X4" 141

Index 47 RESTORE WOUND CARE RIGHTEST GC300 HIGH ROC RETINOL CORREXION DRESSING 6"X8" 112 CONTROL 147 SENSITIVE EYE 94 RESTORE WOUND CARE RIGHTEST GC300 NORMAL ROC RETINOL CORREXION DRESSING 6"X8" CONTROL 147 SENSITIVE NIGHT 94 ADHESIVE 112 RILUTEK 211 ROCALTROL 122 RESTORE WOUND CARE riluzole 211 rocuronium bromide 212 DRESSING 6"X8" CONTACT LAYER 112 rimantadine hydrochloride 60 ROCURONIUM BROMIDE 212 RESTORE WOUND CARE RIMSO-50 127 ROMIDEPSIN 50 DRESSING 6"X8" NON- ringer's 152 ropinirole hydrochloride 53 ADHESIVE 112 RESTORE WOUND CARE ringer's irrigation 155 ropivacaine hcl 137 DRESSING 8"X8" 112 RIOMET 29 ROPIVACAINE RISABAL-PH 94 HYDROCHLORIDE 137 RESTORIL 134 ROPIVACAINE RETAINE VISION 208 RISAQUAD 33 HYDROCHLORIDE/SODIUM RETIN-A 78 RISAQUAD-2 33 CHLORIDE 137 RETIN-A MICRO 79 risedronate sodium 120 ROSADAN KIT 101 RETIN-A MICRO PUMP 79 RISPERDAL 54 ROSE MILK 95 RETISERT 220 RISPERDAL CONSTA 54 ROSULA 79 RETROVIR 58 RISPERDAL M-TAB 54 rosuvastatin calcium 40 RETROVIR IV INFUSION 58 risperidone 54 ROTARIX 237 REVATIO 64 RISPERIDONE ODT 54 ROTATEQ 237 REVESTA 132 RITALIN 2 ROWASA 126 REVITADERM WOUND RITALIN LA 2 ROXICODONE 10 CARE 112 ritonavir 58 ROXIFOL-D 132 REVLIMID 154 RITUXAN 48 ROXYBOND 10 REXAPHENAC 80 rivastigmine 226 ROZEREM 134 REXULTI 56 rivastigmine tartrate 226 RRB PAK 88 REYATAZ 58 rizatriptan benzoate 150 RTD WOUND CARE DRESSING2" X 2" 112 REZAMID 79 ROBAXIN 209 REZIRA 75 RTD WOUND CARE ROBAXIN-750 209 DRESSING4" X 4" 112 RHEUMATREX 3 ROBINUL 232 RTD WOUND CARE RHINOCORT AQUA 211 ROBINUL FORTE 232 DRESSING4" X 5" 112 RHOFADE 101 ROBITUSSIN CHILDRENS RUBRACA 50 RHOGAM ULTRA-FILTERED COUGH & COLD CF 75 RUCONEST 128 PLUS 223 ROBITUSSIN DM 75 RULAVITE DHA 205 RHOPHYLAC 223 ROBITUSSIN PEAK COLD RXOSINE 216 RHOPRESSA 219 DM 76 RYANODEX 210 RIAX 79 ROC DEEP WRINKLE SERUM 94 RYDAPT 50 RIBASPHERE 60 ROC MULTI CORREXION 5 RYNODERM 89 RIBASPHERE RIBAPAK 60 IN1 RESTORING EYE RYTARY 53 CREAM 94 ribavirin 61 RYTHMOL 18 ribavirin (hepatitis c) 60 ROC MULTI CORREXION 5 IN1 RESTORING NIGHT RYTHMOL SR 18 RIDAURA 3 CREAM 94 SABRIL 25 rifabutin 45 ROC RETINOL SAF-CLENS AF 112 CORREXION 94 RIFADIN 45 SAF-GEL 112 RIFAMATE 45 ROC RETINOL CORREXION MAX 94 SAFYRAL 68 rifampin 45 ROC RETINOL CORREXION SAIZEN 121 NIGHT 94 RIFATER 45 SAIZEN CLICK.EASY 121 RIGHT STEP PRENATAL 205

Index 48 SAIZENPREP SEASONIQUE 68 SILAZONE-II 88 RECONSTITUTIONKIT 121 SEASORB-AG 112 sildenafil citrate (pulmonary SALAGEN 157 SEBUDERM 100 hypertension) 64 SALEX 96 SILENOR 134 SECONAL SODIUM 134 SALEX CREAM 96 SILIQ 83 SECTRAL 61 SALEX LOTION 96 SILMANIX PAIN SEEBRI NEOHALER 19 SALICYLIC ACID 67 RELIEIVINGCREAM 96 SEGLUROMET 29 SILPHEN COUGH 37 salicylic acid 96 SELECT-OB 205 SILVADENE 84 salicylic acid w/ cleanser 96 SELECT-OB+DHA 205 SILVASORB 113 SALIMEZ FORTE 96 selegiline hcl 54 SILVER NITRATE 84 saline, bacteriostatic 225 SELENIUM 153 silver sulfadiazine 84 SALISOL 96 selenium sulfide 84 SILVERA PAIN RELIEF 98 SALITECH 96 SELZENTRY 58 SILVERMED 113 SALIVAMAX 157 SEMPREX-D 76 SIMBRINZA 218 SALIVATE RX 157 SENIOR VITES 197 SIMPONI 3 SALRIX 89 SENSI-CARE SIMPONI ARIA 3 salsalate 7 MOISTURIZING 101 SIMULECT 155 SALVAX 96 SENSIPAR 122 simvastatin 40 SALVAX DUO PLUS 96 SENSORCAINE- SINEMET 53 SAMSCA 123 MPF/EPINEPHRINE 136 SENTRY 197 SINEMET CR 53 SANCUSO 35 SENTRY SENIOR 197 SINGERS SAVING GRACE SANDIMMUNE 155 SENTRY SOOTHING THROAT SANDOSTATIN 123 SENIOR/LUTEIN 197 SPRAY 156 SANDOSTATIN LAR SEREVENT DISKUS 20 SINGERS SAVING GRACE DEPOT 123 SOOTHING THROAT SPRAY SERNIVO 88 SANTYL 95 EXTRA STRENGTH 156 SEROQUEL 55 SINGERS SAVING GRACE SAPHRIS 55 SOOTHING THROAT SPRAY SAPS CARE ALCOHOL PREP SEROQUEL XR 55 SEROSTIM 121 PROFESSIONAL 156 PADS 148 SINGULAIR 19 SAPS HEALTH ALCOHOL sertraline hcl 27 sirolimus 155 PREPPADS 148 sevelamer carbonate 126 SARAFEM 228 SIRTURO 46 sevoflurane 127 SASH KIT FOR FLUSHING SITAVIG 60 SFROWASA 126 VASCULAR ACCESS SIVEXTRO 16 DEVICES 22 SHELLGEL 221 SKELAXIN 209 SAVAYSA 21 SHINGRIX 237 skin protectants, misc. 101 SAVELLA 227 SHOHLS SOLUTION SAVELLA TITRATION MODIFIED 127 SKIN REPAIR 95 PACK 227 SHOPKO ALCOHOL SKINTEGRITY 2" X 2" 113 SAVISION 197 SWABS 148 SKINTEGRITY 4" X 4" 113 SB ALCOHOL PREP SHUR-CLENS 112 SKINTEGRITY PADS 148 SHUR-SEAL 237 HYDROGEL 113 SCALACORT DK 88 SIDEROL 197 SKINTEGRITY WOUND 113 scar treatment products 102 SIGNIFOR 123 SKLICE 101 SCLEROSOL SIGNIFOR LAR 123 SKYLA 69 INTRAPLEURAL 228 SIL-K PAD/LARGE 112 SM ACIDOPHILUS PEARLS33 scopolamine 35 SIL-K PAD/MEDIUM 113 SM ALCOHOL PREP SE-NATAL 19 205 PADS 148 SEA-CLENS WOUND SIL-K PAD/SMALL 113 SM B-COMPLEX/VITAMIN CLEANSER 112 SILAZONE PHARMAPAK 88 C 159

Index 49 SM BENZOIN TINCTURE 101 sodium polystyrene SORBITOL 127 SM GAUZE PADS 2"X2" 142 sulfonate 156 SORBITOL-MANNITOL 127 SODIUM SULFACETAMIDE SM GAUZE PADS 3"X3" 142 WASH 84 SORBOLENE 95 SM GAUZE PADS 4"X4" 142 SODIUM SORBSAN TOPICAL WOUND SM IODIDES TINCTURE 56 SULFACETAMIDE/SULFUR DRESSING 12" 113 79 SORBSAN TOPICAL WOUND SM IODINE TINCTURE 56 SODIUM DRESSING 2" X 2" 113 SM IPECAC SYRUP 34 SULFACETAMIDE/SULFUR SORBSAN TOPICAL WOUND SM ONE DAILY MENS 197 CLEANSER IN UREA 79 DRESSING 3 X 3 113 SORBSAN TOPICAL WOUND SM ONE DAILY WOMENS 197 SODIUM SULFACETAMIDE/SULFUR IN DRESSING 4 X 4 113 SM STERILE PADS 142 UREA 79 SORBSAN TOPICAL WOUND SM STERILE PADS 2"X2" 142 SODIUM THIOSULFATE 34 DRESSING 4" X 8" 113 76 SMARTEST CONTROL SOF-WICK 4"X4" 142 SORBUTUSS NR SOLUTIONMEDIUM 147 SORIATANE 83 SMARTRX GABA KIT 227 SOLARAZE 83 SOLARTEK GLUCOSE SORILUX 83 SMARTRX GABA-V KIT 227 CONTROLSOLUTIONS 147 sotalol hcl 62 SMOFLIPID 212 SOLIQUA 100/33 29 sotalol hcl (afib/afl) 62 sod benzoate & sod SOLIRIS 128 SOTALOL phenylacetate 122 SOLO 197 HYDROCHLORIDE 62 SODIUM ACETATE 151 SOTRADECOL 156 SOLODYN 229 sodium acetate 151 SOTYLIZE 62 SOLOSEC 2 SODIUM ASCORBATE 240 SOVALDI 60 sodium ascorbate 240 SOLOSITE 113 SOLOSITE CONFORMABLE SP ANTIPRURITIC 113 SODIUM BICARBONATE 14 WOUND 2"X2" 113 SP SCAR MANAGEMENT 102 sodium bicarbonate 151 SOLOSITE CONFORMABLE SPATONE IRON PLUS 156 SODIUM BICARBONATE 151 WOUND 4"X4" 113 SPECIAL CARE CREAM 95 SOLTAMOX 48 SODIUM CHLORIDE 153 specialty vitamins products 208 SOLU-CORTEF 73 sodium chloride 153 SPECTRACEF 66 SOLU-MEDROL 73 sodium chloride (gu SPECTRAGEL 113 irrigant) 127 SOLUPAK 98 sodium chloride (inhalant) 76 SOLUS V2 CONTROL SPINOSAD 101 sodium chloride flush 153 HIGH 147 SPIRIVA HANDIHALER 19 SOLUS V2 CONTROL SPIRIVA RESPIMAT 19 SODIUM CITRATE 21 LOW 147 sodium citrate & citric acid 127 spironolactone 119 SOMA 209 spironolactone & SODIUM DIURIL 119 SOMATULINE DEPOT 123 hydrochlorothiazide 118 SODIUM EDECRIN 119 SOMAVERT 120 SPLEEN 208 sodium ferric gluconate complex SONATA 134 SPORANOX 36 in sucrose 133 sodium fluoride 152 SOOLANTRA 101 SPORANOX PULSEPAK 36 SOOTHE & COOL SODIUM FLUORIDE 152 SPRITAM 24 MOISTURIZING BODY SPRIX 5 SODIUM L-ASPARTATE 67 LOTION WITH ALOE 95 SODIUM LACTATE 151 SOOTHE & COOL SKIN SPRYCEL 50 SODIUM NITRITE 34 CREAMWITH ALOE & SSS 10-5 79 VITAMINS A, D & E 95 ST IVES SWISS FORMULA sodium phenylbutyrate 122 SOOTHEE 98 24HOUR MOISTURE 95 SODIUM PHOSPHATE 153 SORBACELL FOAM STALEVO 100 54 SODIUM PHOSPHATE/SODIUM DRESSING 4"X4" 113 STALEVO 125 54 CHLORIDE 153 SORBACELL FOAM STALEVO 150 54 sodium phosphates (sodium DRESSINGSTRIP 1"X8" 113 phosphate dibasic & SORBIDON HYDRATE 101 STALEVO 200 54 monobasic) 153 STALEVO 50 54

Index 50 STALEVO 75 54 sufentanil citrate 10 SUPREME II HIGH/LOW STARLIX 31 SULAR 63 CONTROL SOLUTION 147 SUPREP BOWEL PREP stavudine 58 sulfacetamide sod- KIT 135 STEGLATRO 31 prednisolone 220 SURE COMFORT ALCOHOL sulfacetamide sodium 84 STEGLUJAN 29 PREP PADS 101 SULFACETAMIDE SURE RESULT O3D3 STELARA 83,126 SODIUM 219 SYSTEM 38 STERILE DILUENT FOR sulfacetamide sodium SURE-PREP ALCOHOL PREP FLOLAN 225 (acne) 79 PADS 148 STERILE DILUENT FOR sulfacetamide sodium SURESTEP GLUCOSE REMODOULIN 225 (ophth) 219 CONTROL 147 STERILE GAUZE PADS sulfacetamide sodium w/ SURESTEP GLUCOSE 2"X2" 142 sulfur 79 CONTROLSOLUTION 147 STERILE GAUZE PADS sulfacetamide sodium-sulfur w/ SURESTEP PRO HIGH 3"X3" 142 skin cleanser 79 GLUCOSECONTROL 147 STERILE PADS 2"X2" 142 sulfacetamide sodium-sulfur- SURESTEP PRO LOW STERILE PADS 3"X3" 142 sunscreen 79 GLUCOSECONTROL 147 STERILE PADS 4"X4" 142 SULFADIAZINE 229 SURESTEP PRO NORMAL sulfamethoxazole-trimethoprim GLUCOSE CONTROL 147 STERILE TALC POWDER 228 15 SURGICAL GAUZE STIMATE 123 SULFAMYLON 84 SPONGE 142 STIMULEN 113 sulfasalazine 126 SURMONTIL 28 STIOLTO RESPIMAT 21 SURVANTA SULFURATED LIME 101 INTRATRACHEAL 229 STIVARGA 50 sulindac 6 SUSTIVA 58 STOMACH 208 SUMADAN KIT 79 SUSTOL 35 STRATASORB COMPOSITE SUMADAN WASH 79 ISLAND DRESSING 4" X SUTENT 50 4" 113 SUMADAN XLT 79 SWAMP ROOT 156 STRATTERA 1 sumatriptan 150 SYLATRON 51 STRENSIQ 122 sumatriptan succinate 150 SYLVANT 155 STREPTOMYCIN SULFATE 3 SUMATRIPTAN SYMAX DUOTAB 232 SUCCINATE 150 STRESS RELEAF 156 sumatriptan succinate 150 SYMBICORT 21 STRIANT 13 sumatriptan-naproxen SYMBYAX 227 STRIBILD 58 sodium 149 SYMDEKO 228 STRIVERDI RESPIMAT 21 SUMAVEL DOSEPRO 150 SYMFI 58 STROMECTOL 14 SUMAXIN 79 SYMLINPEN 120 28 STROVITE FORTE 197 SUMAXIN CP KIT 79 SYMLINPEN 60 28 STROVITE ONE 197 SUMAXIN TS 79 SYMPROIC 126 STUDIO 35 EXTRA SUMAXIN WASH 79 SYMTUZA 58 MOISTURIZING LOTION 95 SUPARTZ 210 STUDIO 35 MOISTURIZING SYNAGEX 198 SKIN 95 SUPARTZ FX 210 SYNAGIS 223 SUBLIMAZE 10 SUPER ANTIOXIDANT 197 SYNALAR 88 SUBLOCADE 12 SUPER PROBIOTIC 33 SYNALAR CREAM KIT 88 SUBOXONE 12 SUPER PROBIOTIC SYNALAR OINTMENT KIT 88 DIGESTIVE SUPPORT 33 SUBSYS 10 SYNALAR TS 88 SUPERB NAILS 198 succinylcholine chloride 211 SYNALGOS-DC 12 SUPERVITE 159 SUCCINYLCHOLINE SYNAPRYN FUSEPAQ 10 SUPPORT 198 CHLORIDE 211 SYNAREL 121 SUCRAID 118 SUPPORT-500 208 SYNATEK 198 sucralfate 233 SUPPRELIN LA 121 SYNDROS 35 SUFENTANIL CITRATE 10 SUPRAX 66

Index 51 SYNERA 98 TAURINE 216 TEGADERM HYDROCOLLOID SYNERCID 16 TAXOL 52 DRESSING 6-3/4"X6-3/8" 114 TEGADERM HYDROCOLLOID SYNERDERM 100 TAXOTERE 52 DRESSING 6-3/4"X8" 114 SYNERTROPIN 208 TAYTULLA 68 TEGADERM HYDROCOLLOID SYNJARDY 29 tazarotene 84 THIN DRESSING 4"X4" 114 TEGADERM HYDROCOLLOID SYNJARDY XR 29 TAZICEF 66 THIN DRESSING 4"X4-3/4"114 SYNRIBO 51 TAZORAC 84 TEGADERM HYDROCOLLOID SYNTHAMIN 17 216 TECENTRIQ 48 THIN DRESSING 6-3/4"X8"114 SYNTHROID 230 TECFIDERA 227 TEGADERM HYDROGEL WOUND FILLER 114 TECFIDERA STARTER SYNVEXIA TC 98 TEGRETOL 24 SYNVISC 210 PACK 227 TECHNIVIE 60 TEGRETOL-XR 24 SYNVISC ONE 210 TEFLARO 66 TEKTURNA 44 SYPRINE 154 TEGADERM AG MESH TEKTURNA HCT 43 T-VITES 198 DRESSING WITH SILVER TELCARE GLUCOSE CONTROL TABLOID 47 2"X2" 113 SOLUTION LEVEL 1/2 147 TABRADOL FUSEPAQ 210 TEGADERM AG MESH telmisartan 41 DRESSING WITH SILVER telmisartan-amlodipine 44 TABRADOL RAPIDPAQ 210 4"X5" 113 TACLONEX 88 telmisartan-hydrochlorothiazide TEGADERM AG MESH 44 tacrolimus 155 DRESSING WITH SILVER temazepam 134 tacrolimus (topical) 95 4"X8" 113 TEGADERM AG MESH TEMODAR 46 TAFINLAR 50 DRESSING WITH SILVER TEMOVATE 88 TAGAMET HB 232 8"X8" 113 TEMOVATE E 88 TAGRISSO 50 TEGADERM ALGINATE AG temozolomide 46 TAI DOC CONTROL 147 DRESSING 113 TEGADERM ALGINATE AG TENCON 6 TALIVA 132 ROPE 113 TENDERWET ACTIVE 1.6"114 TALTZ 84 TEGADERM FOAM TENDERWET ACTIVE 2.2"114 TALWIN 12 DRESSING 2"X2" 142 TEGADERM FOAM TENDERWET ACTIVE TAMIFLU 60,61 DRESSING 4"X4" 142 3"X3" 114 tamoxifen citrate 49 TEGADERM HIGH GELLING TENDERWET ACTIVE tamsulosin hcl 128 ALGINATE DRESSING 12" 4"X5" 114 ROPE 113 TENDERWET ACTIVE CAVITY TANDEM F 132 TEGADERM HIGH GELLING 1.6" 114 TANDEM PLUS 132 ALGINATE DRESSING TENDERWET ACTIVE CAVITY TANZEUM 29 4"X4" 113 2.2" 114 TENDERWET ACTIVE CAVITY TAPAZOLE 230 TEGADERM HIGH INTEGRITY ALGINATE DRESSING 12" 3"X3" 114 TAPERDEX 12-DAY 73 ROPE 113 TENDERWET ACTIVE CAVITY TAPERDEX 6-DAY 73 TEGADERM HIGH INTEGRITY 3"X8" 114 ALGINATE DRESSING TENDERWET ACTIVE CAVITY TARCEVA 50 4"X5" 114 TARGADOX 230 4"X4" 113 TEGADERM HYDROCOLLIOD TENDERWRAP UNNA TARGRETIN 51,83 THIN DRESSING 5- BOOT 114 TARKA 43 1/8"X6" 113 TENDERWRAP UNNA BOOT BANDAGE 114 TARON FORTE 132 TEGADERM HYDROCOLLOID DRESSING 4"X4" 113 TENEX 42 TARON-BC 205 TEGADERM HYDROCOLLOID TENIPOSIDE 52 TARON-C DHA 205 DRESSING 4"X4-3/4" 113 TENIVAC 231 TEGADERM HYDROCOLLOID TARON-PREX 205 tenofovir disoproxil fumarate 58 TASIGNA 50 DRESSING 5-1/8"X6" 114 TEGADERM HYDROCOLLOID TENORETIC 100 44 TASMAR 53 DRESSING 6"X6" 114 TENORETIC 50 44

Index 52 TENORMIN 61 THERABETIC MULTI- thyroid 230 TEPADINA 46 VITAMIN 198 THYROLAR-1 230 THERABETIC SKIN CARE95 TERAZOL 3 238 THYROLAR-1/2 230 THERACYS 51 TERAZOL 7 238 THYROLAR-1/4 230 THERAGAUZE 142 terazosin hcl 42 THYROLAR-2 230 THERAGRAN-M 198 terbinafine hcl 36 THYROLAR-3 230 THERAGRAN-M terbutaline sulfate 21 ADVANCED 198 tiagabine hcl 25 TERCONAZOLE 238 THERAGRAN-M ADVANCED TIAZAC 63 terconazole vaginal 238 50 PLUS 198 TIBSOVO 50 THERAGRAN-M TEROCIN 98 PREMIER 198 TICASPRAY 210 TESSALON PERLES 73 THERAGRAN-M PREMIER 50 TICE BCG 51 TESTIM 13 PLUS 198 TIGAN 35 TESTONE CIK 13 THERAHONEY 114 TIGECYCLINE 16 TESTOPEL 13 THERAMILL FORTE 198 tigecycline 16 testosterone 13 THERANATAL CORE TIKOSYN 19 NUTRITION 205 TESTOSTERONE 13 THERANATAL LACTATION timolol maleate 62 testosterone 13 COMPLETE 198 timolol maleate (ophth) 217 TESTOSTERONE 13 THERANATAL LACTATION TIMOLOL MALEATE ONE 198 testosterone 13 OPHTHALMIC GEL THERAPEUTIC FORMING 217 TESTOSTERONE 13 MOISTURIZING 95 TIMOLOL/BRIMONIDE/DORZOL testosterone 13 THERAPLEX AMIDE 217 testosterone cypionate 13 HYDROLOTION 95 TIMOLOL/BRIMONIDINE/DORZ THEREMS-H 198 OLAMIDE/LATANOPROST testosterone enanthate 13 THEREMS-M 198 217 TESTOSTERONE PUMP 13 THIAMINE HCL 240 TIMOLOL/DORZOLAMIDE/LATA TESTRED 13 NOPROST 217 TETANUS/DIPHTHERIA thiamine hcl 240 TIMOLOL/LATANOPROST TOXOIDS-ADSORBED 231 THIAMINE 217 tetrabenazine 227 HYDROCHLORIDE 240 TIMOPTIC 218 THIOLA 128 TETRACAINE HCL 137 TIMOPTIC OCUDOSE 217 thioridazine hcl 56 tetracaine hcl (ophth) 219 TIMOPTIC-XE 218 thiotepa 46 tetracycline hcl 230 TINDAMAX 15 thiothixene 56 TETRACYCLINE HCL 230 tinidazole 15 THREONINE 216 TETRIX 100 TIROSINT 230 THREOSTAT 216 TEXACORT 88 TISSEEL 133 THRIVITE 19 205 TEXAVITE LQ 201 TISSEEL VH 133 THRIVITE RX 205 TIVICAY 58 TGT ALCOHOL SWABS 148 THROMBIN-JMI THALOMID 154 DILUENT 133 TIVORBEX 6 THE LIQUILIFT TRACE THROMBIN-JMI TIZANIDINE COMFORT KIT 153 EPISTAXIS 133 PAC 210 THEO-24 21 THROMBIN-JMI SYRINGE tizanidine hcl 210 theophylline 21 SPRAY KIT 133 TL FOLATE 205 THROMBIN-JMI W/DIL TL G-FOL OS 160 THEOPHYLLINE/D5W 21 SPRAYPUMP THERA M PLUS 198 ACTUATOR 133 TL-CARE DHA 205 THERA-M 198 THROMBOGEN 133 TL-FLUORIVITE 201 THERA-TABS M 198 THUM 100 TL-SELECT 205 THERABETIC EYE THYMOGLOBULIN 155 TNKASE 129 HEALTH 208 THYMUS 208 TOBI 3

Index 53 TOBI PODHALER 3 TRACLEER 64 triamcinolone acetonide TOBRADEX 220 TRADJENTA 29 (topical) 88 triamcinolone acetonide- TOBRADEX ST 220 tramadol hcl 10 dimethicone-silicone 88 tobramycin 3 TRAMADOL HCL ER 10 TRIAMCINOLONE TOBRAMYCIN 3 tramadol-acetaminophen 12 ACETONIDE/BUPIVACAINE HYDROCHLORIDE 73 tobramycin (ophth) 219 trandolapril 41 TRIAMCINOLONE TOBRAMYCIN SULFATE 3 trandolapril-verapamil hcl 44 DIACETATE 73 tobramycin sulfate 3 TRANDOLAPRIL/VERAPAMIL TRIAMSIL COMBIPAK 88 tobramycin- HCL ER 44 TRIAMSIL MULTIPAK 88 dexamethasone 220 tranexamic acid 133 triamterene & TOBREX 219 TRANSDERM-SCOP 35 hydrochlorothiazide 118 TODAY SPONGE 237 TRANXENE T 18 TRIANEX 88 TOE-AID 114 tranylcypromine sulfate 26 TRIAZOLAM 134 TOFRANIL 28 TRANZAREL 98 triazolam 134 TOLAK 83 TRAVASOL 216 TRIBENZOR 44 TOLAZAMIDE 31 TRAVATAN Z 222 TRICARE 206 tolbutamide 31 TRAVOPROST 222 TRICARE PRENATAL 206 tolcapone 53 trazodone hcl 27 TRICARE PRENATAL 1 206 TOLMETIN SODIUM 6 TREANDA 46 TRICARE PRENATAL tolmetin sodium 6 TRECATOR 46 COMPLEAT 206 TRICARE PRENATAL DHA TOLMETIN SODIUM 6 TRELEGY ELLIPTA 21 ONE 206 tolterodine tartrate 235 TRELSTAR 49 TRICARE PRENATAL DHA TOPAMAX 24 TRELSTAR MIXJECT 49 ONE/FOLATE 206 TOPAMAX SPRINKLE 24 TREMFYA 84 TRICITRASOL 22 TOPICORT 88 TRESIBA FLEXTOUCH 31 TRICITRATES 127 TOPIDEX 73 TRETIN-X 79 TRICOR 39 topiramate 24,25 tretinoin 79 TRIDESILON 88 TOPIRAMATE ER 24 tretinoin (chemotherapy) 51 trientine hcl 154 topotecan hcl 52 tretinoin microsphere 79 TRIESENCE 220 TOPOTECAN HCL 52 TREXALL 47 TRIFERIC 133 topotecan hcl 52 TREXIMET 149 trifluoperazine hcl 56 TOPPER DRESSING SPONGES TREZIX 12 trifluridine 219 4"X4" 142 TRI-CHLOR 84 TRIGLIDE 39 TOPROL XL 62 TRI-NORINYL 28 68 trihexyphenidyl hcl 53 TORISEL 50 TRI-TABS DHA 206 TRILEPTAL 25 TORONOVA II SUIK 6 TRI-VI-FLOR 200 TRILIPIX 39 TORONOVA SUIK 6 TRI-VI-FLORO 200 TRILOAN II SUIK 73 torsemide 119 TRI-VIT/FLUORIDE/IRON TRILOAN SUIK 73 TOTECT 51 201 trimethobenzamide hcl 35 TOUJEO MAX SOLOSTAR 30 TRIADVANCE 206 trimethoprim 15 TOUJEO SOLOSTAR 30 TRIAMCINOLONE 73 trimipramine maleate 28 TOVIAZ 235 TRIAMCINOLONE TRIMPEX 15 ACETONIDE 73 TRACE ELEMENTS TRINATAL GT 206 4/PEDIATRIC 154 triamcinolone acetonide 73 trace minerals (cr-cu-mn-se- triamcinolone acetonide TRINATAL RX 1 206 zn) 154 (mouth) 157 TRINATE 206 trace minerals (cr-cu-mn- triamcinolone acetonide TRINTELLIX 27 zn) 154 (nasal) 211 TRIOSTAT 230

Index 54 TRIPLE CREAM 95 TURKEL PNEUMOTHORAX ULTRA WOMAN 208 TRIPLE DYE 56 PROCEDURE ULTRA WOMENS PACK 198 TRAY/8FRENCH 137 TRIPLE HELIX COLLAGEN ULTRA-CARE ALCOHOL PREP 12"ROPE 114 TURPENTINE SPIRITS 96 PADS 148 TRIPLE HELIX COLLAGEN TUSNEL C 76 ULTRABAG/DIANEAL PD- 2"X2" 114 TUSSI-PRES PEDIATRIC 76 2/1.5% DEXTROSE 156 TRIPLE PMB 220 TUSSICAPS 76 ULTRACET 12 TRIPLE PMK 220 TUSSIONEX PENNKINETIC ULTRAFLORA IMMUNE TRIPTODUR 121 EXTENDED RELEASE 76 HEALTH 33 ULTRAM 10 TRISENOX 51 TUZISTRA XR 76 ULTRAM ER 10 TRISTART DHA 206 TWINRIX 237 ULTRASAL-ER 96 TRISTART ONE 206 TWYNSTA 44 TYBOST 58 ULTRATRAK PRO CONTROL TRIUMEQ 58 SOLUTION 2 LEVELS 147 TRIVEEN-DUO DHA 206 TYGACIL 16 ULTRATRAK PRO NORMAL TRIVEEN-PRX RNF 206 TYKERB 50 CONTROL 147 TYLENOL/CODEINE #3 12 ULTRATRAK ULTIMATE TRIZIVIR 58 CONTROL SOLUTION 2 TROGARZO 58 TYLENOL/CODEINE #4 12 LEVELS 147 TROKENDI XR 25 TYMLOS 120 ULTRAVATE 88 TROPAZONE 95 TYSABRI 227 ULTRAVATE X 89 TROPHAMINE 216,217 TYVASO 64 UMECTA 89 trospium chloride 235 TYVASO REFILL 64 UMECTA NAIL FILM 89 TRUBIOTICS 33 TYVASO STARTER 64 UNASYN 224 TRUE METRIX CONTROL TYZEKA 60 UNASYN BULK PACK 224 SOLUTION LEVEL 1 147 TYZINE PEDIATRIC NASAL UNICOMPLEX-M 198 TRUE METRIX CONTROL DROPS 211 SOLUTION LEVEL 2 147 UNISTRIP CONTROL UCERIS 13,73 SOLUTIONHIGH 147 TRUE METRIX CONTROL UDAMIN SP 198 SOLUTION LEVEL 3 147 UNISTRIP CONTROL TRUECONTROL GLUCOSE UDDERLY SMOOTH 95 SOLUTIONLOW 147 CONTROL LEVEL 0 147 UDDERLY SMOOTH EXTRA UNITUXIN 48 TRUECONTROL GLUCOSE CARE 95 UNJURY 217 CONTROL LEVEL 1 147 UDDERLY SMOOTH EXTRA UNJURY UNFLAVORED 217 CARE20 95 TRUETEST GLUCOSE UNNA-FLEX ELASTIC UNNA CONTROLLEVEL 1 147 ULESFIA 101 BOOT 114 TRUETEST GLUCOSE ULORIC 128 UNNA-FLEX PLUS VENOUS CONTROLLEVEL 2 147 114 TRUETEST GLUCOSE ULTANE 127 ULCER CONTROLLEVEL 3 147 ULTEC HYDROCOLLOID UPTRAVI 64 TRULANCE 125 DRESSING 114 URAMAXIN 89 ULTICARE ALCOHOL URAMAXIN GT 89 TRULICITY 29 SWABS 148 TRUMENBA 235 ULTILET ALCOHOL URAMAXIN GT KIT 89 TRUNATURE DIGESTIVE SWABS 148 urea 89 PROBIOTIC 33 ULTIMATECARE ONE 206 UREA 89 TRUSOPT 222 ULTIMATECARE ONE urea 89 NF 206 TRUVADA 58 urea in lactic acid vehicle 89 ULTIVA 10 TRYPTOPHAN 217 urea in zinc undecylenate-lactic TUDORZA PRESSAIR 19 ULTRA MAN 208 acid vehicle 89 TURKEL PARACENTESIS ULTRA MEGA 198 UREA IN ZINC PROCEDURE ULTRA MEGA GOLD 198 UNDECYLENATE/LACTIC ACID VEHICLE 89 TRAY/8FRENCH 137 ULTRA MEGA TWO 198 UREA NAIL 89 ULTRA MENS PACK 198 UREA NAIL KIT 89

Index 55 UREA TOPICAL 89 VANCOMYCIN HCL/SODIUM VCF VAGINAL URECHOLINE 235 CHLORIDE 15 CONTRACEPTIVE FOAM 237 VANCOMYCIN VECAMYL 44 URESOL 89 HYDROCHLORIDE/DEXTROS VECTIBIX 48 UREVAZ 89 E 15 VECTICAL 84 URIMAR-T 234 VANCOMYCIN HYDROCHLORIDE/SODIUM vecuronium bromide 212 UROCIT-K 10 127 CHLORIDE 15 VECURONIUM BROMIDE 212 UROCIT-K 15 127 VANICREAM 95 VECURONIUM UROCIT-K 5 127 VANICREAM LITE 95 BROMIDE/SODIUM UROGESIC-BLUE 234 VANISHPOINT INSULIN CHLORIDE 212 UROXATRAL 128 SYRINGE/0.5ML/30G X VEINPUNCTURE PX1 PHLEBOTOMY SYSTEM 98 URSO 250 125 3/16" 149 VANISHPOINT INSULIN VELCADE 50 URSO FORTE 125 SYRINGE/1ML/30G X VELETRI 64 ursodiol 125 3/16" 149 VELMA PAIN RELIEF 98 UTA 234 VANOS 89 VELPHORO 126 UTERUS 208 VANTAS 49 VELTASSA 156 UTIBRON NEOHALER 21 VAPRISOL 123 VELTIN 79 UTOPIC 89 VAQTA 237 VELTRIX 98 UVADEX 51 VARITHENA 156 VELVACHOL 95 VACUSTIM BLACK 114 VARIVAX 237 VEMAVITE-PRX 2 206 VACUSTIM SILVER 114 VARIZIG 223 VEMLIDY 60 VAGIFEM 238 VARUBI 35 VENA-BAL DHA 206 valacyclovir hcl 60 VASCEPA 38 VENCLEXTA 48 VALCHLOR 83 VASCUDERM HYDROGEL WOUNDDRESSING 114 VENCLEXTA STARTING VALCYTE 59 VASCUDERM STASIS PACK 48 valganciclovir hcl 59 KIT 114 VENELEX 115 VALINE 217 VASELINE PETROLATUM VENIPUNCTURE CPI 98 VALIUM 18 GAUZE 114 venlafaxine hcl 27 VASELINE PETROLATUM valproate sodium 26 GAUZECISION VENLAFAXINE HCL ER 27 valproic acid 26 DRESSING 114 VENOFER 133 valsartan 41 VASELINE PETROLATUM VENTAVIS 64 valsartan-hydrochlorothiazide GAUZECISION DRESSING VENTOLIN HFA 21 OVERWRAP 114 44 VERAMYST 211 VALSTAR 49 VASELINE PETROLATUM GAUZEOVERWRAP 114 verapamil hcl 63 VALTREX 60 VASELINE PETROLATUM VERAPAMIL HCL SR 63 VANATOL LQ 6 GAUZESTRIP 114 VERASENS GLUCOSE VANATOL S 6 VASELINE PETROLATUM CONTROLLEVEL 1 147 GAUZESTRIP VANCOCIN HCL 15 OVERWRAP 114 VERDESO 89 VANCOMYCIN 15 VASELINE PETROLATUM VEREGEN 79 vancomycin hcl 15 GAUZETUBE FOIL VERELAN 63 VANCOMYCIN HCL 15 OVERWRAP 114 VERELAN PM 63 VASERETIC 44 vancomycin hcl 15 VERIPRED 20 73 VASOPRESSIN/SODIUM VANCOMYCIN HCL 15 CHLORIDE 123 VERSACLOZ 55 vancomycin hcl 15 VASOSTRICT 123 VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBER VANCOMYCIN HCL + VASOTEC 41 SYRSPENDSF PH4 15 TECHNOLOGY 142 VANCOMYCIN HCL IN VAZCULEP 239 VERSIVA XC 4" X 4" FOAM DEXTROSE 15 VCF VAGINAL DRESSING/HYDROFIBER CONTRACEPTIVE FILM 237 TECHNOLOGY 142

Index 56 VERZENIO 50 VIROPTIC 219 VITAMIN D3 240 VESICARE 235 VIRT NATE 206 VITAMIN D3 COMPLETE 198 VEXASYN 115 VIRT-ADVANCE 206 VITAMIN DEFICIENCY VEXOL 221 VIRT-C DHA 206 INJECTABLE SYSTEM- B12 129 VFEND 36 VIRT-NATE DHA 206 VITAMIN E ACETATE 240 VFEND IV 36 VIRT-PN 206 VITAMIN E WITH VIBATIV 15 VIRT-PN DHA 206 PANTHENOL 95 VIBERZI 126 VIRT-PN PLUS 206 VITAMIN K1 240 VIBRAMYCIN 230 VIRT-SELECT 206 VITAMINS FOR THE HAIR 209 VICTORY CONTROL LEVEL VIRT-VITE GT 206 VITAMINS TO GO MAXIMUM 198 1/2 147 VIRTPREX 206 VITAMINS TO GO MEN 198 VICTOZA 30 VISBIOME PROBIOTIC HIGH VIDAZA 47 POTENCY 33 VITAMINS TO GO WOMEN 198 VIDEX EC 58 VISCO-3 210 VITAPEARL 207 VIDEXPEDIATRIC 58 VISTARIL 17 VITAROCA PLUS 198 VIEKIRA PAK 60 VISTEC X-RAY DETECTABLE VITASANA 198 VIEKIRA XR 60 SPONGES 4"X4" 16 PLY 142 VISTOGARD 34 VITATRUE 207 vigabatrin 25 VISUDYNE 219 VITATRUM 198 VIGAMOX 219 VITEKTA 59 VIGILON PRIMARY WOUND VITA-BOB 198 DRESSING/13" X 24" 115 VITA-PREN 206 VITRASE 154 VIGILON PRIMARY WOUND VITA-RX DIABETIC VITRUM 50+ SENIOR DRESSING/3" X 8" 115 VITAMIN 208 MULTI 198 VIGILON PRIMARY WOUND VITABEX 198 VITUZ 76 DRESSING/4" X 4" 115 VITAFOL 159 VIVA DHA 207 VIGILON PRIMARY WOUND DRESSING/6" X 8" 115 VITAFOL FE+ 206 VIVELLE-DOT 124 VIIBRYD 27 VITAFOL GUMMIES 206 VIVITROL 34 VIIBRYD STARTER PACK 27 VITAFOL ULTRA 206 VIVLODEX 6 VIL-RX 206 VITAFOL-NANO 206 VOGELXO 13 VIMIZIM 122 VITAFOL-OB 206 VOGELXO PUMP 13 VIMOVO 6 VITAFOL-OB+DHA 206 VOL-NATE 207 VIMPAT 25 VITAFOL-ONE 206 VOL-PLUS 207 VINATE CARE 206 VITAJECT 158 VOL-TAB RX 207 VINATE DHA RF 206 VITAL-D RX 159 VOLTAREN 80 VINATE II 206 VITALINE TOTAL FORMULA VOPAC 81 2 198 VOPAC 5 80 VINATE M 206 VITALINE TOTAL FORMULA VINATE ONE 206 3 198 VOPAC GB 81 VINBLASTINE SULFATE 52 VITAMEDMD ONE VOPAC KT 81 vincristine sulfate 52 RX/QUATREFOLIC 207 VOPAC MDS 81 VITAMEDMD PLUS VORAXAZE 51 vinorelbine tartrate 52 RX/QUATREFOLIC 207 VIOKACE 118 VITAMEDMD REDICHEW voriconazole 36 VIRACEPT 58 RX 207 VOSEVI 60 VIRAMUNE 58,59 VITAMEZ 132 VOSPIRE ER 21 VITAMIN & MINERAL VOTRIENT 50 VIRAMUNE XR 59 SUPPLEMENT 198 VIRASAL 96 VITAMIN B12/FOLIC VP DERMABASE 95 VIRAZOLE 61 ACID 132 VP FC KIT 81 VIREAD 59 VITAMIN D2 240 VP-CH PLUS 207

Index 57 VP-CH-PNV 207 WIDE-SEAL SILICONE XERMELO 126 VP-GGR-B6 PRENATAL 207 DIAPHRAGM KIT 85 142 XEROFLO DRESSING WIDE-SEAL SILICONE VP-HEME OB 207 1"X8" 115 DIAPHRAGM KIT 90 142 XEROFLO DRESSING VP-HEME OB + DHA 207 WIDE-SEAL SILICONE 2"X2" 115 VP-HEME ONE 207 DIAPHRAGM KIT 95 142 XEROFLO DRESSING VP-PNV-DHA 207 WINRHO SDF 223 5"X9" 115 XEROFORM NON-OCCLUSIVE VP-ZEL 198 WITCH HAZEL 101 witch hazel (hamamelis OIL EMULSION GAUZE STRIP VPRIV 129 virginiana) 101 5"X9" 115 VRAYLAR 54 WOMENS 50+ MULTI XEROFORM NON-OCCLUSIVE VSL#3 33 VITAMIN& MINERAL OIL EMULSION PATCH 2"X2" 115 VSL#3 DS 33 FORMULA 198 WOMENS BIOMULTIPLE198 XEROFORM NON-OCCLUSIVE VUSION 82 WOMENS MULTI VITAMIN & OIL EMULSION ROLL VYTORIN 38 4"X9" 115 MINERAL FORMULA 198 XEROFORM NON-OCCLUSIVE VYVANSE 1 WOMENS PACK 199 OIL EMULSION VYZULTA 222 WOUN'DRES COLLAGEN STRIP/OVERWRAP 1"X8" 115 warfarin sodium 21 HYDROGEL WOUND XEROFORM OCCLUSIVE DRESSING 115 water for injection, sterile 225 PETROLATUM GAUZE ROLL WOUND CLEANSER 115 4"X9' 115 water for irrigation, sterile 155 wound cleansers 115 XEROFORM OCCLUSIVE WEBCOL ALCOHOL PREP WOUND DEBRIDEMENT115 PETROLATUM GAUZE STRIP LARGE 1 PLY 148 1"X8" 115 WEBCOL ALCOHOL PREP wound dressings 115 XEROFORM OCCLUSIVE LARGE 2 PLY 148 WOUND GEL 115 PETROLATUM GAUZE STRIP WEBCOL ALCOHOL PREP WOUND GEL SPRAY 115 5"X9" 115 MEDIUM 2 PLY 148 XEROFORM OCCLUSIVE WELCHOL 38 WOUND WASH 115 PETROLATUM GAUZE WELLBUTRIN SR 26 WOUNDGARD 2-1/2"X2- STRIP/OVERWRAP 1"X8" 115 1/2" 115 WELLBUTRIN XL 26 XEROFORM OCCLUSIVE WOUNDGARD 4"X4-1/4" 115 PETROLATUM GAUZE WELLESSE VITAMIN D3 240 WOUNDGARD 4"X6" 115 STRIP/OVERWRAP 5"X9" 115 WELLNESS PROTEIN XEROFORM OCCLUSIVE SHAKE 217 WP THYROID 230 WPR PLUS WOUND HEALING PETROLTUM GAUZE PATCH WESTCORT 89 2"X2" 115 SYSTEM 98 XEROFORM OCCLUSIVE WESTHROID 230 XADAGO 54 WHEAT GERM 240 PETROLTUM GAUZE PATCH XALATAN 222 4"X4" 115 WHEY PROTEIN 217 XALKORI 50 XEROFORM PETROLATUM WHEY PROTEIN DRESSING 116 CONCENTRATE 217 XANAX 18 XEROFORM PETROLATUM white petrolatum 225 XANAX XR 18 DRESSING OVERWRAP WHOLE FOOD XARELTO 21 1"X8" 115 MULTIVITAMIN 198 XARELTO STARTER XEROFORM PETROLATUM WIBI 95 PACK 21 DRESSING OVERWRAP WIDE-SEAL SILICONE XARTEMIS XR 12 5"X9" 115 DIAPHRAGM KIT 60 142 XEROFORM PETROLATUM XATMEP 47 DRESSING ROLL 4"X3YD 116 WIDE-SEAL SILICONE XELJANZ 3 DIAPHRAGM KIT 65 142 XGEVA 120 WIDE-SEAL SILICONE XELJANZ XR 3 XHANCE 211 DIAPHRAGM KIT 70 142 XELODA 47 XIAFLEX 154 WIDE-SEAL SILICONE XENAZINE 227 DIAPHRAGM KIT 75 142 XIFAXAN 15 WIDE-SEAL SILICONE XEOMIN 212 XIGDUO XR 29 DIAPHRAGM KIT 80 142 XERALUX 100 XIIDRA 219 XERESE 84 XILAPAK 89

Index 58 XIMINO 230 ZANAFLEX 210 ZINECARD 52 XODOL 12 ZANOSAR 46 ZINGO 137 XOFIGO 51 ZANTAC 232,233 ZIOPTAN 222 XOLAIR 19 ZANTAC 150 MAXIMUM ziprasidone hcl 54 XOLEGEL 83 STRENGTH 232 ZIPSOR 6 ZARONTIN 25 XOLEGEL COREPAK 83 ZIRGAN 219 ZARXIO 130 XOLEGEL DUO/HEAD & ZITHRANOL 84 ZATEAN-CH 207 SHOULDERS 83 ZITHRANOL-RR 84 XOLEGEL DUO/XOLEX 83 ZATEAN-PN DHA 207 ZITHROMAX 137 XOPENEX 21 ZATEAN-PN PLUS 207 ZITHROMAX TRI-PAK 137 XOPENEX CONCENTRATE 21 ZAVARA 132 ZITHROMAX Z-PAK 137 XOPENEX HFA 21 ZAVESCA 129 ZMAX 137 XRYLIDERM 98 ZEBETA 62 ZN-PLUS 209 XRYLIX 81 ZEGERID 234 ZOCOR 40 XTAMPZA ER 10 ZEGERID OTC 234 ZODEX 12-DAY 73 XTANDI 49 ZEJULA 50 ZODEX 6-DAY 73 XULANE 69 ZELAPAR 54 ZOFRAN 35 XULTOPHY 100/3.6 29 ZELBORAF 50 ZOFRAN ODT 35 XURIDEN 122 ZEMAIRA 228 ZOHYDRO ER 10 XYLOCAINE 18 ZEMBRACE ZOLADEX 49 XYLOCAINE-MPF 137 SYMTOUCH 150 ZOLATE 132 XYLOCAINE- ZEMDRI 3 MPF/EPINEPHRINE 136 ZEMPLAR 122 zoledronic acid 120 XYLOCAINE/EPINEPHRINE ZENPEP 118 ZOLEDRONIC ACID 120 136 ZENZEDI 1 zoledronic acid 120 XYREM 226 ZEPATIER 60 ZOLEDRONIC ACID 120 XYZAL 37 ZERBAXA 65 ZOLINZA 50 XYZAL ALLERGY 24HR 37 ZERIT 59 zolmitriptan 150 XYZAL ALLERGY 24HR CHILDRENS 37 ZESTORETIC 44 ZOLOFT 27 YASMIN 28 68 ZESTRIL 41 zolpidem tartrate 134 YAZ 68 ZETIA 40 ZOLPIMIST 134 YELETS TEENAGE ZETONNA 211 ZOMACTON 121 FORMULA 199 ZEVALIN Y-90 48 ZOMETA 120 YERVOY 48 ZEYOCAINE 98 ZOMIG 151 YODORA DEODORANT 100 ZIAC 44 ZOMIG ZMT 151 YONDELIS 46 ZIAGEN 59 ZONALON 83 YOSPRALA 129 ZIANA 79 ZONEGRAN 25 Z-TUSS AC 76 zidovudine 59 zonisamide 25 ZACARE 4% KIT 79 zileuton 19 ZONTIVITY 129 ZACARE 8% KIT 79 ZIMS CRACK CREME ZORBTIVE 121 ZACLIR CLEANSING 79 DAYTIME 95 ZORTRESS 155 ZADITOR 222 ZINACEF 65,66 ZORVOLEX 6 zafirlukast 19 ZINBRYTA 227 ZOSTAVAX 237 zaleplon 134 ZINC GLUCONATE 154 ZOSYN 225 ZALTRAP 47 zinc sulfate 154 ZOVIRAX 60,84 ZAMICET 12 ZINC SULFATE 154 ZUBSOLV 12,13 ZANABIN ANTIPRURITIC ZINC TRACE METAL 154 ZUPLENZ 35 HYDROGEL 116

Index 59 ZURAMPIC 128 ZUTRIPRO 76 ZYBAN 228 ZYCLARA 95 ZYCLARA PUMP 95 ZYDELIG 50 ZYFLO 19 ZYFLO CR 19 ZYKADIA 51 ZYLET 221 ZYLOPRIM 128 ZYMAXID 219 ZYPITAMAG 40 ZYPREXA 55 ZYPREXA RELPREVV 55 ZYPREXA ZYDIS 55 ZYRTEC ALLERGY 37 ZYRTEC CHILDRENS ALLERGY 37 ZYRTEC-D ALLERGY/CONGESTION 76 ZYTIGA 49 ZYVOX 16

Index 60