QUALIFIED HEALTH PLAN FORMULARY Effective July 2015

Provided by EnvisionRxOptions

Introduction

The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management.

Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC & EnvisionRxOptions, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature.

This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.

How to Read the Formulary

All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

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Tier Guidelines

Generic Tier 1

Preferred Brand Tier 2

Non-Preferred Brand Tier 3 Non- Preferred Generic Specialty Tier 4

Preventive Tier 5 $0 co-pay at in-network pharmacies

The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, co- insurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit. Prescribing Guidelines

Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include:

Prior Authorization Drug requires prior authorization through a specific physician request Required (PA) process.

Over the Counter Drug coverage is available for drugs that are available OTC with an Drugs (OTC) authorized prescription from your provider.

Specialty Drugs (SP) Drug requires processing through THC’s contracted specialty pharmacy, Diplomat Specialty Pharmacy.

Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.

Age Limit (AL) Drug coverage may depend on patient age.

Gender Restriction Drug coverage may depend on patient gender. (GR) Step Therapy Drug coverage requires that an alternative or trial of another drug be used Required (ST) before the medication is covered.

Custom (C) Drug coverage has unique restrictions.

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Saving on Out-Of-Pocket Costs

Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC Qualified Health Plan Formulary. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year.

Preventive Medications Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations.

Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-877-503-7231. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request.

Non-Formulary Agents Drugs not located on the Total Health Care Qualified Health Plan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non- formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:  The patient has failed an appropriate trial of formulary or preferred agents.  The use of preferred or formulary agent is contraindicated in the patient.  The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action.

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Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to:  OTC medications or their equivalents unless otherwise specified in the Formulary listing.  Drug products used for cosmetic purposes.  Experimental drug products, or any drug product used in an experimental manner.  Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay.

Total Health Care Pharmacy and Therapeutics (P&T) Committee

Total Health Care’s Pharmacy & Therapeutic Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel.

Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies

Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Diplomat Specialty Pharmacy.

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A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRxOptions at 1-877-503-7231 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com.

Once the order is received, EnvisionRxOptions obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then the Diplomat Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRxOptions at 1-844- 222-5584 or Diplomat Specialty Pharmacy at 1-877-977-9118.

Contact Information

The Total Health Care Qualified Health Plan Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862.

Medication Limitations

Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy.

Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit.

Gender Restrictions Gender restrictionss are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage.

Step Therapy Criteria Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.

Step Therapy Criteria Therapy Class First Line Second Line Third Line Fourth Step Therapy Criteria Line Acetylcholinesterase Aricept Galantamine Prior use of Aricept Inhibitors Immediate- Extended- Immediate-Release or Release, Release Galantamine Galantamine Immediate-Release in Immediate- the last 90 days. v

Release

Aminosalicylic Acid Apriso, Delzicol Pentasa, Prior use of Apriso or Derivative Agents Asacol HD Delzicol in the last 90 days. Analgesic Norco, Reprexain, Prior use of Norco Combination Agents Ibuprofen Hydrocodone- and Ibuprofen in the Ibuprofen last 90 days. Angiotensin Receptor Losartan / Candesa- Benicar, Second Line: Prior Blocker Losartan-HCTZ HCTZ, Benicar- use of losartan in the (Cozaar) Micardis, HCT last 90 days. Micardis- Third Line: Prior use HCT, of Candesa-HCTZ, Ibesartan, Micardis, Micardis- Ibesartan- HCTZ, Ibesartan or HCTZ Ibesartan-HCTZ in the last 90 days. Angiotensin- Trandolapril, Tarka Prior use of Converting Enzyme Verapamil Trandolapril and and Calcium Channel Verapamil in the last Blocker 90 days. Antianginal Agents Nitro-Bid Rectiv Prior use of Nitro-Bid Ointment in the last 90 days. Antidiabetic Agents Januvia Tradjenta, Prior use of Januvia Onglyza in the last 90 days. Antiemetic Agents Ondansetron Anzemet Prior use of Ondansetron in the last 90 days. Antiglaucoma Agents Latanoprost Lumigan, Prior use of Travatan-Z, Latanoprost in the last Zioptan 90 days. Antihemorrhoidal Anusol HC Cortifoam Prior use of Anusol Agents Cream, HC Cream or Hydrocortisone Hydrocortisone Suppositories Suppositories in the last 90 days. Antimigraine Sumatriptan Naratriptan Axert, Second Line: Prior (Imitrex) Frova, use of sumatriptan or Rizatriptan Relpax rizatriptan in the last (Maxalt) 90 days Third Line: Prior use of Naratriptan in the last 90 days. Anti-Parkinson's Selegiline tablets Emsam Prior use of Selegiline Agents tablets in the last 90 days. Anti-Parkinson's Ropinirole Ropinirole Prior use of Agents Immediate- Extended- Ropinirole

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Release Release Immediate-Release in the last 90 days. Antiprotozoal Flagyl Flagyl Prior use of Flagyl Antibiotic Immediate Extended Immediate Release in Release Release the last 90 days. Antipsychotic Agents Quetiapine Ziprasidone, Seroquel Saphris Second Line: Prior Immediate- Olanzapine XR use of Quetiapine Release within the last 90 days. Third Line: Prior use of Ziprasidone or Olanzapine in the last 90 days. Fourth Line: Prior use of Seroquel XR in the last 90 days. Antiviral Agents Valacyclovir Famciclovir Prior use of Valacyclovir in the last 90 days. Benign Prostatic Doxazosin Avodart Prior use of Hyperplasia agents Immediate- Doxazosin Release, Immediate-Release, Finasteride, Finasteride, Tamsulosin, Tamsulosin or Terazosin Terazosin in the last 90 days (Member must have paid claims for two first line drugs). Angiotensin Receptor Amlodipine, Azor, Prior use of Blocker and Calcium Losartan Exforge Amlodipine and Channel Blocker Losartan in the last 90 days. Beta2 Agonist Albuterol Levalbuterol Prior use of Albuterol Nebulizer Nebulizer Nebulizer in the last 90 days. Beta2 Agonist Ventolin HFA, Xo penex HFA Prior use of Ventolin Proair HFA HFA or Proair HFA in the last 90 days. Beta Blocker Coreg Coreg Prior use of Coreg Immediate- Controlled- Immediate-Release in Release Release, the last 90 days. Bystolic Glucocorticoid Qvar Dulera, Advair Second Line: Prior Inhaler Symbicort Diskus, use of Qvar within Advair HFA the last 90 days. Third Line: Prior use of Dulera or Symbicort in the last vii

90 days.

Beta Blocker Propranolol Propranolol Prior use of Immediate- Extended- Propranolol Release Release Immediate-Release in the last 90 days. HMG-CoA Reductase Atorvastatin, Crestor, Prior use of Inhibitor Simvastatin Livalo, Atorvastatin and Vytorin Simvastatin in the last 90 days. Insulin Combination Novolog Mix Humalog Mix Prior use of Humalog 70/30 75/25 Mix in the last 90 days. Macrolide Antibiotics Clindamycin Erythromycin Prior use of 250mg BS, Clindamycin in the Erythromycin last 90 days. 500mg BS Melatonin Receptor Temazepam, Rozerem Prior use of Agonists Zaleplon, Temazepam, Zolpidem Zaleplon or Zolpidem Immediate- Immediate-Release in Release, the last 90 days (Member must have paid claims for two first line drugs). Nasal Corticosteriods Flunisolide, Astepro, Prior use of Fluticasone, Azelastine, Flunisolide, Nasacort OTC Beconase AQ, fluticasone or Nasonex, Nasacort OTC in the Patanase, last 180 days QNASL, (Member must have Rhinocort, paid claims for two Veramyst first line drugs). Osteoporosis Alendronate Actonel, Miacalcin Second Line: Prior (Fosamax) Altelvia, use of alendronate Ibandronate within the last 90 days. Third Line: Prior use of Actonel, Altevia or Ibandronate in the last 90 days (Member must have paid claims for two first line drugs). Pleuromutilin Mupirocin Altabax Prior use of Antibiotic Mupirocin in the last 90 days. Rapid-Acting Insulin Apidra vials Humalog vials Prior use of Apidra vials in the last 90 viii

days.

Retinoic Acid Tretinoin Atralin Gel, Prior use of Tretinoin Derivatives 0.025%, Tretinoin 0.025%, Tretinoin Tretinoin 0.05%, 0.04% Gel 0.05% or Tretinoin Tretinoin 0.1% 0.1% in the last 90 days. Scabicidal Agent Permethrin 5% Natroba 0.9% Prior use of Permethrin 5% in the last 90 days. Selective Serotonin Citalopram Escitalopram Prior use of Reuptake Inhibitors Citalopram in the last 90 days. Short-Acting Insulin Novolin N, Humulin N, Prior use of Novolin Novolin R Humulin R in the last 90 days. Tetracycline Doxycycline Minocycline Doxycycline Second Line: Prior Antibiotics Hyclate, Tablets, 75mg, use of Doxycycline Doxycycline Minocycline Doxycycline Hyclate, Doxycycline Monohydrate, Capsules 150mg Monohydrate or Doxycycline Doxycycline Suspension Suspension in the last 90 days. Third Line: Prior use of Minocycline tablets or capsules in the last 90 days. Topical Ketoconazole Capex Prior use of Corticosteroids 2% Shampoo Shampoo Ketoconazole 2% Shampoo in the last 90 days. Topical Clobetasol, Taclonex Prior use of Corticosteroids Desonide, Suspension, Clobetasol, Desonide, Betamethasone, Taclonex Betamethasone, Flucinolone, Ointment Flucinolone, Flucinonide, Flucinonide, Hydrocortisone, Hydrocortisone or Triamcinolone Triamcinolone in the last 90 days (Member must have paid claims for two first line drugs). Urinary Oxybutynin, Tolterodine, Enablex, Second Line: Prior Antispasmodics Oxybutynin-ER, Tolterodine Toviaz, use of Oxytrol OTC, Oxytrol OTC, Extended- Vesicare, Oxybutynin, Oxytrol Syrup Release, Trospium oxybutynin-ER or Trospium ER Oxybutynin Syrup in the last 90 days.

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Third Line: Prior use of Tolterodine, Tolterodine ER or Trospium in the last 90 days.

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRxOptions. The presence of a medication on this formulary list does not guarantee coverage.

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LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Anti-infective Agents

ALBENZA TAB 200 MG albendazole 2

hyophen tab 81.6 mg 1 MEBENDAZOLE CHEW TAB 100 MG mebendazole 1

methenamine hippurate tab 1 gm 1 METHENAMINE MANDELATE TAB 0.5 GM methenamine mandelate 1 MONUROL PACKET 3 GM fosfomycin tromethamine 3

nitrofurantoin macrocrystal cap 100 mg 1

nitrofurantoin macrocrystal cap 50 mg 1

nitrofurantoin suspension 25 mg/5ml 3

phosphasal tab 81.6 mg 1

sulfamethoxazole-tmp ds tab 800-160 mg 1

sulfamethoxazole-trimethoprim suspension 200-40 mg/5ml 1

sulfamethoxazole-trimethoprim suspension 800-160 mg/20ml 1

sulfamethoxazole-trimethoprim tab 400-80 mg 1

sulfatrim pediatric suspension 200-40 mg/5ml 1

trimethoprim tab 100 mg 1

uretron d/s tab 1 URETRON D/S TAB methenamine-hyosc-methylene blue-sod phos-phenyl sal 1

ustell cap 120 mg 1

uticap cap 120 mg 1

utira-c tab 81.6 mg 1

utrona-c tab 81.6 mg 1 Antibacterials

amoxicillin cap 250 mg 1

amoxicillin cap 500 mg 1

PAGE 11 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AMOXICILLIN CHEW TAB 125 MG amoxicillin 1 AMOXICILLIN CHEW TAB 250 MG amoxicillin 1

amoxicillin recon susp 125 mg/5ml 1

amoxicillin recon susp 200 mg/5ml 1

amoxicillin recon susp 250 mg/5ml 1

amoxicillin recon susp 400 mg/5ml 1

amoxicillin tab 500 mg 1

amoxicillin tab 875 mg 1

amoxicillin-pot clavulanate chew tab 200-28.5 mg 1

amoxicillin-pot clavulanate chew tab 400-57 mg 1

amoxicillin-pot clavulanate er tab er 12h 1000-62.5 mg 3

amoxicillin-pot clavulanate recon susp 200-28.5 mg/5ml 1

amoxicillin-pot clavulanate recon susp 400-57 mg/5ml 1

amoxicillin-pot clavulanate tab 250-125 mg 1 QL 28 / 14 days

amoxicillin-pot clavulanate tab 500-125 mg 1 QL 28 / 14 days

amoxicillin-pot clavulanate tab 875-125 mg 1 QL 28 / 14 days

ampicillin cap 250 mg 1

ampicillin cap 500 mg 1 AMPICILLIN RECON SUSP 125 MG/5ML ampicillin 1 AMPICILLIN RECON SUSP 250 MG/5ML ampicillin 1 AUGMENTIN RECON SUSP 125-31.25 MG/5ML amoxicillin & pot clavulanate 2 AVELOX ABC PACK TAB 400 MG moxifloxacin hcl 3 AVELOX TAB 400 MG moxifloxacin hcl 3 AVIDOXY DK KIT 100 MG doxycycline w/ suncreen & salicylic acid 1

avidoxy tab 100 mg 1 AZITHROMYCIN PACKET 1 GM QL 30 / 30 days azithromycin 1

PAGE 12 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

azithromycin recon soln 500 mg 1

azithromycin recon susp 100 mg/5ml 1

azithromycin recon susp 200 mg/5ml 1

QL 12 / 30 days azithromycin tab 250 mg 1 C max 2 fills per 30 days

azithromycin tab 600 mg 1 QL 60 / 30 days

BICILLIN L-A SUSPENSION 1200000 UNIT/2ML penicillin g benzathine 2 BICILLIN L-A SUSPENSION 600000 UNIT/ML PA penicillin g benzathine 4

cefaclor cap 250 mg 1

cefaclor cap 500 mg 1 CEFACLOR ER TAB ER 12H 500 MG cefaclor monohydrate 1 CEFACLOR RECON SUSP 125 MG/5ML cefaclor 1 CEFACLOR RECON SUSP 250 MG/5ML cefaclor 1 CEFACLOR RECON SUSP 375 MG/5ML cefaclor 1

cefadroxil cap 500 mg 1

cefadroxil recon susp 250 mg/5ml 1

cefadroxil recon susp 500 mg/5ml 1

cefadroxil tab 1 gm 1

cefdinir cap 300 mg 1

cefdinir recon susp 125 mg/5ml 1 AL Up to 11 yrs old

cefdinir recon susp 250 mg/5ml 1 AL Up to 11 yrs old

cefpodoxime proxetil recon susp 100 mg/5ml 1

cefpodoxime proxetil recon susp 50 mg/5ml 1

cefpodoxime proxetil tab 100 mg 1

cefpodoxime proxetil tab 200 mg 1

cefprozil recon susp 125 mg/5ml 1

cefprozil recon susp 250 mg/5ml 1

PAGE 13 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cefprozil tab 250 mg 1

cefprozil tab 500 mg 1

ceftriaxone sodium recon soln 10 gm 1

ceftriaxone sodium recon soln 2 gm 1

ceftriaxone sodium recon soln 2 gm 1

ceftriaxone sodium recon soln 250 mg 1

cefuroxime axetil tab 250 mg 1

cefuroxime axetil tab 500 mg 1

cephalexin cap 250 mg 1

cephalexin cap 500 mg 1

cephalexin recon susp 125 mg/5ml 1

cephalexin recon susp 250 mg/5ml 1 CEPHALEXIN TAB 250 MG cephalexin 1 CEPHALEXIN TAB 500 MG cephalexin 1 CIPRO RECON SUSP 250 MG/5ML (5%) ciprofloxacin 3 CIPRO RECON SUSP 500 MG/5ML (10%) ciprofloxacin 3

ciprofloxacin hcl tab 100 mg 1 CIPROFLOXACIN HCL TAB 100 MG ciprofloxacin hcl 1

ciprofloxacin hcl tab 250 mg 1

ciprofloxacin hcl tab 500 mg 1

ciprofloxacin hcl tab 750 mg 1

ciprofloxacin-ciproflox hcl er tab er 24h 1000 mg 1

ciprofloxacin-ciproflox hcl er tab er 24h 500 mg 1

clarithromycin er tab er 24h 500 mg 1

clarithromycin recon susp 125 mg/5ml 1

clarithromycin recon susp 250 mg/5ml 1

clarithromycin tab 250 mg 1

clarithromycin tab 500 mg 1

PAGE 14 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clindamycin hcl cap 150 mg 1

clindamycin hcl cap 300 mg 1

clindamycin hcl cap 75 mg 1

clindamycin palmitate hcl recon soln 75 mg/5ml 1

demeclocycline hcl tab 150 mg 3

demeclocycline hcl tab 300 mg 3

dicloxacillin sodium cap 250 mg 1

dicloxacillin sodium cap 500 mg 1 DIFICID TAB 200 MG PA fidaxomicin 3

doxycycline hyclate cap 100 mg 1

doxycycline hyclate cap 50 mg 1

doxycycline hyclate tab 100 mg 1

doxycycline hyclate tab 20 mg 1

doxycycline hyclate tab dr 150 mg 3

doxycycline hyclate tab dr 75 mg 3

doxycycline monohydrate cap 150 mg 3 ST

doxycycline monohydrate cap 75 mg 3 ST

doxycycline monohydrate recon susp 25 mg/5ml 1

doxycycline monohydrate tab 150 mg 3

doxycycline monohydrate tab 50 mg 1

doxycycline monohydrate tab 75 mg 1 E.E.S. 400 TAB 400 MG erythromycin ethylsuccinate 1 ERY-TAB TAB DR 333 MG erythromycin base 3 ERYTHROCIN STEARATE TAB 250 MG erythromycin stearate 1

erythromycin base cp dr part 250 mg 1 ERYTHROMYCIN BASE CP DR PART 250 MG erythromycin base 1 ERYTHROMYCIN BASE TAB 250 MG erythromycin base 1

PAGE 15 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ERYTHROMYCIN BASE TAB 500 MG erythromycin base 1

erythromycin ethylsuccinate tab 400 mg 1 ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG erythromycin ethylsuccinate 1 FACTIVE TAB 320 MG gemifloxacin mesylate 3 KEFLEX CAP 750 MG PA cephalexin 3 KETEK TAB 400 MG PA telithromycin 3

levofloxacin tab 250 mg 1 QL 14 / 30 days

levofloxacin tab 500 mg 1 QL 14 / 30 days

levofloxacin tab 750 mg 1 QL 14 / 30 days

minocycline hcl cap 100 mg 1 ST

minocycline hcl cap 50 mg 1

minocycline hcl cap 75 mg 1 ST

PA minocycline hcl er tab er 24h 135 mg 4 ST

PA minocycline hcl er tab er 24h 45 mg 4 ST

PA minocycline hcl er tab er 24h 90 mg 3 ST

minocycline hcl tab 100 mg 1 ST

minocycline hcl tab 50 mg 1 ST

minocycline hcl tab 75 mg 1 ST

morgidox cap 100 mg 1 MYCOBUTIN CAP 150 MG PA rifabutin 2

neomycin sulfate tab 500 mg 1

ofloxacin tab 400 mg 1 OFLOXACIN TAB 400 MG ofloxacin 1

PAGE 16 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

penicillin v potassium recon soln 125 mg/5ml 1

penicillin v potassium recon soln 250 mg/5ml 1

penicillin v potassium tab 250 mg 1

penicillin v potassium tab 500 mg 1

rifampin cap 150 mg 1

rifampin cap 300 mg 1 SULFADIAZINE TAB 500 MG sulfadiazine 3

sulfamethoxazole-tmp ds tab 800-160 mg 1

sulfamethoxazole-trimethoprim suspension 200-40 mg/5ml 1

sulfamethoxazole-trimethoprim suspension 800-160 mg/20ml 1

sulfamethoxazole-trimethoprim tab 400-80 mg 1

sulfasalazine tab 500 mg 1

sulfasalazine tab dr 500 mg 1

sulfatrim pediatric suspension 200-40 mg/5ml 1

sulfazine ec tab dr 500 mg 1

sulfazine tab 500 mg 1 SUPRAX RECON SUSP 500 MG/5ML cefixime 3

tetracycline hcl cap 250 mg 1 TETRACYCLINE HCL CAP 250 MG tetracycline hcl 1

tetracycline hcl cap 500 mg 1 TETRACYCLINE HCL CAP 500 MG tetracycline hcl 1

vancomycin hcl recon soln 10 gm 3

vancomycin hcl recon soln 1000 mg 1

vancomycin hcl recon soln 500 mg 1 VANCOMYCIN HCL RECON SOLN 750 MG vancomycin hcl 1 ZITHROMAX PACKET 1 GM azithromycin 3 ZYVOX RECON SUSP 100 MG/5ML PA linezolid 3

PAGE 17 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZYVOX SOLUTION 2 MG/ML PA linezolid 3 ZYVOX TAB 600 MG PA linezolid 3 Antifungals

fluconazole recon susp 10 mg/ml 1 QL 105 / 30 days

fluconazole recon susp 40 mg/ml 1 QL 105 / 30 days

fluconazole tab 100 mg 1 QL 30 / 30 days

fluconazole tab 150 mg 1 QL 30 / 30 days

fluconazole tab 200 mg 1 QL 30 / 30 days

fluconazole tab 50 mg 1 QL 30 / 30 days

griseofulvin microsize suspension 125 mg/5ml 1

griseofulvin microsize tab 500 mg 1

griseofulvin ultramicrosize tab 125 mg 1

griseofulvin ultramicrosize tab 250 mg 1

ketoconazole tab 200 mg 1

nystatin suspension 100000 unit/ml 1

nystatin tab 500000 unit 1

terbinafine hcl tab 250 mg 1 Antimycobacterials

AVELOX ABC PACK TAB 400 MG moxifloxacin hcl 3 AVELOX TAB 400 MG moxifloxacin hcl 3 CIPRO RECON SUSP 250 MG/5ML (5%) ciprofloxacin 3 CIPRO RECON SUSP 500 MG/5ML (10%) ciprofloxacin 3

ciprofloxacin hcl tab 100 mg 1 CIPROFLOXACIN HCL TAB 100 MG ciprofloxacin hcl 1

ciprofloxacin hcl tab 250 mg 1

ciprofloxacin hcl tab 500 mg 1

PAGE 18 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ciprofloxacin hcl tab 750 mg 1

ciprofloxacin-ciproflox hcl er tab er 24h 1000 mg 1

ciprofloxacin-ciproflox hcl er tab er 24h 500 mg 1

clarithromycin er tab er 24h 500 mg 1

clarithromycin recon susp 125 mg/5ml 1

clarithromycin recon susp 250 mg/5ml 1

clarithromycin tab 250 mg 1

clarithromycin tab 500 mg 1 DAPSONE TAB 100 MG dapsone 1 DAPSONE TAB 25 MG dapsone 1

ethambutol hcl tab 100 mg 1

ethambutol hcl tab 400 mg 1 ISONIAZID SYRUP 50 MG/5ML isoniazid 1

isoniazid tab 100 mg 1

isoniazid tab 300 mg 1

levofloxacin tab 250 mg 1 QL 14 / 30 days

levofloxacin tab 500 mg 1 QL 14 / 30 days

levofloxacin tab 750 mg 1 QL 14 / 30 days

MYCOBUTIN CAP 150 MG PA rifabutin 2

pyrazinamide tab 500 mg 3 RIFAMATE CAP 150-300 MG isoniazid & rifampin 3

rifampin cap 150 mg 1

rifampin cap 300 mg 1 RIFATER TAB 50-120-300 MG isoniazid-rifampin w/ pyrazinamide 3 Antiprotozoals

ALINIA RECON SUSP 100 MG/5ML PA nitazoxanide 4

PAGE 19 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALINIA TAB 500 MG PA nitazoxanide 4

atovaquone-proguanil hcl tab 250-100 mg 1 QL 30 / 30 days

atovaquone-proguanil hcl tab 62.5-25 mg 1 QL 30 / 30 days

avidoxy tab 100 mg 1

chloroquine phosphate tab 250 mg 1

chloroquine phosphate tab 500 mg 1 DAPSONE TAB 100 MG dapsone 1 DAPSONE TAB 25 MG dapsone 1 DARAPRIM TAB 25 MG pyrimethamine 2

doxycycline hyclate cap 100 mg 1

doxycycline hyclate cap 50 mg 1

doxycycline hyclate tab 100 mg 1

doxycycline hyclate tab dr 150 mg 3

doxycycline hyclate tab dr 75 mg 3

doxycycline monohydrate cap 150 mg 3 ST

doxycycline monohydrate cap 75 mg 3 ST

doxycycline monohydrate recon susp 25 mg/5ml 1

doxycycline monohydrate tab 150 mg 3

doxycycline monohydrate tab 50 mg 1

doxycycline monohydrate tab 75 mg 1 FLAGYL ER TAB ER 24H 750 MG ST metronidazole 3

hydroxychloroquine sulfate tab 200 mg 1

mefloquine hcl tab 250 mg 1 MEPRON SUSPENSION 750 MG/5ML QL 210 / 18 days atovaquone 2

metronidazole cap 375 mg 1

metronidazole gel 0.75 % 1

metronidazole tab 250 mg 1

PAGE 20 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metronidazole tab 500 mg 1

minocycline hcl cap 100 mg 1 ST

minocycline hcl cap 50 mg 1

minocycline hcl cap 75 mg 1 ST

minocycline hcl tab 100 mg 1 ST

minocycline hcl tab 50 mg 1 ST

minocycline hcl tab 75 mg 1 ST

morgidox cap 100 mg 1 PRIMAQUINE PHOSPHATE TAB 26.3 MG primaquine phosphate 1 QUALAQUIN CAP 324 MG quinine sulfate 1

quinidine gluconate er tab er 324 mg 1 QUINIDINE SULFATE ER TAB ER 300 MG quinidine sulfate 1

quinidine sulfate tab 200 mg 1 QUINIDINE SULFATE TAB 200 MG quinidine sulfate 1

quinidine sulfate tab 300 mg 1

quinine sulfate cap 324 mg 1

sulfamethoxazole-tmp ds tab 800-160 mg 1

sulfamethoxazole-trimethoprim suspension 200-40 mg/5ml 1

sulfamethoxazole-trimethoprim suspension 800-160 mg/20ml 1

sulfamethoxazole-trimethoprim tab 400-80 mg 1

sulfatrim pediatric suspension 200-40 mg/5ml 1

tetracycline hcl cap 250 mg 1 TETRACYCLINE HCL CAP 250 MG tetracycline hcl 1

tetracycline hcl cap 500 mg 1 TETRACYCLINE HCL CAP 500 MG tetracycline hcl 1

tinidazole tab 250 mg 3

tinidazole tab 500 mg 3

PAGE 21 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vandazole gel 0.75 % 1 Antivirals

abacavir sulfate tab 300 mg 3 QL 60 / 30 days

acyclovir cap 200 mg 1

acyclovir suspension 200 mg/5ml 1 AL Up to 12 yrs old

acyclovir tab 400 mg 1

acyclovir tab 800 mg 1

amantadine hcl cap 100 mg 1

amantadine hcl syrup 50 mg/5ml 1 AMANTADINE HCL TAB 100 MG amantadine hcl 1 APTIVUS CAP 250 MG QL 120 / 30 days tipranavir 3 APTIVUS SOLUTION 100 MG/ML QL 300 / 30 days tipranavir 3 ATRIPLA TAB 600-200-300 MG QL 30 / 30 days efavirenz-emtricitabine-tenofovir disoproxil fumarate 2 BARACLUDE SOLUTION 0.05 MG/ML PA entecavir 4 COMPLERA TAB 200-25-300 MG QL 30 / 30 days emtricitabine-rilpivirine-tenofovir disoproxil fumarate 2 CRIXIVAN CAP 200 MG QL 360 / 30 days indinavir sulfate 2 CRIXIVAN CAP 400 MG QL 180 / 30 days indinavir sulfate 2

didanosine cap dr 125 mg 3 QL 60 / 30 days

didanosine cap dr 200 mg 3 QL 60 / 30 days

didanosine cap dr 250 mg 3 QL 30 / 30 days

didanosine cap dr 400 mg 3 QL 30 / 30 days

EDURANT TAB 25 MG QL 30 / 30 days rilpivirine hcl 2 EMTRIVA CAP 200 MG QL 30 / 30 days emtricitabine 2 EMTRIVA SOLUTION 10 MG/ML emtricitabine 2

PAGE 22 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EPIVIR HBV SOLUTION 5 MG/ML QL 1800 / 30 days lamivudine (hbv) 3 EPIVIR HBV TAB 100 MG QL 90 / 30 days lamivudine (hbv) 2 EPIVIR SOLUTION 10 MG/ML QL 900 / 30 days lamivudine 3 EPZICOM TAB 600-300 MG QL 30 / 30 days abacavir sulfate-lamivudine 2

QL 90 / 30 days famciclovir tab 125 mg 3 ST

QL 90 / 30 days famciclovir tab 250 mg 3 ST

QL 90 / 30 days famciclovir tab 500 mg 3 ST

HEPSERA TAB 10 MG PA adefovir dipivoxil 4 INCIVEK TAB 375 MG PA telaprevir 4 INFERGEN INJECTABLE 15 MCG/0.5ML PA interferon alfacon-1 4 INTELENCE TAB 100 MG QL 120 / 30 days etravirine 3 INTELENCE TAB 200 MG QL 60 / 30 days etravirine 3 INTELENCE TAB 25 MG QL 480 / 30 days etravirine 3 INTRON A RECON SOLN 10000000 UNIT PA interferon alfa-2b 4 INTRON A RECON SOLN 18000000 UNIT PA interferon alfa-2b 4 INTRON A RECON SOLN 50000000 UNIT PA interferon alfa-2b 4 INTRON A SOLUTION 6000000 UNIT/ML PA interferon alfa-2b 4 INVIRASE CAP 200 MG QL 300 / 30 days saquinavir mesylate 2 INVIRASE TAB 500 MG QL 120 / 30 days saquinavir mesylate 2

PAGE 23 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ISENTRESS CHEW TAB 100 MG QL 60 / 30 days raltegravir potassium 3 ISENTRESS CHEW TAB 25 MG QL 60 / 30 days raltegravir potassium 3 ISENTRESS TAB 400 MG QL 60 / 30 days raltegravir potassium 2 KALETRA SOLUTION 400-100 MG/5ML QL 450 / 23 days lopinavir-ritonavir 2 KALETRA TAB 100-25 MG QL 360 / 30 days lopinavir-ritonavir 2 KALETRA TAB 200-50 MG QL 180 / 30 days lopinavir-ritonavir 2

lamivudine tab 150 mg 3 QL 60 / 30 days

lamivudine tab 300 mg 3 QL 30 / 30 days

lamivudine-zidovudine tab 150-300 mg 3 QL 60 / 30 days

LEXIVA SUSPENSION 50 MG/ML QL 180 / 30 days fosamprenavir calcium 2 LEXIVA TAB 700 MG QL 120 / 30 days fosamprenavir calcium 2 MODERIBA 800 DOSE PACK TAB 400 MG PA ribavirin (hepatitis c) 4 NEVIRAPINE SUSPENSION 50 MG/5ML PA nevirapine 1

nevirapine tab 200 mg 1 QL 60 / 30 days

NORVIR CAP 100 MG QL 360 / 30 days ritonavir 2 NORVIR SOLUTION 80 MG/ML QL 450 / 23 days ritonavir 2 NORVIR TAB 100 MG QL 360 / 30 days ritonavir 2 PEG-INTRON KIT 120 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON KIT 150 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON KIT 50 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON KIT 80 MCG/0.5ML PA peginterferon alfa-2b 4

PAGE 24 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PEG-INTRON REDIPEN KIT 120 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN KIT 150 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN KIT 50 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN KIT 80 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN PAK 4 KIT 120 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN PAK 4 KIT 150 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN PAK 4 KIT 50 MCG/0.5ML PA peginterferon alfa-2b 4 PEG-INTRON REDIPEN PAK 4 KIT 80 MCG/0.5ML PA peginterferon alfa-2b 4 PEGASYS KIT 180 MCG/0.5ML PA peginterferon alfa-2a 4 PEGASYS PROCLICK SOLUTION 135 MCG/0.5ML PA peginterferon alfa-2a 4 PEGASYS SOLUTION 180 MCG/ML PA peginterferon alfa-2a 4 PREZISTA SUSPENSION 100 MG/ML QL 480 / 30 days darunavir ethanolate 3 PREZISTA TAB 150 MG QL 240 / 30 days darunavir ethanolate 2 PREZISTA TAB 600 MG QL 60 / 30 days darunavir ethanolate 2 PREZISTA TAB 75 MG QL 480 / 30 days darunavir ethanolate 2 PREZISTA TAB 800 MG QL 60 / 30 days darunavir ethanolate 3 REBETOL SOLUTION 40 MG/ML PA ribavirin (hepatitis c) 4

RELENZA DISKHALER AER POW BA 5 MG/BLISTER QL 20 / 5 days 2 zanamivir PA

RESCRIPTOR TAB 100 MG QL 360 / 30 days delavirdine mesylate 2

PAGE 25 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RESCRIPTOR TAB 200 MG QL 180 / 30 days delavirdine mesylate 2 REYATAZ CAP 150 MG QL 60 / 30 days atazanavir sulfate 2 REYATAZ CAP 200 MG QL 60 / 30 days atazanavir sulfate 2 REYATAZ CAP 300 MG QL 30 / 30 days atazanavir sulfate 2

ribasphere cap 200 mg 4 PA

RIBASPHERE RIBAPAK TAB 400 & 600 MG PA ribavirin (hepatitis c) 4 RIBASPHERE RIBAPAK TAB 400 MG PA ribavirin (hepatitis c) 4

ribasphere tab 200 mg 4 PA

RIBASPHERE TAB 400 MG PA ribavirin (hepatitis c) 4 RIBASPHERE TAB 600 MG PA ribavirin (hepatitis c) 4 RIBATAB MISC 400 & 600 MG PA ribavirin (hepatitis c) 4 RIBATAB TAB 400 MG PA ribavirin (hepatitis c) 4 RIBATAB TAB 600 MG PA ribavirin (hepatitis c) 4

ribavirin cap 200 mg 4 PA

ribavirin tab 200 mg 4 PA

rimantadine hcl tab 100 mg 1 SELZENTRY TAB 150 MG QL 120 / 30 days maraviroc 3 SELZENTRY TAB 300 MG QL 120 / 30 days maraviroc 3

stavudine cap 15 mg 1 QL 60 / 30 days

stavudine cap 20 mg 1 QL 60 / 30 days

stavudine cap 30 mg 1 QL 60 / 30 days

stavudine cap 40 mg 1 QL 60 / 30 days

PAGE 26 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

stavudine recon soln 1 mg/ml 1 QL 1200 / 30 days

STRIBILD TAB 150-150-200-300 MG QL 30 / 30 days elvitegravir-cobicistat-emtricitabine-tenofovir 2 SUSTIVA CAP 200 MG QL 90 / 30 days efavirenz 2 SUSTIVA CAP 50 MG QL 360 / 30 days efavirenz 2 SUSTIVA TAB 600 MG QL 30 / 30 days efavirenz 2 SYLATRON KIT 200 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 300 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 4 X 200 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 4 X 300 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 600 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYNAGIS SOLUTION 100 MG/ML PA palivizumab 4 TAMIFLU CAP 30 MG QL 10 / 5 days oseltamivir phosphate 2 TAMIFLU CAP 45 MG QL 10 / 5 days oseltamivir phosphate 2 TAMIFLU CAP 75 MG QL 10 / 5 days oseltamivir phosphate 2

TAMIFLU RECON SUSP 6 MG/ML QL 120 / 10 days 2 oseltamivir phosphate AL Up to 6 yrs old

TRIZIVIR TAB 300-150-300 MG QL 60 / 30 days abacavir sulfate-lamivudine-zidovudine 2 TRUVADA TAB 200-300 MG QL 30 / 30 days emtricitabine-tenofovir disoproxil fumarate 2 TYZEKA TAB 600 MG PA telbivudine 4

valacyclovir hcl tab 1 gm 1

valacyclovir hcl tab 500 mg 1

PAGE 27 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VALCYTE RECON SOLN 50 MG/ML PA valganciclovir hcl 4 VICTRELIS CAP 200 MG PA boceprevir 4 VIDEX RECON SOLN 2 GM QL 603 / 30 days didanosine 2 VIRACEPT TAB 250 MG QL 300 / 30 days nelfinavir mesylate 2 VIRACEPT TAB 625 MG QL 120 / 30 days nelfinavir mesylate 2 VIRAMUNE SUSPENSION 50 MG/5ML QL 1200 / 30 days nevirapine 2 VIRAMUNE XR TAB ER 24H 400 MG QL 30 / 30 days nevirapine 2 VIREAD TAB 150 MG QL 30 / 30 days tenofovir disoproxil fumarate 2 VIREAD TAB 200 MG QL 30 / 30 days tenofovir disoproxil fumarate 2 VIREAD TAB 250 MG QL 30 / 30 days tenofovir disoproxil fumarate 2 VIREAD TAB 300 MG QL 30 / 30 days tenofovir disoproxil fumarate 2 ZIAGEN SOLUTION 20 MG/ML QL 900 / 30 days abacavir sulfate 2

zidovudine cap 100 mg 1 QL 180 / 30 days

zidovudine syrup 50 mg/5ml 1 QL 1800 / 30 days

zidovudine tab 300 mg 1 QL 60 / 30 days

Autonomic Drugs

Anticholinergic Agents

altaryl syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

ATROVENT HFA AERO SOLN 17 MCG/ACT QL 26 / 25 days ipratropium bromide hfa 2 BELLADONNA ALKALOIDS-OPIUM SUPPOS 16.2-60 MG AL Up to 64 yrs old belladonna alkaloids & opium 1 BELLADONNA-OPIUM SUPPOS 16.2-30 MG AL Up to 64 yrs old belladonna alkaloids & opium 1

PAGE 28 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

benztropine mesylate solution 1 mg/ml 3

benztropine mesylate tab 0.5 mg 1 AL Up to 64 yrs old

benztropine mesylate tab 1 mg 1 AL Up to 64 yrs old

benztropine mesylate tab 2 mg 1 AL Up to 64 yrs old

chlordiazepoxide-clidinium cap 5-2.5 mg 1 COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT QL 4 / 25 days ipratropium-albuterol 3

dicyclomine hcl cap 10 mg 1 AL Up to 64 yrs old

DICYCLOMINE HCL SOLUTION 10 MG/5ML AL Up to 64 yrs old dicyclomine hcl 1

dicyclomine hcl tab 20 mg 1 AL Up to 64 yrs old

diphenhydramine hcl cap 50 mg 1 AL Up to 64 yrs old

diphenhydramine hcl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

diphenhydramine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

DIPHENOXYLATE-ATROPINE LIQUID 2.5-0.025 MG/5ML diphenoxylate w/ atropine 1

diphenoxylate-atropine tab 2.5-0.025 mg 1

ed-spaz tab disp 0.125 mg 1 AL Up to 64 yrs old

eq allergy relief childrens elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

glycopyrrolate tab 1 mg 1

glycopyrrolate tab 2 mg 1

hydrocodone-homatropine syrup 5-1.5 mg/5ml 1

hydrocodone-homatropine tab 5-1.5 mg 1

hydromet syrup 5-1.5 mg/5ml 1

hyomax-sl sl tab 0.125 mg 1 AL Up to 64 yrs old

hyophen tab 81.6 mg 1

hyoscyamine sulfate elixir 0.125 mg/5ml 1 AL Up to 64 yrs old

hyoscyamine sulfate er tab er 12h 0.375 mg 1 AL Up to 64 yrs old

hyoscyamine sulfate sl tab 0.125 mg 1 AL Up to 64 yrs old

hyoscyamine sulfate solution 0.125 mg/ml 1 AL Up to 64 yrs old

PAGE 29 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hyoscyamine sulfate tab 0.125 mg 1 AL Up to 64 yrs old

hyoscyamine sulfate tab disp 0.125 mg 1 AL Up to 64 yrs old

hyosyne elixir 0.125 mg/5ml 1 AL Up to 64 yrs old

hyosyne solution 0.125 mg/ml 1 AL Up to 64 yrs old

ipratropium bromide solution 0.02 % 1

ipratropium bromide solution 0.03 % 1 QL 30 / 25 days

ipratropium bromide solution 0.06 % 1 QL 15 / 25 days

ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml 1

lonox tab 2.5-0.025 mg 1

medi-phedryl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

methscopolamine bromide tab 2.5 mg 3 AL Up to 64 yrs old

methscopolamine bromide tab 5 mg 3 AL Up to 64 yrs old

nulev tab disp 0.125 mg 1 AL Up to 64 yrs old

oscimin sr tab er 12h 0.375 mg 1 AL Up to 64 yrs old

oscimin tab 0.125 mg 1 AL Up to 64 yrs old

oscimin tab disp 0.125 mg 1 AL Up to 64 yrs old

phosphasal tab 81.6 mg 1 PROPANTHELINE BROMIDE TAB 15 MG propantheline bromide 1

quenalin syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

silphen cough syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

SPIRIVA HANDIHALER CAP 18 MCG QL 30 / 30 days tiotropium bromide monohydrate 2

symax fastabs tab disp 0.125 mg 1 AL Up to 64 yrs old

symax-sl sl tab 0.125 mg 1 AL Up to 64 yrs old

symax-sr tab er 12h 0.375 mg 1 AL Up to 64 yrs old

TUDORZA PRESSAIR AER POW BA 400 MCG/ACT QL 60 / 30 days aclidinium bromide 2

tussigon tab 5-1.5 mg 1

PAGE 30 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

uretron d/s tab 1 URETRON D/S TAB methenamine-hyosc-methylene blue-sod phos-phenyl sal 1

ustell cap 120 mg 1

uticap cap 120 mg 1

utira-c tab 81.6 mg 1

utrona-c tab 81.6 mg 1

bethanechol chloride tab 10 mg 1

bethanechol chloride tab 25 mg 1

bethanechol chloride tab 5 mg 1

bethanechol chloride tab 50 mg 1 CHANTIX CONTINUING MONTH PAK TAB 1 MG QL 180 / 365 days varenicline tartrate 5 CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1 MG X 42 5 QL 180 / 90 days varenicline tartrate CHANTIX TAB 0.5 MG QL 180 / 365 days varenicline tartrate 5 CHANTIX TAB 1 MG QL 180 / 365 days varenicline tartrate 5

cvs nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

cvs nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

cvs nts step 1 patch 24hr 21 mg/24hr 5 QL 90 / 365 days

donepezil hcl tab 10 mg 1

donepezil hcl tab 23 mg 3

donepezil hcl tab 5 mg 1

donepezil hcl tab disp 10 mg 1 PA

donepezil hcl tab disp 5 mg 3

eq nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

eq nicotine patch 24hr 21 mg/24hr 5 QL 90 / 365 days

eq nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

eq nicotine step 3 patch 24hr 7 mg/24hr 5 QL 90 / 365 days

PAGE 31 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

eql nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

eql nicotine patch 24hr 21 mg/24hr 5 QL 90 / 365 days

eql nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

EXELON PATCH 24HR 13.3 MG/24HR PA rivastigmine 3 EXELON PATCH 24HR 4.6 MG/24HR PA rivastigmine 3 EXELON PATCH 24HR 9.5 MG/24HR PA rivastigmine 3

galantamine hydrobromide er cap er 24h 16 mg 1 ST

galantamine hydrobromide er cap er 24h 24 mg 1 ST

galantamine hydrobromide er cap er 24h 8 mg 1 ST

galantamine hydrobromide tab 12 mg 1

galantamine hydrobromide tab 4 mg 1

galantamine hydrobromide tab 8 mg 1

hm nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

hm nicotine patch 24hr 21 mg/24hr 5 QL 90 / 365 days

hm nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

MESTINON SYRUP 60 MG/5ML PA pyridostigmine bromide 2 MESTINON TAB ER 180 MG PA pyridostigmine bromide 2

nicorelief gum 2 mg 5 QL 810 / 365 days

nicorelief gum 4 mg 5 QL 810 / 365 days

nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

nicotine patch 24hr 21 mg/24hr 5 QL 90 / 365 days

nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

nicotine polacrilex gum 2 mg 5 QL 810 / 365 days

nicotine polacrilex gum 4 mg 5 QL 810 / 365 days

nicotine step 1 patch 24hr 21 mg/24hr 5 QL 90 / 365 days

PAGE 32 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nicotine step 2 patch 24hr 14 mg/24hr 5 QL 90 / 365 days

nicotine step 3 patch 24hr 7 mg/24hr 5 QL 90 / 365 days

NICOTROL INHALER 10 MG nicotine 5 NICOTROL NS SOLUTION 10 MG/ML nicotine 5 PHYSOSTIGMINE SALICYLATE SOLUTION 1 MG/ML physostigmine salicylate 1

pilocarpine hcl tab 5 mg 1

pilocarpine hcl tab 7.5 mg 1

pyridostigmine bromide tab 60 mg 1

ra nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

ra nicotine patch 24hr 21 mg/24hr 5 QL 90 / 365 days

ra nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

rivastigmine tartrate cap 1.5 mg 3

rivastigmine tartrate cap 3 mg 3

rivastigmine tartrate cap 4.5 mg 3

rivastigmine tartrate cap 6 mg 3 PA

sm nicotine patch 24hr 14 mg/24hr 5 QL 90 / 365 days

sm nicotine patch 24hr 21 mg/24hr 5 QL 90 / 365 days

sm nicotine patch 24hr 7 mg/24hr 5 QL 90 / 365 days

tgt nicotine step one patch 24hr 21 mg/24hr 5 QL 90 / 365 days

tgt nicotine step three patch 24hr 7 mg/24hr 5 QL 90 / 365 days

tgt nicotine step two patch 24hr 14 mg/24hr 5 QL 90 / 365 days

thrive gum 2 mg 5 QL 810 / 90 days

thrive gum 4 mg 5 QL 810 / 90 days

Skeletal Muscle Relaxants

baclofen tab 10 mg 1

baclofen tab 20 mg 1

chlorzoxazone tab 500 mg 1 AL Up to 64 yrs old

PAGE 33 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cyclobenzaprine hcl tab 10 mg 1 AL Up to 64 yrs old

cyclobenzaprine hcl tab 5 mg 1 AL Up to 64 yrs old

DYSPORT RECON SOLN 500 UNIT PA abobotulinumtoxina 4 LORZONE TAB 375 MG chlorzoxazone 3

PA metaxalone tab 800 mg 3 AL Up to 64 yrs old

methocarbamol tab 500 mg 1 AL Up to 64 yrs old

methocarbamol tab 750 mg 1 AL Up to 64 yrs old

orphenadrine citrate er tab er 12h 100 mg 1 AL Up to 64 yrs old

orphenadrine-aspirin-caffeine tab 25-385-30 mg 1 AL Up to 64 yrs old

tizanidine hcl cap 2 mg 3 QL 90 / 30 days

tizanidine hcl cap 4 mg 3 QL 90 / 30 days

tizanidine hcl cap 6 mg 3 QL 90 / 30 days

tizanidine hcl tab 2 mg 1 QL 90 / 30 days

tizanidine hcl tab 4 mg 1 QL 90 / 30 days

Sympatholytic (Adrenergic Blocking) Agents

acebutolol hcl cap 200 mg 1

acebutolol hcl cap 400 mg 1

alfuzosin hcl er tab er 24h 10 mg 3

atenolol tab 100 mg 1

atenolol tab 25 mg 1

atenolol tab 50 mg 1

betaxolol hcl tab 10 mg 1

betaxolol hcl tab 20 mg 1

bisoprolol fumarate tab 10 mg 1

bisoprolol fumarate tab 5 mg 1 BYSTOLIC TAB 10 MG ST nebivolol hcl 3

PAGE 34 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BYSTOLIC TAB 2.5 MG ST nebivolol hcl 3 BYSTOLIC TAB 20 MG ST nebivolol hcl 3 BYSTOLIC TAB 5 MG ST nebivolol hcl 3 CAFERGOT TAB 1-100 MG ergotamine w/ caffeine 2 CARDURA XL TAB ER 24H 4 MG doxazosin mesylate (bph) 3

carvedilol tab 12.5 mg 1

carvedilol tab 25 mg 1

carvedilol tab 3.125 mg 1

carvedilol tab 6.25 mg 1 COREG CR CAP ER 24H 10 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 20 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 40 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 80 MG ST carvedilol phosphate 3 DIBENZYLINE CAP 10 MG PA phenoxybenzamine hcl 3 DIHYDROERGOTAMINE MESYLATE SOLUTION 4 MG/ML dihydroergotamine mesylate 3

doxazosin mesylate tab 1 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 2 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 4 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 8 mg 1 AL Up to 64 yrs old

ergoloid mesylates tab 1 mg 3 PA

labetalol hcl tab 100 mg 1

labetalol hcl tab 200 mg 1

labetalol hcl tab 300 mg 1

metoprolol succinate er tab er 24h 100 mg 1 QL 30 / 30 days

PAGE 35 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metoprolol succinate er tab er 24h 200 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 25 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 50 mg 1 QL 30 / 30 days

metoprolol tartrate tab 100 mg 1

metoprolol tartrate tab 25 mg 1

metoprolol tartrate tab 50 mg 1

nadolol tab 20 mg 1

nadolol tab 40 mg 1

nadolol tab 80 mg 1

pindolol tab 10 mg 1

pindolol tab 5 mg 1

prazosin hcl cap 1 mg 1

prazosin hcl cap 2 mg 1

prazosin hcl cap 5 mg 1

propranolol hcl er cap er 24h 120 mg 1 ST

propranolol hcl er cap er 24h 160 mg 1 ST

propranolol hcl er cap er 24h 60 mg 1 ST

propranolol hcl er cap er 24h 80 mg 1 ST

PROPRANOLOL HCL SOLUTION 20 MG/5ML propranolol hcl 1 PROPRANOLOL HCL SOLUTION 40 MG/5ML propranolol hcl 1

propranolol hcl tab 10 mg 1

propranolol hcl tab 20 mg 1

propranolol hcl tab 40 mg 1

propranolol hcl tab 60 mg 1

propranolol hcl tab 80 mg 1 RAPAFLO CAP 4 MG PA silodosin 3 RAPAFLO CAP 8 MG PA silodosin 3

sorine tab 120 mg 1

PAGE 36 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sorine tab 160 mg 1

sorine tab 240 mg 1

sorine tab 80 mg 1

sotalol hcl tab 120 mg 1

sotalol hcl tab 160 mg 1

sotalol hcl tab 240 mg 1

sotalol hcl tab 80 mg 1

tamsulosin hcl cap 0.4 mg 1 QL 60 / 30 days

terazosin hcl cap 1 mg 1 AL Up to 64 yrs old

terazosin hcl cap 10 mg 1 AL Up to 64 yrs old

terazosin hcl cap 2 mg 1 AL Up to 64 yrs old

terazosin hcl cap 5 mg 1 AL Up to 64 yrs old

TIMOLOL MALEATE TAB 10 MG timolol maleate 1 TIMOLOL MALEATE TAB 20 MG timolol maleate 1 TIMOLOL MALEATE TAB 5 MG timolol maleate 1 Sympathomimetic (Adrenergic) Agents

ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML epinephrine 3 ADVAIR DISKUS AER POW BA 100-50 MCG/DOSE QL 60 / 30 days fluticasone-salmeterol 2 ADVAIR DISKUS AER POW BA 250-50 MCG/DOSE ST fluticasone-salmeterol 3 ADVAIR DISKUS AER POW BA 500-50 MCG/DOSE ST fluticasone-salmeterol 3 ADVAIR HFA AEROSOL 115-21 MCG/ACT ST fluticasone-salmeterol 3 ADVAIR HFA AEROSOL 230-21 MCG/ACT ST fluticasone-salmeterol 3 ADVAIR HFA AEROSOL 45-21 MCG/ACT ST fluticasone-salmeterol 3

albuterol sulfate er tab er 12h 4 mg 1

PAGE 37 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

albuterol sulfate er tab er 12h 8 mg 1

albuterol sulfate nebu soln (2.5 mg/3ml) 0.083% 1

albuterol sulfate nebu soln (5 mg/ml) 0.5% 1

albuterol sulfate nebu soln 0.63 mg/3ml 1

albuterol sulfate nebu soln 1.25 mg/3ml 1

albuterol sulfate syrup 2 mg/5ml 1

ARCAPTA NEOHALER CAP 75 MCG QL 30 / 30 days 3 indacaterol maleate PA

AUVI-Q SOLN A-INJ 0.15 MG/0.15ML epinephrine 3

bromfed dm syrup 30-2-10 mg/5ml 1 BROVANA NEBU SOLN 15 MCG/2ML PA arformoterol tartrate 3

clonidine hcl patch wk 0.1 mg/24hr 3

clonidine hcl patch wk 0.2 mg/24hr 3

clonidine hcl patch wk 0.3 mg/24hr 3

clonidine hcl tab 0.1 mg 1

clonidine hcl tab 0.2 mg 1

clonidine hcl tab 0.3 mg 1 COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT QL 4 / 25 days ipratropium-albuterol 3

DULERA AEROSOL 100-5 MCG/ACT QL 13 / 25 days 2 mometasone furoate-formoterol fumarate dihydrate ST

DULERA AEROSOL 200-5 MCG/ACT QL 13 / 25 days 2 mometasone furoate-formoterol fumarate dihydrate ST

entre-b suspension 6-10 mg/5ml 1

epinephrine hcl soln prsyr 0.1 mg/ml 1

epinephrine hcl solution 1 mg/ml 1 EPINEPHRINE SOLN A-INJ 0.15 MG/0.15ML QL 2 / 90 days epinephrine 1 EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML epinephrine 1 EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML epinephrine 2

PAGE 38 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML QL 2 / 90 days epinephrine 2 FORADIL AEROLIZER CAP 12 MCG QL 60 / 30 days formoterol fumarate 2

ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml 1

levalbuterol hcl nebu soln 0.31 mg/3ml 1 ST

levalbuterol hcl nebu soln 0.63 mg/3ml 1 ST

levalbuterol hcl nebu soln 1.25 mg/0.5ml 1 ST

metaproterenol sulfate syrup 10 mg/5ml 1 METAPROTERENOL SULFATE SYRUP 10 MG/5ML metaproterenol sulfate 1 METAPROTERENOL SULFATE TAB 10 MG metaproterenol sulfate 1 METAPROTERENOL SULFATE TAB 20 MG metaproterenol sulfate 1

methyldopa tab 250 mg 1

methyldopa tab 500 mg 1

midodrine hcl tab 10 mg 1

midodrine hcl tab 2.5 mg 1

midodrine hcl tab 5 mg 1 PERFOROMIST NEBU SOLN 20 MCG/2ML PA formoterol fumarate 3 PHENYLEPHRINE-CHLORPHEN-DM LIQUID 1.75-0.75-2.75 MG/ML 1 phenylephrine-chlorphen-dm

phenylephrine-guaifenesin liquid 1.5-20 mg/ml 1 PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate 3 PROMETHAZINE VC PLAIN SYRUP 6.25-5 MG/5ML promethazine & phenylephrine 1 PROMETHAZINE VC/CODEINE SYRUP 6.25-5-10 MG/5ML phenyleph-promethazine w/ cod 1 PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT QL 6.7 / 30 days albuterol sulfate 3 RESCON-JR TAB ER 12H 3-20 MG dexchlorpheniramine-phenylephrine 1

PAGE 39 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RESCON-JR TAB ER 12H 4-20 MG chlorpheniramine & phenylephrine 1 SEREVENT DISKUS AER POW BA 50 MCG/DOSE PA salmeterol xinafoate 2

SYMBICORT AEROSOL 160-4.5 MCG/ACT QL 10.2 / 25 days 2 budesonide-formoterol fumarate dihydrate ST

SYMBICORT AEROSOL 80-4.5 MCG/ACT QL 10.2 / 25 days 2 budesonide-formoterol fumarate dihydrate ST

terbutaline sulfate solution 1 mg/ml 1

terbutaline sulfate tab 2.5 mg 1

terbutaline sulfate tab 5 mg 1 TGQ 15DM/5PEH/2CPM SYRUP 15-5-2 MG/5ML phenylephrine-chlorphen-dm 1 TGQ 30PSE/150GFN/15DM SYRUP 30-150-15 MG/5ML pseudoephedrine w/ dm-gg 1 VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate 2

XOPENEX HFA AEROSOL 45 MCG/ACT QL 60 / 30 days 3 levalbuterol tartrate ST

Blood Formation,Coagulation & Thrombosis

Antihemorrhagic Agents

AMINOCAPROIC ACID TAB 1000 MG aminocaproic acid 3

aminocaproic acid tab 500 mg 3

desmopressin ace rhinal tube solution 0.01 % 1

desmopressin ace spray refrig solution 0.01 % 3

desmopressin acetate solution 4 mcg/ml 4 PA

desmopressin acetate spray solution 0.01 % 1

desmopressin acetate tab 0.1 mg 1

desmopressin acetate tab 0.2 mg 1 STIMATE SOLUTION 1.5 MG/ML PA desmopressin acetate 4

PAGE 40 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Antithrombotic Agents

QL 60 / 30 days adult aspirin ec low strength tab dr 81 mg 5 AL 40 to 79 yrs old

AGGRENOX CAP ER 12H 25-200 MG aspirin-dipyridamole 3

anagrelide hcl cap 0.5 mg 1

anagrelide hcl cap 1 mg 1

QL 60 / 30 days aspir-low tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin adult low strength chew tab 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin adult low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin chew tab 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec lo-dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin low strength chew tab 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days aspirin tab 325 mg 5 AL 40 to 79 yrs old

PAGE 41 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 days aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days bayer aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer aspirin tab 325 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer aspirin tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days bayer low dose chew tab 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer low dose tab dr 81 mg 5 AL 40 to 79 yrs old

BRILINTA TAB 90 MG PA ticagrelor 3 CEPROTIN RECON SOLN 500 UNIT PA protein c concentrate (human) 4

cilostazol tab 100 mg 1

cilostazol tab 50 mg 1

clopidogrel bisulfate tab 300 mg 1 QL 30 / 30 days

clopidogrel bisulfate tab 75 mg 1 QL 30 / 30 days

QL 60 / 30 days cvs aspirin adult low strength tab dr 81 mg 5 AL 40 to 79 yrs old

dipyridamole tab 25 mg 1

dipyridamole tab 50 mg 1

dipyridamole tab 75 mg 1

QL 60 / 30 days ec-81 aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days ecotrin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days ecpirin tab dr 325 mg 5 AL 40 to 79 yrs old

PAGE 42 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

enoxaparin sodium solution 100 mg/ml 4 PA

enoxaparin sodium solution 120 mg/0.8ml 4 PA

enoxaparin sodium solution 150 mg/ml 4 PA

enoxaparin sodium solution 30 mg/0.3ml 4 PA

enoxaparin sodium solution 300 mg/3ml 4 PA

enoxaparin sodium solution 40 mg/0.4ml 4 PA

enoxaparin sodium solution 60 mg/0.6ml 4 PA

enoxaparin sodium solution 80 mg/0.8ml 4 PA

QL 60 / 30 days eq adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eq aspirin adult low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eql adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eql aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

fondaparinux sodium solution 10 mg/0.8ml 4 PA

fondaparinux sodium solution 2.5 mg/0.5ml 4 PA

fondaparinux sodium solution 5 mg/0.4ml 4 PA

fondaparinux sodium solution 7.5 mg/0.6ml 4 PA

FRAGMIN SOLUTION 10000 UNIT/ML PA dalteparin sodium 4 FRAGMIN SOLUTION 12500 UNIT/0.5ML PA dalteparin sodium 4 FRAGMIN SOLUTION 15000 UNIT/0.6ML PA dalteparin sodium 4 FRAGMIN SOLUTION 18000 UNT/0.72ML PA dalteparin sodium 4 FRAGMIN SOLUTION 2500 UNIT/0.2ML PA dalteparin sodium 4 FRAGMIN SOLUTION 5000 UNIT/0.2ML PA dalteparin sodium 4

PAGE 43 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FRAGMIN SOLUTION 7500 UNIT/0.3ML PA dalteparin sodium 4

QL 60 / 30 days gnp adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days gnp aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days goodsense aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

heparin (porcine) lock flush solution 10 unit/ml 1

heparin (porcine) lock flush solution 100 unit/ml 1

heparin lock flush solution 1 unit/ml 1 HEPARIN LOCK FLUSH SOLUTION 1 UNIT/ML heparin sodium (porcine) lock flush 1

heparin lock flush solution 10 unit/ml 1

heparin lock flush solution 100 unit/ml 1 HEPARIN LOCK FLUSH SOLUTION 2 UNIT/ML heparin sodium (porcine) lock flush 1

heparin sodium (porcine) pf solution 5000 unit/0.5ml 1

heparin sodium (porcine) solution 1000 unit/ml 1

heparin sodium (porcine) solution 10000 unit/ml 1 HEPARIN SODIUM (PORCINE) SOLUTION 2000 UNIT/ML heparin sodium (porcine) 1

heparin sodium (porcine) solution 20000 unit/ml 1

heparin sodium (porcine) solution 5000 unit/ml 1

heparin sodium lock flush solution 10 unit/ml 1

heparin sodium lock flush solution 100 unit/ml 1

QL 60 / 30 days hm aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days hm aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

jantoven tab 1 mg 1

jantoven tab 10 mg 1

PAGE 44 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

jantoven tab 2 mg 1

jantoven tab 2.5 mg 1

jantoven tab 3 mg 1

jantoven tab 4 mg 1

jantoven tab 5 mg 1

jantoven tab 6 mg 1

jantoven tab 7.5 mg 1

monoject flush syr/hep lock solution 10 unit/ml 1

monoject flush syr/hep lock solution 100 unit/ml 1 PRADAXA CAP 150 MG PA dabigatran etexilate mesylate 3 PRADAXA CAP 75 MG PA dabigatran etexilate mesylate 3

QL 60 / 30 days qc aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days sb aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days sb low dose asa ec tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days st joseph aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days tgt aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days tgt aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

ticlopidine hcl tab 250 mg 1

warfarin sodium tab 1 mg 1

warfarin sodium tab 10 mg 1

warfarin sodium tab 2 mg 1

warfarin sodium tab 2.5 mg 1

warfarin sodium tab 3 mg 1

warfarin sodium tab 4 mg 1

PAGE 45 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

warfarin sodium tab 5 mg 1

warfarin sodium tab 6 mg 1

warfarin sodium tab 7.5 mg 1 XARELTO TAB 10 MG PA rivaroxaban 3 XARELTO TAB 15 MG PA rivaroxaban 3 XARELTO TAB 20 MG PA rivaroxaban 3 ARANESP (ALBUMIN FREE) SOLUTION 100 MCG/0.5ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 100 MCG/ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 150 MCG/0.3ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 150 MCG/0.75ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 200 MCG/0.4ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 200 MCG/ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 25 MCG/0.42ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 25 MCG/ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 300 MCG/0.6ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 300 MCG/ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 40 MCG/0.4ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 40 MCG/ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 500 MCG/ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 60 MCG/0.3ML PA darbepoetin alfa-polysorbate 80 4 ARANESP (ALBUMIN FREE) SOLUTION 60 MCG/ML PA darbepoetin alfa-polysorbate 80 4

PAGE 46 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cvs iron tab 240 (27 fe) mg 5

cvs iron tab 325 (65 fe) mg 5

cyanocobalamin solution 1000 mcg/ml 1

dexferrum solution 50 mg/ml 1 PA

EPOGEN SOLUTION 10000 UNIT/ML PA epoetin alfa 4 EPOGEN SOLUTION 2000 UNIT/ML PA epoetin alfa 4 EPOGEN SOLUTION 20000 UNIT/ML PA epoetin alfa 4 EPOGEN SOLUTION 3000 UNIT/ML PA epoetin alfa 4 EPOGEN SOLUTION 4000 UNIT/ML PA epoetin alfa 4

eql iron supplement therapy tab 325 mg 5

fe tabs tab dr 325 (65 fe) mg 5

feosol tab 325 (65 fe) mg 5

ferate tab 240 (27 fe) mg 5

ferosul elixir 220 (44 fe) mg/5ml 5

ferotrinsic cap 1 FERRAPLUS 90 TAB 90-1 MG iron-folic acid-vitamin b12-vitamin c-docusate sodium 1

ferrogels forte cap 460-60-0.01-1 mg 1

ferrotabs tab 240 mg 5

ferrous gluconate tab 240 (27 fe) mg 5

ferrous sulfate elixir 220 (44 fe) mg/5ml 5

ferrous sulfate tab 325 (65 fe) mg 5

ferrous sulfate tab dr 325 (65 fe) mg 5

ferrousul tab 325 (65 fe) mg 5

gnp b-12 sl tab 2500 mcg 5

hematinic/folic acid tab 324-1 mg 1 HEMATOGEN FA CAP 200-250-0.01-1 MG fe fumarate-vitamin c-vitamin b12-folic acid 1

hematogen forte cap 460-60-0.01-1 mg 1

PAGE 47 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hemocyte-f tab 324-1 mg 1 HYDROXOCOBALAMIN SOLUTION 1000 MCG/ML hydroxocobalamin 1

iferex 150 forte cap 150-25-1 mg-mcg-mg 1 INFED SOLUTION 50 MG/ML PA iron dextran 4

iron supplement tab 325 (65 fe) mg 5

iron tab 240 (27 fe) mg 5

iron tab 325 (65 fe) mg 5

kp ferrous sulfate tab 325 (65 fe) mg 5 LEUKINE RECON SOLN 250 MCG PA sargramostim 4

meijer ferrous sulfate tab 325 (65 fe) mg 5 MULTI PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 NEUMEGA RECON SOLN 5 MG PA oprelvekin 4 NEUPOGEN SOLUTION 300 MCG/0.5ML PA filgrastim 4 NEUPOGEN SOLUTION 300 MCG/ML PA filgrastim 4 NEUPOGEN SOLUTION 480 MCG/0.8ML PA filgrastim 4 OMONTYS SOLUTION 10 MG/ML PA peginesatide acetate 4

pentoxifylline er tab er 400 mg 1 QL 90 / 30 days

PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1

poly-iron 150 forte cap 150-25-1 mg-mcg-mg 1 PRENATAL 19 TAB prenatal vit w/ docusate-fe fumarate-folic acid 1 PRENATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1 PRENATAL LOW IRON TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 PRENATAL ONE DAILY TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5

PAGE 48 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 PROCRIT SOLUTION 10000 UNIT/ML PA epoetin alfa 4 PROCRIT SOLUTION 2000 UNIT/ML PA epoetin alfa 4 PROCRIT SOLUTION 20000 UNIT/ML PA epoetin alfa 4 PROCRIT SOLUTION 3000 UNIT/ML PA epoetin alfa 4 PROCRIT SOLUTION 4000 UNIT/ML PA epoetin alfa 4 PROCRIT SOLUTION 40000 UNIT/ML PA epoetin alfa 4

qc ferrous sulfate tab 325 (65 fe) mg 5

ra iron tab 325 (65 fe) mg 5 RIGHT STEP PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 SE-NATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1

sm iron tab 325 (65 fe) mg 5 TANDEM F CAP 162-115.2-1 MG ferrous fumarate-iron polysaccharide complex-folic acid 1 TARON-PREX CAP 30-1.2-265 MG prenatal w/o vit a w/ fe fumarate-dss-fa-dha 1

th iron tab 325 (65 fe) mg 5 Cardiovascular Drugs

Antilipemic Agents

atorvastatin calcium tab 10 mg 1 QL 30 / 30 days

atorvastatin calcium tab 20 mg 1 QL 30 / 30 days

atorvastatin calcium tab 40 mg 1 QL 30 / 30 days

atorvastatin calcium tab 80 mg 1 QL 30 / 30 days

cholestyramine light packet 4 gm 1

cholestyramine light powder 4 gm/dose 1

colestipol hcl granules 5 gm 1

PAGE 49 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

colestipol hcl packet 5 gm 1

colestipol hcl tab 1 gm 1

CRESTOR TAB 10 MG QL 30 / 30 days 3 rosuvastatin calcium ST

CRESTOR TAB 20 MG QL 30 / 30 days 3 rosuvastatin calcium ST

CRESTOR TAB 40 MG QL 30 / 30 days 3 rosuvastatin calcium ST

CRESTOR TAB 5 MG QL 30 / 30 days 3 rosuvastatin calcium ST

fenofibrate micronized cap 130 mg 1

fenofibrate micronized cap 134 mg 1

fenofibrate micronized cap 200 mg 1

fenofibrate micronized cap 43 mg 1

fenofibrate micronized cap 67 mg 1

fenofibrate tab 145 mg 1 PA

fenofibrate tab 160 mg 1

fenofibrate tab 48 mg 1 PA

fenofibrate tab 54 mg 1 FENOFIBRIC ACID TAB 105 MG fenofibric acid 1 FENOFIBRIC ACID TAB 35 MG fenofibric acid 1

fluvastatin sodium cap 20 mg 3

fluvastatin sodium cap 40 mg 3

gemfibrozil tab 600 mg 1 LIPOFEN CAP 150 MG PA fenofibrate 3 LIPOFEN CAP 50 MG PA fenofibrate 3 LIVALO TAB 1 MG ST pitavastatin calcium 3 LIVALO TAB 2 MG ST pitavastatin calcium 3

PAGE 50 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LIVALO TAB 4 MG ST pitavastatin calcium 3

lovastatin tab 10 mg 1

lovastatin tab 20 mg 1

lovastatin tab 40 mg 1 LOVAZA CAP 1 GM PA omega-3-acid ethyl esters 3

micronized colestipol hcl tab 1 gm 1 NIASPAN TAB ER 1000 MG niacin (antihyperlipidemic) 3 NIASPAN TAB ER 500 MG niacin (antihyperlipidemic) 3 NIASPAN TAB ER 750 MG niacin (antihyperlipidemic) 3

pravastatin sodium tab 10 mg 1

pravastatin sodium tab 20 mg 1

pravastatin sodium tab 40 mg 1

pravastatin sodium tab 80 mg 1

prevalite packet 4 gm 1

prevalite powder 4 gm/dose 1

simvastatin tab 10 mg 1

simvastatin tab 20 mg 1

simvastatin tab 40 mg 1

simvastatin tab 5 mg 1

simvastatin tab 80 mg 1 PA

TRIGLIDE TAB 160 MG PA fenofibrate 3 TRILIPIX CAP DR 135 MG PA choline fenofibrate 3 TRILIPIX CAP DR 45 MG PA choline fenofibrate 3 VYTORIN TAB 10-10 MG ST ezetimibe-simvastatin 3 VYTORIN TAB 10-20 MG ST ezetimibe-simvastatin 3

PAGE 51 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VYTORIN TAB 10-40 MG ST ezetimibe-simvastatin 3 VYTORIN TAB 10-80 MG ST ezetimibe-simvastatin 3 WELCHOL PACKET 3.75 GM PA colesevelam hcl 3 WELCHOL TAB 625 MG PA colesevelam hcl 3 ZETIA TAB 10 MG PA ezetimibe 3 Calcium-Channel Blocking Agents

afeditab cr tab er 24h 30 mg 1 QL 30 / 30 days

afeditab cr tab er 24h 60 mg 1 QL 30 / 30 days

amlodipine besy-benazepril hcl cap 10-20 mg 1

amlodipine besy-benazepril hcl cap 10-40 mg 1

amlodipine besy-benazepril hcl cap 2.5-10 mg 1

amlodipine besy-benazepril hcl cap 5-10 mg 1

amlodipine besy-benazepril hcl cap 5-20 mg 1

amlodipine besy-benazepril hcl cap 5-40 mg 1

amlodipine besylate tab 10 mg 1 QL 30 / 30 days

amlodipine besylate tab 2.5 mg 1 QL 30 / 30 days

amlodipine besylate tab 5 mg 1 QL 30 / 30 days

amlodipine besylate-valsartan tab 10-160 mg 3 ST

amlodipine besylate-valsartan tab 10-320 mg 3 ST

amlodipine besylate-valsartan tab 5-160 mg 3 ST

amlodipine besylate-valsartan tab 5-320 mg 3 ST

AZOR TAB 10-20 MG ST amlodipine besylate-olmesartan medoxomil 3 AZOR TAB 10-40 MG ST amlodipine besylate-olmesartan medoxomil 3 AZOR TAB 5-20 MG ST amlodipine besylate-olmesartan medoxomil 3 AZOR TAB 5-40 MG ST amlodipine besylate-olmesartan medoxomil 3

PAGE 52 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cartia xt cap er 24h 120 mg 1 QL 30 / 30 days

cartia xt cap er 24h 180 mg 1 QL 30 / 30 days

cartia xt cap er 24h 240 mg 1 QL 30 / 30 days

cartia xt cap er 24h 300 mg 1 QL 30 / 30 days

dilt-xr cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 120 mg 1 QL 60 / 30 days

diltiazem cd cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 360 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 420 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 12h 120 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 60 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 90 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 24h 120 mg 1

diltiazem hcl er cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 300 mg 1 QL 30 / 30 days

diltiazem hcl tab 120 mg 1

diltiazem hcl tab 30 mg 1

diltiazem hcl tab 60 mg 1

diltiazem hcl tab 90 mg 1

felodipine er tab er 24h 10 mg 1 QL 30 / 30 days

felodipine er tab er 24h 2.5 mg 1 QL 30 / 30 days

felodipine er tab er 24h 5 mg 1 QL 30 / 30 days

PAGE 53 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

isradipine cap 2.5 mg 1

isradipine cap 5 mg 1

nicardipine hcl cap 20 mg 1

nicardipine hcl cap 30 mg 1

nifediac cc tab er 24h 30 mg 1 QL 30 / 30 days

nifediac cc tab er 24h 60 mg 1 QL 30 / 30 days

nifedical xl tab er 24h 30 mg 1 QL 30 / 30 days

nifedical xl tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine cap 10 mg 1

nifedipine cap 20 mg 1

nifedipine er osmotic tab er 24h 30 mg 1 QL 30 / 30 days

nifedipine er osmotic tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine er osmotic tab er 24h 90 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 30 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 90 mg 1 QL 30 / 30 days

nimodipine cap 30 mg 1

nisoldipine er tab er 24h 17 mg 1 NISOLDIPINE ER TAB ER 24H 20 MG nisoldipine 1

nisoldipine er tab er 24h 25.5 mg 1 NISOLDIPINE ER TAB ER 24H 25.5 MG nisoldipine 1 NISOLDIPINE ER TAB ER 24H 30 MG nisoldipine 1

nisoldipine er tab er 24h 34 mg 1 NISOLDIPINE ER TAB ER 24H 40 MG nisoldipine 1

nisoldipine er tab er 24h 8.5 mg 1 TARKA TAB ER 1-240 MG ST trandolapril-verapamil hcl 3

PAGE 54 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TARKA TAB ER 2-180 MG ST trandolapril-verapamil hcl 3 TARKA TAB ER 2-240 MG ST trandolapril-verapamil hcl 3 TARKA TAB ER 4-240 MG ST trandolapril-verapamil hcl 3

taztia xt cap er 24h 120 mg 1 QL 30 / 30 days

taztia xt cap er 24h 180 mg 1 QL 30 / 30 days

taztia xt cap er 24h 240 mg 1 QL 30 / 30 days

taztia xt cap er 24h 300 mg 1 QL 30 / 30 days

taztia xt cap er 24h 360 mg 1 QL 30 / 30 days

verapamil hcl er cap er 24h 100 mg 1

verapamil hcl er cap er 24h 120 mg 1

verapamil hcl er cap er 24h 180 mg 1

verapamil hcl er cap er 24h 200 mg 1

verapamil hcl er cap er 24h 240 mg 1

verapamil hcl er cap er 24h 300 mg 1

verapamil hcl er cap er 24h 360 mg 1

verapamil hcl er tab er 120 mg 1 QL 30 / 30 days

verapamil hcl er tab er 180 mg 1 QL 30 / 30 days

verapamil hcl er tab er 240 mg 1 QL 30 / 30 days

verapamil hcl tab 120 mg 1 VERAPAMIL HCL TAB 40 MG verapamil hcl 1

verapamil hcl tab 80 mg 1 Cardiac Drugs

acebutolol hcl cap 200 mg 1

acebutolol hcl cap 400 mg 1

amiodarone hcl tab 200 mg 1

amiodarone hcl tab 400 mg 1

atenolol tab 100 mg 1

PAGE 55 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

atenolol tab 25 mg 1

atenolol tab 50 mg 1

betaxolol hcl tab 10 mg 1

betaxolol hcl tab 20 mg 1

bisoprolol fumarate tab 10 mg 1

bisoprolol fumarate tab 5 mg 1

cartia xt cap er 24h 120 mg 1 QL 30 / 30 days

cartia xt cap er 24h 180 mg 1 QL 30 / 30 days

cartia xt cap er 24h 240 mg 1 QL 30 / 30 days

cartia xt cap er 24h 300 mg 1 QL 30 / 30 days

carvedilol tab 12.5 mg 1

carvedilol tab 25 mg 1

carvedilol tab 3.125 mg 1

carvedilol tab 6.25 mg 1 COREG CR CAP ER 24H 10 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 20 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 40 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 80 MG ST carvedilol phosphate 3

digitek tab 250 mcg 1

digox tab 250 mcg 1 DIGOXIN SOLUTION 0.05 MG/ML digoxin 1

digoxin tab 125 mcg 1

digoxin tab 250 mcg 1 DILANTIN CAP 100 MG phenytoin sodium extended 2 DILANTIN CAP 30 MG phenytoin sodium extended 2

dilt-xr cap er 24h 120 mg 1 QL 30 / 30 days

PAGE 56 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diltiazem cd cap er 24h 120 mg 1 QL 60 / 30 days

diltiazem cd cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 360 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 420 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 12h 120 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 60 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 90 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 24h 120 mg 1

diltiazem hcl er cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 300 mg 1 QL 30 / 30 days

diltiazem hcl tab 120 mg 1

diltiazem hcl tab 30 mg 1

diltiazem hcl tab 60 mg 1

diltiazem hcl tab 90 mg 1

disopyramide phosphate cap 100 mg 1

disopyramide phosphate cap 150 mg 1

flecainide acetate tab 100 mg 1

flecainide acetate tab 150 mg 1

flecainide acetate tab 50 mg 1

labetalol hcl tab 100 mg 1

labetalol hcl tab 200 mg 1

labetalol hcl tab 300 mg 1 LANOXIN TAB 250 MCG digoxin 1

PAGE 57 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metoprolol succinate er tab er 24h 100 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 200 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 25 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 50 mg 1 QL 30 / 30 days

metoprolol tartrate tab 100 mg 1

metoprolol tartrate tab 25 mg 1

metoprolol tartrate tab 50 mg 1

mexiletine hcl cap 150 mg 1

mexiletine hcl cap 200 mg 1

mexiletine hcl cap 250 mg 1 MULTAQ TAB 400 MG PA dronedarone hcl 3 NORPACE CR CAP ER 12H 100 MG disopyramide phosphate 3

pacerone tab 100 mg 3 PA

pacerone tab 200 mg 1

phenytoin chew tab 50 mg 1

phenytoin infatabs chew tab 50 mg 1

phenytoin sodium extended cap 100 mg 1

phenytoin sodium extended cap 200 mg 1

phenytoin sodium extended cap 300 mg 1

phenytoin sodium solution 50 mg/ml 1

phenytoin suspension 125 mg/5ml 1

pindolol tab 10 mg 1

pindolol tab 5 mg 1

propafenone hcl er cap er 12h 225 mg 3

propafenone hcl er cap er 12h 325 mg 3

propafenone hcl er cap er 12h 425 mg 3

propafenone hcl tab 150 mg 1

propafenone hcl tab 225 mg 1

propafenone hcl tab 300 mg 1

PAGE 58 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

propranolol hcl er cap er 24h 120 mg 1 ST

propranolol hcl er cap er 24h 160 mg 1 ST

propranolol hcl er cap er 24h 60 mg 1 ST

propranolol hcl er cap er 24h 80 mg 1 ST

PROPRANOLOL HCL SOLUTION 20 MG/5ML propranolol hcl 1 PROPRANOLOL HCL SOLUTION 40 MG/5ML propranolol hcl 1

propranolol hcl tab 10 mg 1

propranolol hcl tab 20 mg 1

propranolol hcl tab 40 mg 1

propranolol hcl tab 60 mg 1

propranolol hcl tab 80 mg 1

quinidine gluconate er tab er 324 mg 1 QUINIDINE SULFATE ER TAB ER 300 MG quinidine sulfate 1

quinidine sulfate tab 200 mg 1 QUINIDINE SULFATE TAB 200 MG quinidine sulfate 1

quinidine sulfate tab 300 mg 1 RANEXA TAB ER 12H 1000 MG PA ranolazine 3 RANEXA TAB ER 12H 500 MG PA ranolazine 3

sorine tab 120 mg 1

sorine tab 160 mg 1

sorine tab 240 mg 1

sorine tab 80 mg 1

sotalol hcl tab 120 mg 1

sotalol hcl tab 160 mg 1

sotalol hcl tab 240 mg 1

sotalol hcl tab 80 mg 1

taztia xt cap er 24h 120 mg 1 QL 30 / 30 days

PAGE 59 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

taztia xt cap er 24h 180 mg 1 QL 30 / 30 days

taztia xt cap er 24h 240 mg 1 QL 30 / 30 days

taztia xt cap er 24h 300 mg 1 QL 30 / 30 days

taztia xt cap er 24h 360 mg 1 QL 30 / 30 days

TIMOLOL MALEATE TAB 10 MG timolol maleate 1 TIMOLOL MALEATE TAB 20 MG timolol maleate 1 TIMOLOL MALEATE TAB 5 MG timolol maleate 1

verapamil hcl er cap er 24h 100 mg 1

verapamil hcl er cap er 24h 120 mg 1

verapamil hcl er cap er 24h 180 mg 1

verapamil hcl er cap er 24h 200 mg 1

verapamil hcl er cap er 24h 240 mg 1

verapamil hcl er cap er 24h 300 mg 1

verapamil hcl er cap er 24h 360 mg 1

verapamil hcl er tab er 120 mg 1 QL 30 / 30 days

verapamil hcl er tab er 180 mg 1 QL 30 / 30 days

verapamil hcl er tab er 240 mg 1 QL 30 / 30 days

verapamil hcl tab 120 mg 1 VERAPAMIL HCL TAB 40 MG verapamil hcl 1

verapamil hcl tab 80 mg 1

acebutolol hcl cap 200 mg 1

acebutolol hcl cap 400 mg 1

atenolol tab 100 mg 1

atenolol tab 25 mg 1

atenolol tab 50 mg 1

atenolol-chlorthalidone tab 100-25 mg 1

atenolol-chlorthalidone tab 50-25 mg 1

betaxolol hcl tab 10 mg 1

PAGE 60 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

betaxolol hcl tab 20 mg 1

bisoprolol fumarate tab 10 mg 1

bisoprolol fumarate tab 5 mg 1

bisoprolol-hydrochlorothiazide tab 10-6.25 mg 1

bisoprolol-hydrochlorothiazide tab 2.5-6.25 mg 1

bisoprolol-hydrochlorothiazide tab 5-6.25 mg 1 BYSTOLIC TAB 10 MG ST nebivolol hcl 3 BYSTOLIC TAB 2.5 MG ST nebivolol hcl 3 BYSTOLIC TAB 20 MG ST nebivolol hcl 3 BYSTOLIC TAB 5 MG ST nebivolol hcl 3 CARDURA XL TAB ER 24H 4 MG doxazosin mesylate (bph) 3

carvedilol tab 12.5 mg 1

carvedilol tab 25 mg 1

carvedilol tab 3.125 mg 1

carvedilol tab 6.25 mg 1 COREG CR CAP ER 24H 10 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 20 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 40 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 80 MG ST carvedilol phosphate 3

doxazosin mesylate tab 1 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 2 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 4 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 8 mg 1 AL Up to 64 yrs old

labetalol hcl tab 100 mg 1

labetalol hcl tab 200 mg 1

PAGE 61 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

labetalol hcl tab 300 mg 1 LEVATOL TAB 20 MG PA penbutolol sulfate 3

metoprolol succinate er tab er 24h 100 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 200 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 25 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 50 mg 1 QL 30 / 30 days

metoprolol tartrate tab 100 mg 1

metoprolol tartrate tab 25 mg 1

metoprolol tartrate tab 50 mg 1

metoprolol-hydrochlorothiazide tab 100-25 mg 1

metoprolol-hydrochlorothiazide tab 100-50 mg 1

metoprolol-hydrochlorothiazide tab 50-25 mg 1

nadolol tab 20 mg 1

nadolol tab 40 mg 1

nadolol tab 80 mg 1

nadolol-bendroflumethiazide tab 40-5 mg 1

nadolol-bendroflumethiazide tab 80-5 mg 1

pindolol tab 10 mg 1

pindolol tab 5 mg 1

prazosin hcl cap 1 mg 1

prazosin hcl cap 2 mg 1

prazosin hcl cap 5 mg 1

propranolol hcl er cap er 24h 120 mg 1 ST

propranolol hcl er cap er 24h 160 mg 1 ST

propranolol hcl er cap er 24h 60 mg 1 ST

propranolol hcl er cap er 24h 80 mg 1 ST

PROPRANOLOL HCL SOLUTION 20 MG/5ML propranolol hcl 1 PROPRANOLOL HCL SOLUTION 40 MG/5ML propranolol hcl 1

PAGE 62 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

propranolol hcl tab 10 mg 1

propranolol hcl tab 20 mg 1

propranolol hcl tab 40 mg 1

propranolol hcl tab 60 mg 1

propranolol hcl tab 80 mg 1 PROPRANOLOL-HCTZ TAB 40-25 MG propranolol & hydrochlorothiazide 1 PROPRANOLOL-HCTZ TAB 80-25 MG propranolol & hydrochlorothiazide 1

sorine tab 120 mg 1

sorine tab 160 mg 1

sorine tab 240 mg 1

sorine tab 80 mg 1

sotalol hcl tab 120 mg 1

sotalol hcl tab 160 mg 1

sotalol hcl tab 240 mg 1

sotalol hcl tab 80 mg 1

terazosin hcl cap 1 mg 1 AL Up to 64 yrs old

terazosin hcl cap 10 mg 1 AL Up to 64 yrs old

terazosin hcl cap 2 mg 1 AL Up to 64 yrs old

terazosin hcl cap 5 mg 1 AL Up to 64 yrs old

TIMOLOL MALEATE TAB 10 MG timolol maleate 1 TIMOLOL MALEATE TAB 20 MG timolol maleate 1 TIMOLOL MALEATE TAB 5 MG timolol maleate 1 Hypotensive Agents

acebutolol hcl cap 200 mg 1

acebutolol hcl cap 400 mg 1

acetazolamide er cap er 12h 500 mg 1 ACETAZOLAMIDE TAB 125 MG acetazolamide 1

PAGE 63 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

acetazolamide tab 250 mg 1

afeditab cr tab er 24h 30 mg 1 QL 30 / 30 days

afeditab cr tab er 24h 60 mg 1 QL 30 / 30 days

amiloride hcl tab 5 mg 1

amlodipine besylate tab 10 mg 1 QL 30 / 30 days

amlodipine besylate tab 2.5 mg 1 QL 30 / 30 days

amlodipine besylate tab 5 mg 1 QL 30 / 30 days

atenolol tab 100 mg 1

atenolol tab 25 mg 1

atenolol tab 50 mg 1

benazepril hcl tab 10 mg 1

benazepril hcl tab 20 mg 1

benazepril hcl tab 40 mg 1

benazepril hcl tab 5 mg 1 BENICAR TAB 20 MG olmesartan medoxomil 3 BENICAR TAB 40 MG olmesartan medoxomil 3 BENICAR TAB 5 MG olmesartan medoxomil 3

betaxolol hcl tab 10 mg 1

betaxolol hcl tab 20 mg 1

bisoprolol fumarate tab 10 mg 1

bisoprolol fumarate tab 5 mg 1

bumetanide solution 0.25 mg/ml 1

bumetanide tab 0.5 mg 1

bumetanide tab 1 mg 1

bumetanide tab 2 mg 1

captopril tab 100 mg 1

captopril tab 12.5 mg 1

captopril tab 25 mg 1

captopril tab 50 mg 1

PAGE 64 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDURA XL TAB ER 24H 4 MG doxazosin mesylate (bph) 3

cartia xt cap er 24h 120 mg 1 QL 30 / 30 days

cartia xt cap er 24h 180 mg 1 QL 30 / 30 days

cartia xt cap er 24h 240 mg 1 QL 30 / 30 days

cartia xt cap er 24h 300 mg 1 QL 30 / 30 days

carvedilol tab 12.5 mg 1

carvedilol tab 25 mg 1

carvedilol tab 3.125 mg 1

carvedilol tab 6.25 mg 1

chlorothiazide tab 250 mg 1 CHLOROTHIAZIDE TAB 250 MG chlorothiazide 1

chlorothiazide tab 500 mg 1 CHLORTHALIDONE TAB 25 MG chlorthalidone 1 CHLORTHALIDONE TAB 50 MG chlorthalidone 1

clonidine hcl patch wk 0.1 mg/24hr 3

clonidine hcl patch wk 0.2 mg/24hr 3

clonidine hcl patch wk 0.3 mg/24hr 3

clonidine hcl tab 0.1 mg 1

clonidine hcl tab 0.2 mg 1

clonidine hcl tab 0.3 mg 1 COREG CR CAP ER 24H 10 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 20 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 40 MG ST carvedilol phosphate 3 COREG CR CAP ER 24H 80 MG ST carvedilol phosphate 3 DIBENZYLINE CAP 10 MG PA phenoxybenzamine hcl 3

PAGE 65 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dilt-xr cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 120 mg 1 QL 60 / 30 days

diltiazem cd cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 360 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 420 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 12h 120 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 60 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 90 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 24h 120 mg 1

diltiazem hcl er cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 300 mg 1 QL 30 / 30 days

diltiazem hcl tab 120 mg 1

diltiazem hcl tab 30 mg 1

diltiazem hcl tab 60 mg 1

diltiazem hcl tab 90 mg 1

doxazosin mesylate tab 1 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 2 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 4 mg 1 AL Up to 64 yrs old

doxazosin mesylate tab 8 mg 1 AL Up to 64 yrs old

DYRENIUM CAP 100 MG triamterene 3 EDARBI TAB 40 MG PA azilsartan medoxomil 3

PAGE 66 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EDARBI TAB 80 MG PA azilsartan medoxomil 3 EDECRIN TAB 25 MG ethacrynic acid 3 ELIXOPHYLLIN ELIXIR 80 MG/15ML theophylline 2

enalapril maleate tab 10 mg 1

enalapril maleate tab 2.5 mg 1

enalapril maleate tab 20 mg 1

enalapril maleate tab 5 mg 1

eplerenone tab 25 mg 3

eplerenone tab 50 mg 3

eprosartan mesylate tab 600 mg 1 PA

felodipine er tab er 24h 10 mg 1 QL 30 / 30 days

felodipine er tab er 24h 2.5 mg 1 QL 30 / 30 days

felodipine er tab er 24h 5 mg 1 QL 30 / 30 days

fosinopril sodium tab 10 mg 1

fosinopril sodium tab 20 mg 1

fosinopril sodium tab 40 mg 1

furosemide solution 10 mg/ml 1

furosemide solution 10 mg/ml 1 FUROSEMIDE SOLUTION 8 MG/ML furosemide 1

furosemide tab 20 mg 1

furosemide tab 40 mg 1

furosemide tab 80 mg 1

guanfacine hcl tab 1 mg 1

guanfacine hcl tab 2 mg 1

hydralazine hcl tab 10 mg 1

hydralazine hcl tab 100 mg 1

hydralazine hcl tab 25 mg 1

hydralazine hcl tab 50 mg 1

PAGE 67 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrochlorothiazide cap 12.5 mg 1

hydrochlorothiazide tab 12.5 mg 1

hydrochlorothiazide tab 25 mg 1

hydrochlorothiazide tab 50 mg 1

indapamide tab 1.25 mg 1

indapamide tab 2.5 mg 1

irbesartan tab 150 mg 3 QL 30 / 30 days

irbesartan tab 300 mg 3 QL 30 / 30 days

irbesartan tab 75 mg 3 QL 30 / 30 days

isradipine cap 2.5 mg 1

isradipine cap 5 mg 1

labetalol hcl tab 100 mg 1

labetalol hcl tab 200 mg 1

labetalol hcl tab 300 mg 1

lisinopril tab 10 mg 1

lisinopril tab 2.5 mg 1

lisinopril tab 20 mg 1

lisinopril tab 30 mg 1

lisinopril tab 40 mg 1

lisinopril tab 5 mg 1

losartan potassium tab 100 mg 1 QL 30 / 30 days

losartan potassium tab 25 mg 1 QL 30 / 30 days

losartan potassium tab 50 mg 1 QL 30 / 30 days

METHYCLOTHIAZIDE TAB 5 MG methyclothiazide 1

methyldopa tab 250 mg 1

methyldopa tab 500 mg 1

metolazone tab 10 mg 1

metolazone tab 2.5 mg 1

metolazone tab 5 mg 1

metoprolol succinate er tab er 24h 100 mg 1 QL 30 / 30 days

PAGE 68 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metoprolol succinate er tab er 24h 200 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 25 mg 1 QL 30 / 30 days

metoprolol succinate er tab er 24h 50 mg 1 QL 30 / 30 days

metoprolol tartrate tab 100 mg 1

metoprolol tartrate tab 25 mg 1

metoprolol tartrate tab 50 mg 1 MICARDIS TAB 20 MG telmisartan 3 MICARDIS TAB 40 MG telmisartan 3 MICARDIS TAB 80 MG telmisartan 3

minoxidil tab 10 mg 1

minoxidil tab 2.5 mg 1

moexipril hcl tab 15 mg 1

moexipril hcl tab 7.5 mg 1

nadolol tab 20 mg 1

nadolol tab 40 mg 1

nadolol tab 80 mg 1

nicardipine hcl cap 20 mg 1

nicardipine hcl cap 30 mg 1

nifediac cc tab er 24h 30 mg 1 QL 30 / 30 days

nifediac cc tab er 24h 60 mg 1 QL 30 / 30 days

nifedical xl tab er 24h 30 mg 1 QL 30 / 30 days

nifedical xl tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine cap 10 mg 1

nifedipine cap 20 mg 1

nifedipine er osmotic tab er 24h 30 mg 1 QL 30 / 30 days

nifedipine er osmotic tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine er osmotic tab er 24h 90 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 30 mg 1 QL 30 / 30 days

PAGE 69 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nifedipine er tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 90 mg 1 QL 30 / 30 days

nimodipine cap 30 mg 1

nisoldipine er tab er 24h 17 mg 1 NISOLDIPINE ER TAB ER 24H 20 MG nisoldipine 1

nisoldipine er tab er 24h 25.5 mg 1 NISOLDIPINE ER TAB ER 24H 25.5 MG nisoldipine 1 NISOLDIPINE ER TAB ER 24H 30 MG nisoldipine 1

nisoldipine er tab er 24h 34 mg 1 NISOLDIPINE ER TAB ER 24H 40 MG nisoldipine 1

nisoldipine er tab er 24h 8.5 mg 1

perindopril erbumine tab 2 mg 1

perindopril erbumine tab 4 mg 1

perindopril erbumine tab 8 mg 1

pindolol tab 10 mg 1

pindolol tab 5 mg 1

prazosin hcl cap 1 mg 1

prazosin hcl cap 2 mg 1

prazosin hcl cap 5 mg 1

propranolol hcl er cap er 24h 120 mg 1 ST

propranolol hcl er cap er 24h 160 mg 1 ST

propranolol hcl er cap er 24h 60 mg 1 ST

propranolol hcl er cap er 24h 80 mg 1 ST

PROPRANOLOL HCL SOLUTION 20 MG/5ML propranolol hcl 1 PROPRANOLOL HCL SOLUTION 40 MG/5ML propranolol hcl 1

propranolol hcl tab 10 mg 1

propranolol hcl tab 20 mg 1

PAGE 70 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

propranolol hcl tab 40 mg 1

propranolol hcl tab 60 mg 1

propranolol hcl tab 80 mg 1

quinapril hcl tab 10 mg 1

quinapril hcl tab 20 mg 1

quinapril hcl tab 40 mg 1

quinapril hcl tab 5 mg 1

ramipril cap 1.25 mg 1

ramipril cap 10 mg 1

ramipril cap 2.5 mg 1

ramipril cap 5 mg 1 RESERPINE TAB 0.1 MG reserpine 1 RESERPINE TAB 0.25 MG reserpine 1

sorine tab 120 mg 1

sorine tab 160 mg 1

sorine tab 240 mg 1

sorine tab 80 mg 1

sotalol hcl tab 120 mg 1

sotalol hcl tab 160 mg 1

sotalol hcl tab 240 mg 1

sotalol hcl tab 80 mg 1

spironolactone tab 100 mg 1

spironolactone tab 25 mg 1

spironolactone tab 50 mg 1

taztia xt cap er 24h 120 mg 1 QL 30 / 30 days

taztia xt cap er 24h 180 mg 1 QL 30 / 30 days

taztia xt cap er 24h 240 mg 1 QL 30 / 30 days

taztia xt cap er 24h 300 mg 1 QL 30 / 30 days

taztia xt cap er 24h 360 mg 1 QL 30 / 30 days

PAGE 71 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

terazosin hcl cap 1 mg 1 AL Up to 64 yrs old

terazosin hcl cap 10 mg 1 AL Up to 64 yrs old

terazosin hcl cap 2 mg 1 AL Up to 64 yrs old

terazosin hcl cap 5 mg 1 AL Up to 64 yrs old

theochron tab er 12h 100 mg 1

theochron tab er 12h 200 mg 1

theochron tab er 12h 300 mg 1

theophylline er tab er 12h 100 mg 1

theophylline er tab er 12h 200 mg 1

theophylline er tab er 12h 300 mg 1

theophylline er tab er 12h 450 mg 1

theophylline er tab er 24h 400 mg 1

theophylline er tab er 24h 600 mg 1

theophylline solution 80 mg/15ml 1 TIMOLOL MALEATE TAB 10 MG timolol maleate 1 TIMOLOL MALEATE TAB 20 MG timolol maleate 1 TIMOLOL MALEATE TAB 5 MG timolol maleate 1

torsemide tab 10 mg 1

torsemide tab 100 mg 1

torsemide tab 20 mg 1

torsemide tab 5 mg 1

trandolapril tab 1 mg 1 QL 30 / 30 days

trandolapril tab 2 mg 1 QL 30 / 30 days

trandolapril tab 4 mg 1 QL 30 / 30 days

valsartan tab 160 mg 1

valsartan tab 320 mg 1

valsartan tab 40 mg 1

valsartan tab 80 mg 1

PAGE 72 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

verapamil hcl er cap er 24h 100 mg 1

verapamil hcl er cap er 24h 120 mg 1

verapamil hcl er cap er 24h 180 mg 1

verapamil hcl er cap er 24h 200 mg 1

verapamil hcl er cap er 24h 240 mg 1

verapamil hcl er cap er 24h 300 mg 1

verapamil hcl er cap er 24h 360 mg 1

verapamil hcl er tab er 120 mg 1 QL 30 / 30 days

verapamil hcl er tab er 180 mg 1 QL 30 / 30 days

verapamil hcl er tab er 240 mg 1 QL 30 / 30 days

verapamil hcl tab 120 mg 1 VERAPAMIL HCL TAB 40 MG verapamil hcl 1

verapamil hcl tab 80 mg 1 Renin-Angiotensin-Aldosterone Sys Inhib

amlodipine besy-benazepril hcl cap 10-20 mg 1

amlodipine besy-benazepril hcl cap 10-40 mg 1

amlodipine besy-benazepril hcl cap 2.5-10 mg 1

amlodipine besy-benazepril hcl cap 5-10 mg 1

amlodipine besy-benazepril hcl cap 5-20 mg 1

amlodipine besy-benazepril hcl cap 5-40 mg 1

amlodipine besylate-valsartan tab 10-160 mg 3 ST

amlodipine besylate-valsartan tab 10-320 mg 3 ST

amlodipine besylate-valsartan tab 5-160 mg 3 ST

amlodipine besylate-valsartan tab 5-320 mg 3 ST

AZOR TAB 10-20 MG ST amlodipine besylate-olmesartan medoxomil 3 AZOR TAB 10-40 MG ST amlodipine besylate-olmesartan medoxomil 3 AZOR TAB 5-20 MG ST amlodipine besylate-olmesartan medoxomil 3

PAGE 73 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AZOR TAB 5-40 MG ST amlodipine besylate-olmesartan medoxomil 3

benazepril hcl tab 10 mg 1

benazepril hcl tab 20 mg 1

benazepril hcl tab 40 mg 1

benazepril hcl tab 5 mg 1

benazepril-hydrochlorothiazide tab 10-12.5 mg 1

benazepril-hydrochlorothiazide tab 20-12.5 mg 1

benazepril-hydrochlorothiazide tab 20-25 mg 1

benazepril-hydrochlorothiazide tab 5-6.25 mg 1 BENICAR HCT TAB 20-12.5 MG ST olmesartan medoxomil-hydrochlorothiazide 3 BENICAR HCT TAB 40-12.5 MG ST olmesartan medoxomil-hydrochlorothiazide 3 BENICAR HCT TAB 40-25 MG ST olmesartan medoxomil-hydrochlorothiazide 3 BENICAR TAB 20 MG olmesartan medoxomil 3 BENICAR TAB 40 MG olmesartan medoxomil 3 BENICAR TAB 5 MG olmesartan medoxomil 3

candesartan cilexetil-hctz tab 16-12.5 mg 1

candesartan cilexetil-hctz tab 32-12.5 mg 1

candesartan cilexetil-hctz tab 32-25 mg 1

captopril tab 100 mg 1

captopril tab 12.5 mg 1

captopril tab 25 mg 1

captopril tab 50 mg 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-15 MG captopril & hydrochlorothiazide 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-25 MG captopril & hydrochlorothiazide 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 50-15 MG captopril & hydrochlorothiazide 1

PAGE 74 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 50-25 MG captopril & hydrochlorothiazide 1 EDARBI TAB 40 MG PA azilsartan medoxomil 3 EDARBI TAB 80 MG PA azilsartan medoxomil 3

enalapril maleate tab 10 mg 1

enalapril maleate tab 2.5 mg 1

enalapril maleate tab 20 mg 1

enalapril maleate tab 5 mg 1

enalapril-hydrochlorothiazide tab 10-25 mg 1

enalapril-hydrochlorothiazide tab 5-12.5 mg 1

eplerenone tab 25 mg 3

eplerenone tab 50 mg 3

eprosartan mesylate tab 600 mg 1 PA

fosinopril sodium tab 10 mg 1

fosinopril sodium tab 20 mg 1

fosinopril sodium tab 40 mg 1

fosinopril sodium-hctz tab 10-12.5 mg 1

fosinopril sodium-hctz tab 20-12.5 mg 1

irbesartan tab 150 mg 3 QL 30 / 30 days

irbesartan tab 300 mg 3 QL 30 / 30 days

irbesartan tab 75 mg 3 QL 30 / 30 days

irbesartan-hydrochlorothiazide tab 150-12.5 mg 1

irbesartan-hydrochlorothiazide tab 300-12.5 mg 1

lisinopril tab 10 mg 1

lisinopril tab 2.5 mg 1

lisinopril tab 20 mg 1

lisinopril tab 30 mg 1

lisinopril tab 40 mg 1

lisinopril tab 5 mg 1

lisinopril-hydrochlorothiazide tab 10-12.5 mg 1

PAGE 75 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lisinopril-hydrochlorothiazide tab 20-12.5 mg 1

lisinopril-hydrochlorothiazide tab 20-25 mg 1

losartan potassium tab 100 mg 1 QL 30 / 30 days

losartan potassium tab 25 mg 1 QL 30 / 30 days

losartan potassium tab 50 mg 1 QL 30 / 30 days

losartan potassium-hctz tab 100-12.5 mg 1 QL 30 / 30 days

losartan potassium-hctz tab 100-25 mg 1 QL 30 / 30 days

losartan potassium-hctz tab 50-12.5 mg 1 QL 30 / 30 days

MICARDIS HCT TAB 40-12.5 MG ST telmisartan-hydrochlorothiazide 3 MICARDIS HCT TAB 80-12.5 MG ST telmisartan-hydrochlorothiazide 3 MICARDIS HCT TAB 80-25 MG ST telmisartan-hydrochlorothiazide 3 MICARDIS TAB 20 MG telmisartan 3 MICARDIS TAB 40 MG telmisartan 3 MICARDIS TAB 80 MG telmisartan 3

moexipril hcl tab 15 mg 1

moexipril hcl tab 7.5 mg 1

moexipril-hydrochlorothiazide tab 15-12.5 mg 1

moexipril-hydrochlorothiazide tab 15-25 mg 1

moexipril-hydrochlorothiazide tab 7.5-12.5 mg 1

perindopril erbumine tab 2 mg 1

perindopril erbumine tab 4 mg 1

perindopril erbumine tab 8 mg 1

quinapril hcl tab 10 mg 1

quinapril hcl tab 20 mg 1

quinapril hcl tab 40 mg 1

quinapril hcl tab 5 mg 1

quinapril-hydrochlorothiazide tab 10-12.5 mg 1

PAGE 76 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

quinapril-hydrochlorothiazide tab 20-12.5 mg 1

quinapril-hydrochlorothiazide tab 20-25 mg 1

ramipril cap 1.25 mg 1

ramipril cap 10 mg 1

ramipril cap 2.5 mg 1

ramipril cap 5 mg 1

spironolactone tab 100 mg 1

spironolactone tab 25 mg 1

spironolactone tab 50 mg 1

spironolactone-hctz tab 25-25 mg 1 TARKA TAB ER 1-240 MG ST trandolapril-verapamil hcl 3 TARKA TAB ER 2-180 MG ST trandolapril-verapamil hcl 3 TARKA TAB ER 2-240 MG ST trandolapril-verapamil hcl 3 TARKA TAB ER 4-240 MG ST trandolapril-verapamil hcl 3 TEKTURNA HCT TAB 150-12.5 MG aliskiren-hydrochlorothiazide 3 TEKTURNA HCT TAB 150-25 MG aliskiren-hydrochlorothiazide 3 TEKTURNA HCT TAB 300-12.5 MG aliskiren-hydrochlorothiazide 3 TEKTURNA HCT TAB 300-25 MG aliskiren-hydrochlorothiazide 3 TEKTURNA TAB 150 MG aliskiren fumarate 3 TEKTURNA TAB 300 MG aliskiren fumarate 3

trandolapril tab 1 mg 1 QL 30 / 30 days

trandolapril tab 2 mg 1 QL 30 / 30 days

trandolapril tab 4 mg 1 QL 30 / 30 days

valsartan tab 160 mg 1

valsartan tab 320 mg 1

PAGE 77 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

valsartan tab 40 mg 1

valsartan tab 80 mg 1

valsartan-hydrochlorothiazide tab 160-12.5 mg 1

valsartan-hydrochlorothiazide tab 160-25 mg 1

valsartan-hydrochlorothiazide tab 320-12.5 mg 1

valsartan-hydrochlorothiazide tab 320-25 mg 1

valsartan-hydrochlorothiazide tab 80-12.5 mg 1 Vasodilating Agents

ADCIRCA TAB 20 MG PA tadalafil (pulmonary hypertension) 4

afeditab cr tab er 24h 30 mg 1 QL 30 / 30 days

afeditab cr tab er 24h 60 mg 1 QL 30 / 30 days

alprostadil solution 500 mcg/ml 1

amlodipine besylate tab 10 mg 1 QL 30 / 30 days

amlodipine besylate tab 2.5 mg 1 QL 30 / 30 days

amlodipine besylate tab 5 mg 1 QL 30 / 30 days

cartia xt cap er 24h 120 mg 1 QL 30 / 30 days

cartia xt cap er 24h 180 mg 1 QL 30 / 30 days

cartia xt cap er 24h 240 mg 1 QL 30 / 30 days

cartia xt cap er 24h 300 mg 1 QL 30 / 30 days

CAVERJECT IMPULSE KIT 10 MCG PA alprostadil (vasodilator) 3 CAVERJECT IMPULSE KIT 20 MCG PA alprostadil (vasodilator) 3 CAVERJECT RECON SOLN 20 MCG PA alprostadil (vasodilator) 3 CAVERJECT RECON SOLN 40 MCG PA alprostadil (vasodilator) 3 CIALIS TAB 20 MG PA tadalafil 3 CIALIS TAB 5 MG PA tadalafil 3

PAGE 78 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cilostazol tab 100 mg 1

cilostazol tab 50 mg 1 DILATRATE-SR CAP ER 40 MG isosorbide dinitrate 3

dilt-xr cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 120 mg 1 QL 60 / 30 days

diltiazem cd cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem cd cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 360 mg 1 QL 30 / 30 days

diltiazem hcl er beads cap er 24h 420 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 12h 120 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 60 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 12h 90 mg 1 QL 60 / 30 days

diltiazem hcl er cap er 24h 120 mg 1

diltiazem hcl er cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 120 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 180 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 240 mg 1 QL 30 / 30 days

diltiazem hcl er coated beads cap er 24h 300 mg 1 QL 30 / 30 days

diltiazem hcl tab 120 mg 1

diltiazem hcl tab 30 mg 1

diltiazem hcl tab 60 mg 1

diltiazem hcl tab 90 mg 1

dipyridamole tab 25 mg 1

dipyridamole tab 50 mg 1

dipyridamole tab 75 mg 1 EDEX KIT 10 MCG PA alprostadil (vasodilator) 3

PAGE 79 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EDEX KIT 20 MCG PA alprostadil (vasodilator) 3

isoditrate er tab er 40 mg 1

isosorbide dinitrate er tab er 40 mg 1

isosorbide dinitrate tab 10 mg 1

isosorbide dinitrate tab 20 mg 1

isosorbide dinitrate tab 30 mg 1 ISOSORBIDE DINITRATE TAB 30 MG isosorbide dinitrate 1

isosorbide dinitrate tab 5 mg 1

isosorbide mononitrate er tab er 24h 120 mg 1

isosorbide mononitrate er tab er 24h 30 mg 1

isosorbide mononitrate er tab er 24h 60 mg 1

isosorbide mononitrate tab 10 mg 1

isosorbide mononitrate tab 20 mg 1

isoxsuprine hcl tab 10 mg 1 ISOXSUPRINE HCL TAB 10 MG isoxsuprine hcl 1

minitran patch 24hr 0.1 mg/hr 1

minitran patch 24hr 0.2 mg/hr 1

minitran patch 24hr 0.4 mg/hr 1

minitran patch 24hr 0.6 mg/hr 1 MUSE PELLET 1000 MCG PA alprostadil (vasodilator) 3 MUSE PELLET 125 MCG PA alprostadil (vasodilator) 3 MUSE PELLET 250 MCG PA alprostadil (vasodilator) 3 MUSE PELLET 500 MCG PA alprostadil (vasodilator) 3

nicardipine hcl cap 20 mg 1

nicardipine hcl cap 30 mg 1

nifediac cc tab er 24h 30 mg 1 QL 30 / 30 days

nifediac cc tab er 24h 60 mg 1 QL 30 / 30 days

PAGE 80 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nifedical xl tab er 24h 30 mg 1 QL 30 / 30 days

nifedical xl tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine cap 10 mg 1

nifedipine cap 20 mg 1

nifedipine er osmotic tab er 24h 30 mg 1 QL 30 / 30 days

nifedipine er osmotic tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine er osmotic tab er 24h 90 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 30 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 60 mg 1 QL 30 / 30 days

nifedipine er tab er 24h 90 mg 1 QL 30 / 30 days

nimodipine cap 30 mg 1 NITRO-BID OINTMENT 2 % nitroglycerin 3 NITRO-DUR PATCH 24HR 0.3 MG/HR nitroglycerin 3 NITRO-DUR PATCH 24HR 0.8 MG/HR nitroglycerin 3

nitro-time cap er 2.5 mg 1

nitro-time cap er 6.5 mg 1

nitro-time cap er 9 mg 1 NITROGLYCERIN AERO SOLN 400 MCG/SPRAY nitroglycerin 3

nitroglycerin er cap er 2.5 mg 1

nitroglycerin er cap er 6.5 mg 1

nitroglycerin er cap er 9 mg 1

nitroglycerin patch 24hr 0.1 mg/hr 1

nitroglycerin patch 24hr 0.2 mg/hr 1

nitroglycerin patch 24hr 0.4 mg/hr 1

nitroglycerin patch 24hr 0.6 mg/hr 1 NITROLINGUAL SOLUTION 0.4 MG/SPRAY nitroglycerin 3 NITROSTAT SL TAB 0.3 MG nitroglycerin 2

PAGE 81 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NITROSTAT SL TAB 0.4 MG nitroglycerin 2 NITROSTAT SL TAB 0.6 MG nitroglycerin 2

papaverine hcl solution 30 mg/ml 1 PA

sildenafil citrate tab 20 mg 4 PA

taztia xt cap er 24h 120 mg 1 QL 30 / 30 days

taztia xt cap er 24h 180 mg 1 QL 30 / 30 days

taztia xt cap er 24h 240 mg 1 QL 30 / 30 days

taztia xt cap er 24h 300 mg 1 QL 30 / 30 days

taztia xt cap er 24h 360 mg 1 QL 30 / 30 days

verapamil hcl er cap er 24h 100 mg 1

verapamil hcl er cap er 24h 120 mg 1

verapamil hcl er cap er 24h 180 mg 1

verapamil hcl er cap er 24h 200 mg 1

verapamil hcl er cap er 24h 240 mg 1

verapamil hcl er cap er 24h 300 mg 1

verapamil hcl er cap er 24h 360 mg 1

verapamil hcl er tab er 120 mg 1 QL 30 / 30 days

verapamil hcl er tab er 180 mg 1 QL 30 / 30 days

verapamil hcl er tab er 240 mg 1 QL 30 / 30 days

verapamil hcl tab 120 mg 1 VERAPAMIL HCL TAB 40 MG verapamil hcl 1

verapamil hcl tab 80 mg 1 Central Nervous System Agents

Analgesics and Antipyretics

acetaminophen extra strength tab 500 mg 1

acetaminophen-codeine #2 tab 300-15 mg 1 QL 390 / 30 days

acetaminophen-codeine #3 tab 300-30 mg 1 QL 390 / 30 days

PAGE 82 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

acetaminophen-codeine #4 tab 300-60 mg 1 QL 390 / 30 days

acetaminophen-codeine solution 120-12 mg/5ml 1

acetaminophen-codeine tab 300-15 mg 1 QL 390 / 30 days

acetaminophen-codeine tab 300-30 mg 1 QL 390 / 30 days

acetaminophen-codeine tab 300-60 mg 1 QL 390 / 30 days

QL 60 / 30 days adult aspirin ec low strength tab dr 81 mg 5 AL 40 to 79 yrs old

AGGRENOX CAP ER 12H 25-200 MG aspirin-dipyridamole 3

analgesic creme/aloe cream 10 % 1

ascomp-codeine cap 50-325-40-30 mg 1

QL 60 / 30 days aspir-low tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin adult low strength chew tab 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin adult low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin chew tab 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec lo-dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

PAGE 83 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 days aspirin low strength chew tab 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days aspirin tab 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

astramorph solution 0.5 mg/ml 3 PA

astramorph solution 1 mg/ml 3 PA

QL 60 / 30 days bayer aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer aspirin tab 325 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer aspirin tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days bayer low dose chew tab 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer low dose tab dr 81 mg 5 AL 40 to 79 yrs old

BELLADONNA ALKALOIDS-OPIUM SUPPOS 16.2-60 MG AL Up to 64 yrs old belladonna alkaloids & opium 1 BELLADONNA-OPIUM SUPPOS 16.2-30 MG AL Up to 64 yrs old belladonna alkaloids & opium 1

buprenorphine hcl sl tab 2 mg 3 PA

buprenorphine hcl sl tab 8 mg 3 PA

buprenorphine hcl solution 0.3 mg/ml 3 PA

QL 90 / 30 days buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 3 PA

QL 90 / 30 days buprenorphine hcl-naloxone hcl sl tab 8-2 mg 3 PA

butalbital-acetaminophen tab 50-325 mg 1

PAGE 84 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

butalbital-apap-caff-cod cap 50-300-40-30 mg 1

butalbital-apap-caff-cod cap 50-325-40-30 mg 1

butalbital-apap-caffeine cap 50-300-40 mg 1

butalbital-apap-caffeine cap 50-325-40 mg 1

butalbital-apap-caffeine tab 50-325-40 mg 1

butalbital-asa-caff-codeine cap 50-325-40-30 mg 1

butalbital-aspirin-caffeine cap 50-325-40 mg 1

butorphanol tartrate solution 1 mg/ml 3

butorphanol tartrate solution 10 mg/ml 3

butorphanol tartrate solution 2 mg/ml 3 BUTRANS PATCH WK 10 MCG/HR PA buprenorphine 3 BUTRANS PATCH WK 20 MCG/HR PA buprenorphine 3 BUTRANS PATCH WK 5 MCG/HR PA buprenorphine 3

capacet cap 50-325-40 mg 1

celecoxib cap 100 mg 3 QL 30 / 30 days

celecoxib cap 200 mg 3 QL 30 / 30 days

childrens ibuprofen 100 suspension 100 mg/5ml 1

childrens ibuprofen suspension 100 mg/5ml 1

childrens medi-profen suspension 100 mg/5ml 1

childs ibuprofen suspension 100 mg/5ml 1

choline-mag trisalicylate liquid 500 mg/5ml 1 CODEINE SULFATE SOLUTION 30 MG/5ML codeine sulfate 1

codeine sulfate tab 15 mg 1 CODEINE SULFATE TAB 15 MG codeine sulfate 1

codeine sulfate tab 30 mg 1 CODEINE SULFATE TAB 30 MG codeine sulfate 1

QL 60 / 30 days cvs aspirin adult low strength tab dr 81 mg 5 AL 40 to 79 yrs old

PAGE 85 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cvs childrens ibuprofen suspension 100 mg/5ml 1

cvs ibuprofen infants suspension 50 mg/1.25ml 5 QL 60 / 30 days

diclofenac potassium tab 50 mg 1

diclofenac sodium er tab er 24h 100 mg 1

diclofenac sodium tab dr 25 mg 1

diclofenac sodium tab dr 50 mg 1

diclofenac sodium tab dr 75 mg 1

diclofenac-misoprostol tab dr 50-0.2 mg 3

diclofenac-misoprostol tab dr 75-0.2 mg 3

diflunisal tab 500 mg 1

duramorph solution 0.5 mg/ml 3 PA

duramorph solution 1 mg/ml 3 PA

duraxin cap 300-200-20 mg 1

QL 60 / 30 days ec-81 aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days ecotrin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days ecpirin tab dr 325 mg 5 AL 40 to 79 yrs old

ed-flex cap 300-200-20 mg 1

endocet tab 10-325 mg 1 QL 180 / 30 days

endocet tab 5-325 mg 1 QL 360 / 30 days

endocet tab 7.5-325 mg 1 QL 180 / 30 days

endodan tab 4.8355-325 mg 1

QL 60 / 30 days eq adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eq aspirin adult low dose tab dr 81 mg 5 AL 40 to 79 yrs old

eq childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days eql adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

PAGE 86 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 days eql aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

eql childrens ibuprofen suspension 100 mg/5ml 1

etodolac cap 200 mg 1

etodolac cap 300 mg 1

etodolac er tab er 24h 400 mg 1

etodolac er tab er 24h 500 mg 1

etodolac er tab er 24h 600 mg 1

etodolac tab 400 mg 1

etodolac tab 500 mg 1

QL 10 / 30 days fentanyl patch 72hr 100 mcg/hr 1 PA

QL 10 / 30 days fentanyl patch 72hr 12 mcg/hr 1 PA

QL 10 / 30 days fentanyl patch 72hr 25 mcg/hr 1 PA

QL 10 / 30 days fentanyl patch 72hr 50 mcg/hr 1 PA

QL 10 / 30 days fentanyl patch 72hr 75 mcg/hr 1 PA

flurbiprofen tab 100 mg 1

flurbiprofen tab 50 mg 1

gabapentin cap 100 mg 1

gabapentin cap 300 mg 1

gabapentin cap 400 mg 1

gabapentin solution 250 mg/5ml 1

gabapentin tab 600 mg 1

gabapentin tab 800 mg 1

QL 60 / 30 days gnp adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days gnp aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

PAGE 87 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gnp childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days goodsense aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days hm aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days hm aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

hm ibuprofen childrens suspension 100 mg/5ml 1 HYDROCODONE-ACETAMINOPHEN SOLUTION 10-325 MG/15ML 1 hydrocodone-acetaminophen

hydrocodone-acetaminophen solution 2.5-108 mg/5ml 1

hydrocodone-acetaminophen solution 5-217 mg/10ml 1

hydrocodone-acetaminophen solution 7.5-325 mg/15ml 1

hydrocodone-acetaminophen tab 10-300 mg 3 QL 180 / 30 days

hydrocodone-acetaminophen tab 10-325 mg 1 QL 180 / 30 days

hydrocodone-acetaminophen tab 2.5-325 mg 1

hydrocodone-acetaminophen tab 5-300 mg 3

hydrocodone-acetaminophen tab 5-325 mg 1 QL 360 / 30 days

hydrocodone-acetaminophen tab 7.5-300 mg 3 QL 180 / 30 days

hydrocodone-acetaminophen tab 7.5-325 mg 1 QL 180 / 30 days

hydrocodone-ibuprofen tab 10-200 mg 1 ST

hydrocodone-ibuprofen tab 2.5-200 mg 1

hydrocodone-ibuprofen tab 5-200 mg 1

hydrocodone-ibuprofen tab 7.5-200 mg 1

hydromorphone hcl liquid 1 mg/ml 3 HYDROMORPHONE HCL SUPPOS 3 MG hydromorphone hcl 3

hydromorphone hcl tab 2 mg 1 QL 240 / 30 days

hydromorphone hcl tab 4 mg 1 QL 240 / 30 days

hydromorphone hcl tab 8 mg 1 QL 240 / 30 days

PAGE 88 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hyophen tab 81.6 mg 1

ibudone tab 5-200 mg 1

ibuprofen childrens suspension 100 mg/5ml 1

ibuprofen suspension 100 mg/5ml 1

ibuprofen tab 400 mg 1

ibuprofen tab 600 mg 1

ibuprofen tab 800 mg 1

indomethacin cap 25 mg 1 AL Up to 64 yrs old

indomethacin cap 50 mg 1 AL Up to 64 yrs old

indomethacin er cap er 75 mg 1 AL Up to 64 yrs old

isometheptene-caffeine-apap tab 65-20-325 mg 1

ketoprofen cap 50 mg 1 QL 180 / 30 days

ketoprofen cap 75 mg 1 QL 120 / 30 days

KETOPROFEN ER CAP ER 24H 200 MG QL 30 / 30 days ketoprofen 1 LEVORPHANOL TARTRATE TAB 2 MG levorphanol tartrate 1

lorcet plus tab 7.5-325 mg 1 QL 180 / 30 days

lortab tab 7.5-325 mg 1 QL 180 / 30 days

margesic cap 50-325-40 mg 1

marten-tab tab 50-325 mg 1 MECLOFENAMATE SODIUM CAP 100 MG meclofenamate sodium 3 MECLOFENAMATE SODIUM CAP 50 MG meclofenamate sodium 3 MELOXICAM SUSPENSION 7.5 MG/5ML meloxicam 3

meloxicam tab 15 mg 1

meloxicam tab 7.5 mg 1 MEPERIDINE HCL SOLUTION 10 MG/ML meperidine hcl 3

meperidine hcl solution 100 mg/ml 3

PAGE 89 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

meperidine hcl solution 25 mg/ml 3 MEPERIDINE HCL SOLUTION 50 MG/5ML meperidine hcl 1

meperidine hcl solution 50 mg/ml 3

meperidine hcl tab 100 mg 1

meperidine hcl tab 50 mg 1

meperitab tab 100 mg 1

meperitab tab 50 mg 1

methadone hcl conc 10 mg/ml 1

methadone hcl intensol conc 10 mg/ml 1

methadone hcl solution 10 mg/5ml 1 METHADONE HCL SOLUTION 10 MG/5ML methadone hcl 1 METHADONE HCL SOLUTION 10 MG/ML methadone hcl 3

methadone hcl solution 5 mg/5ml 1 METHADONE HCL SOLUTION 5 MG/5ML methadone hcl 1

methadone hcl tab 10 mg 1 QL 240 / 30 days

methadone hcl tab 5 mg 1

methadone hcl tab sol 40 mg 1 METHADOSE CONC 10 MG/ML methadone hcl 1

methadose tab 10 mg 1 QL 240 / 30 days

methadose tab sol 40 mg 1

morphine sulfate (concentrate) solution 100 mg/5ml 1

morphine sulfate (concentrate) solution 20 mg/ml 1

morphine sulfate (pf) solution 0.5 mg/ml 3

morphine sulfate (pf) solution 1 mg/ml 3 MORPHINE SULFATE (PF) SOLUTION 10 MG/ML morphine sulfate 3 MORPHINE SULFATE (PF) SOLUTION 15 MG/ML morphine sulfate 3 MORPHINE SULFATE (PF) SOLUTION 2 MG/ML morphine sulfate 3

PAGE 90 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MORPHINE SULFATE (PF) SOLUTION 4 MG/ML morphine sulfate 3 MORPHINE SULFATE (PF) SOLUTION 8 MG/ML morphine sulfate 3 MORPHINE SULFATE DEVICE 10 MG/0.7ML morphine sulfate 3

morphine sulfate er tab er 100 mg 1 QL 90 / 30 days

morphine sulfate er tab er 15 mg 1 QL 90 / 30 days

morphine sulfate er tab er 30 mg 1 QL 90 / 30 days

morphine sulfate er tab er 60 mg 1 QL 90 / 30 days

morphine sulfate solution 1 mg/ml 3

morphine sulfate solution 10 mg/5ml 1

morphine sulfate solution 10 mg/ml 3

morphine sulfate solution 15 mg/ml 3 MORPHINE SULFATE SOLUTION 150 MG/30ML morphine sulfate 3 MORPHINE SULFATE SOLUTION 2 MG/ML morphine sulfate 3

morphine sulfate solution 20 mg/5ml 1 MORPHINE SULFATE SOLUTION 25 MG/ML morphine sulfate 3 MORPHINE SULFATE SOLUTION 4 MG/ML morphine sulfate 3 MORPHINE SULFATE SOLUTION 50 MG/ML morphine sulfate 3

morphine sulfate solution 8 mg/ml 3 MORPHINE SULFATE SUPPOS 10 MG morphine sulfate 3 MORPHINE SULFATE SUPPOS 20 MG morphine sulfate 3 MORPHINE SULFATE SUPPOS 30 MG morphine sulfate 3 MORPHINE SULFATE SUPPOS 5 MG morphine sulfate 3 MORPHINE SULFATE TAB 15 MG QL 180 / 30 days morphine sulfate 3

PAGE 91 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MORPHINE SULFATE TAB 30 MG QL 180 / 30 days morphine sulfate 3

nabumetone tab 500 mg 1 QL 120 / 30 days

nabumetone tab 750 mg 1 QL 60 / 30 days

nalbuphine hcl solution 10 mg/ml 3

nalbuphine hcl solution 20 mg/ml 3

naproxen dr tab dr 375 mg 1

naproxen dr tab dr 500 mg 1

naproxen sodium tab 275 mg 1

naproxen sodium tab 550 mg 1

naproxen suspension 125 mg/5ml 1 NAPROXEN SUSPENSION 125 MG/5ML naproxen 1

naproxen tab 250 mg 1

naproxen tab 375 mg 1

naproxen tab 500 mg 1 NORCO TAB 7.5-325 MG hydrocodone-acetaminophen 1 NUCYNTA ER TAB ER 12H 100 MG PA tapentadol hcl 3 NUCYNTA ER TAB ER 12H 150 MG PA tapentadol hcl 3 NUCYNTA ER TAB ER 12H 200 MG PA tapentadol hcl 3 NUCYNTA ER TAB ER 12H 250 MG PA tapentadol hcl 3 NUCYNTA ER TAB ER 12H 50 MG PA tapentadol hcl 3 OPANA ER TB12 DETER 10 MG PA oxymorphone hcl 3 OPANA ER TB12 DETER 15 MG PA oxymorphone hcl 3 OPANA ER TB12 DETER 20 MG PA oxymorphone hcl 3 OPANA ER TB12 DETER 30 MG PA oxymorphone hcl 3

PAGE 92 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OPANA ER TB12 DETER 40 MG PA oxymorphone hcl 3 OPANA ER TB12 DETER 5 MG PA oxymorphone hcl 3 OPANA ER TB12 DETER 7.5 MG PA oxymorphone hcl 3

orphenadrine-aspirin-caffeine tab 25-385-30 mg 1 AL Up to 64 yrs old

oxaprozin tab 600 mg 3

oxycodone hcl cap 5 mg 1 QL 180 / 30 days

oxycodone hcl conc 100 mg/5ml 3 OXYCODONE HCL CONC 100 MG/5ML oxycodone hcl 3

oxycodone hcl solution 5 mg/5ml 1 OXYCODONE HCL SOLUTION 5 MG/5ML oxycodone hcl 1

oxycodone hcl tab 10 mg 1 QL 180 / 30 days

oxycodone hcl tab 15 mg 1 QL 180 / 30 days

oxycodone hcl tab 20 mg 1 QL 180 / 30 days

oxycodone hcl tab 30 mg 1 QL 180 / 30 days

oxycodone hcl tab 5 mg 1 QL 180 / 30 days

oxycodone-acetaminophen tab 10-325 mg 1 QL 180 / 30 days

oxycodone-acetaminophen tab 2.5-325 mg 1

oxycodone-acetaminophen tab 5-325 mg 1 QL 360 / 30 days

oxycodone-acetaminophen tab 7.5-325 mg 1 QL 180 / 30 days

oxycodone-aspirin tab 4.8355-325 mg 1

oxycodone-ibuprofen tab 5-400 mg 1 QL 240 / 30 days

QL 90 / 30 days oxymorphone hcl er tab er 12h 10 mg 3 PA

oxymorphone hcl er tab er 12h 15 mg 3 PA

oxymorphone hcl er tab er 12h 20 mg 3 PA

oxymorphone hcl er tab er 12h 30 mg 3 PA

PAGE 93 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

oxymorphone hcl er tab er 12h 40 mg 3 PA

oxymorphone hcl er tab er 12h 5 mg 3

oxymorphone hcl er tab er 12h 7.5 mg 3 PA

pentazocine-naloxone hcl tab 50-0.5 mg 1

phosphasal tab 81.6 mg 1

piroxicam cap 10 mg 1

piroxicam cap 20 mg 1

px childrens profen ib suspension 100 mg/5ml 1

QL 60 / 30 days qc aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

qc childrens ibuprofen suspension 100 mg/5ml 1

ra ibuprofen childrens suspension 100 mg/5ml 1

ra ibuprofen suspension 100 mg/5ml 1

reprexain tab 10-200 mg 1 ST

roxicet tab 5-325 mg 1 QL 360 / 30 days

salsalate tab 500 mg 1

salsalate tab 750 mg 1

QL 60 / 30 days sb aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

sb childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days sb low dose asa ec tab dr 81 mg 5 AL 40 to 79 yrs old

sm childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days st joseph aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

SUBOXONE FILM 12-3 MG QL 30 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

SUBOXONE FILM 2-0.5 MG QL 90 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

SUBOXONE FILM 4-1 MG QL 90 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

PAGE 94 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SUBOXONE FILM 8-2 MG QL 60 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

sulindac tab 150 mg 1

sulindac tab 200 mg 1

QL 30 / 30 days tgt aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days tgt aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

tgt childrens ibuprofen suspension 100 mg/5ml 1

tgt ibuprofen childrens suspension 100 mg/5ml 1

tolmetin sodium cap 400 mg 1 TOLMETIN SODIUM TAB 200 MG tolmetin sodium 3 TOLMETIN SODIUM TAB 600 MG tolmetin sodium 3

tramadol hcl er (biphasic) tab er 24h 100 mg 3

tramadol hcl er (biphasic) tab er 24h 200 mg 3

tramadol hcl er (biphasic) tab er 24h 300 mg 3 TRAMADOL HCL ER CAP ER 24H 150 MG tramadol hcl 3

tramadol hcl er tab er 24h 100 mg 3

tramadol hcl er tab er 24h 200 mg 3

tramadol hcl er tab er 24h 300 mg 3

tramadol hcl tab 50 mg 1 QL 240 / 30 days

tramadol-acetaminophen tab 37.5-325 mg 1

uretron d/s tab 1 URETRON D/S TAB methenamine-hyosc-methylene blue-sod phos-phenyl sal 1

ustell cap 120 mg 1

uticap cap 120 mg 1

utira-c tab 81.6 mg 1

utrona-c tab 81.6 mg 1

PAGE 95 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vicodin es tab 7.5-300 mg 3 QL 180 / 30 days

vicodin tab 5-300 mg 3

wal-profen tab 200 mg 1 Anorexigenic Agents and Respiratory and CNS Stimulants

QL 30 / 30 days amphetamine-dextroamphet er cap er 24h 10 mg 3 AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphet er cap er 24h 15 mg 3 AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphet er cap er 24h 20 mg 3 AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphet er cap er 24h 25 mg 3 AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphet er cap er 24h 30 mg 3 AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphet er cap er 24h 5 mg 3 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 10 mg 1 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 12.5 mg 1 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 15 mg 1 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 20 mg 1 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 30 mg 1 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 5 mg 1 AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 7.5 mg 1 AL 6 to 17 yrs old

ascomp-codeine cap 50-325-40-30 mg 1

butalbital-apap-caff-cod cap 50-300-40-30 mg 1

butalbital-apap-caff-cod cap 50-325-40-30 mg 1

butalbital-apap-caffeine cap 50-300-40 mg 1

butalbital-apap-caffeine cap 50-325-40 mg 1

butalbital-apap-caffeine tab 50-325-40 mg 1

PAGE 96 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

butalbital-asa-caff-codeine cap 50-325-40-30 mg 1

butalbital-aspirin-caffeine cap 50-325-40 mg 1 CAFERGOT TAB 1-100 MG ergotamine w/ caffeine 2

caffeine citrate solution 20 mg/ml 1

caffeine citrate solution 60 mg/3ml 1

caffeine citrate solution 60 mg/3ml 1 CAFFEINE-SODIUM BENZOATE SOLUTION 125-125 MG/ML caffeine & sodium benzoate 1

capacet cap 50-325-40 mg 1

QL 30 / 30 days DAYTRANA PATCH 10 MG/9HR PA methylphenidate 3 AL 6 to 17 yrs old

QL 30 / 30 days DAYTRANA PATCH 15 MG/9HR PA methylphenidate 3 AL 6 to 17 yrs old

QL 30 / 30 days DAYTRANA PATCH 20 MG/9HR PA methylphenidate 3 AL 6 to 17 yrs old

QL 30 / 30 days DAYTRANA PATCH 30 MG/9HR PA methylphenidate 3 AL 6 to 17 yrs old

dexmethylphenidate hcl tab 10 mg 1 AL 6 to 17 yrs old

dexmethylphenidate hcl tab 2.5 mg 1 AL 6 to 17 yrs old

dexmethylphenidate hcl tab 5 mg 1 AL 6 to 17 yrs old

dextroamphetamine sulfate er cap er 24h 10 mg 1 AL 6 to 17 yrs old

dextroamphetamine sulfate er cap er 24h 15 mg 1 AL 6 to 17 yrs old

dextroamphetamine sulfate er cap er 24h 5 mg 1 AL 6 to 17 yrs old

dextroamphetamine sulfate tab 10 mg 1 AL 6 to 17 yrs old

dextroamphetamine sulfate tab 5 mg 1 AL 6 to 17 yrs old

diethylpropion hcl er tab er 24h 75 mg 1

PAGE 97 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diethylpropion hcl tab 25 mg 1 DIETHYLPROPION HCL TAB 25 MG diethylpropion hcl 1

doxapram hcl solution 20 mg/ml 1 ELIXOPHYLLIN ELIXIR 80 MG/15ML theophylline 2

QL 30 / 30 days FOCALIN XR CAP ER 24H 10 MG PA dexmethylphenidate hcl 3 AL 6 to 17 yrs old

FOCALIN XR CAP ER 24H 15 MG PA 3 dexmethylphenidate hcl AL 6 to 17 yrs old

QL 30 / 30 days FOCALIN XR CAP ER 24H 20 MG PA dexmethylphenidate hcl 3 AL 6 to 17 yrs old

QL 30 / 30 days FOCALIN XR CAP ER 24H 25 MG PA dexmethylphenidate hcl 3 AL 6 to 17 yrs old

FOCALIN XR CAP ER 24H 30 MG PA 3 dexmethylphenidate hcl AL 6 to 17 yrs old

QL 30 / 30 days FOCALIN XR CAP ER 24H 35 MG PA dexmethylphenidate hcl 3 AL 6 to 17 yrs old

FOCALIN XR CAP ER 24H 40 MG PA 3 dexmethylphenidate hcl AL 6 to 17 yrs old

isometheptene-caffeine-apap tab 65-20-325 mg 1

margesic cap 50-325-40 mg 1

QL 30 / 30 days metadate er tab er 20 mg 1 AL 6 to 17 yrs old

methamphetamine hcl tab 5 mg 1 AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl er (cd) cap er 10 mg 1 AL 6 to 17 yrs old

PAGE 98 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 days methylphenidate hcl er (cd) cap er 20 mg 1 AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl er (cd) cap er 30 mg 1 AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl er (cd) cap er 40 mg 1 AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl er (cd) cap er 50 mg 1 AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl er (cd) cap er 60 mg 1 AL 6 to 17 yrs old

METHYLPHENIDATE HCL ER TAB ER 10 MG QL 30 / 30 days 1 methylphenidate hcl AL 6 to 17 yrs old

METHYLPHENIDATE HCL ER TAB ER 18 MG QL 30 / 30 days 3 methylphenidate hcl AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl er tab er 20 mg 1 AL 6 to 17 yrs old

METHYLPHENIDATE HCL ER TAB ER 27 MG QL 30 / 30 days 3 methylphenidate hcl AL 6 to 17 yrs old

METHYLPHENIDATE HCL ER TAB ER 36 MG QL 30 / 30 days 3 methylphenidate hcl AL 6 to 17 yrs old

METHYLPHENIDATE HCL ER TAB ER 54 MG QL 30 / 30 days 3 methylphenidate hcl AL 6 to 17 yrs old

PA methylphenidate hcl solution 10 mg/5ml 1 AL 6 to 17 yrs old

PA methylphenidate hcl solution 5 mg/5ml 1 AL 6 to 17 yrs old

methylphenidate hcl tab 10 mg 1 AL 6 to 17 yrs old

methylphenidate hcl tab 20 mg 1 AL 6 to 17 yrs old

methylphenidate hcl tab 5 mg 1 AL 6 to 17 yrs old

PAGE 99 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

modafinil tab 100 mg 4 PA

modafinil tab 200 mg 4 PA

NUVIGIL TAB 150 MG PA armodafinil 4

orphenadrine-aspirin-caffeine tab 25-385-30 mg 1 AL Up to 64 yrs old

PHENDIMETRAZINE TARTRATE ER CAP ER 24H 105 MG phendimetrazine tartrate 1

phendimetrazine tartrate tab 35 mg 1

phentermine hcl cap 15 mg 1

phentermine hcl cap 30 mg 1

phentermine hcl cap 37.5 mg 1

phentermine hcl tab 37.5 mg 1

theochron tab er 12h 100 mg 1

theochron tab er 12h 200 mg 1

theochron tab er 12h 300 mg 1

theophylline er tab er 12h 100 mg 1

theophylline er tab er 12h 200 mg 1

theophylline er tab er 12h 300 mg 1

theophylline er tab er 12h 450 mg 1

theophylline er tab er 24h 400 mg 1

theophylline er tab er 24h 600 mg 1

theophylline solution 80 mg/15ml 1 Anticonvulsants

acetazolamide er cap er 12h 500 mg 1 ACETAZOLAMIDE TAB 125 MG acetazolamide 1

acetazolamide tab 250 mg 1 BANZEL SUSPENSION 40 MG/ML rufinamide 3

carbamazepine chew tab 100 mg 1

carbamazepine er cap er 12h 100 mg 1

carbamazepine er cap er 12h 200 mg 1

PAGE 100 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

carbamazepine er cap er 12h 300 mg 1

carbamazepine er tab er 12h 200 mg 1

carbamazepine er tab er 12h 400 mg 1

carbamazepine suspension 100 mg/5ml 1

carbamazepine tab 200 mg 1 CELONTIN CAP 300 MG methsuximide 2

clonazepam tab 0.5 mg 1

clonazepam tab 1 mg 1

clonazepam tab 2 mg 1

clonazepam tab disp 0.125 mg 1

clonazepam tab disp 0.25 mg 1

clonazepam tab disp 0.5 mg 1

clonazepam tab disp 1 mg 1

clonazepam tab disp 2 mg 1

clorazepate dipotassium tab 15 mg 1 AL Up to 64 yrs old

clorazepate dipotassium tab 3.75 mg 1 AL Up to 64 yrs old

clorazepate dipotassium tab 7.5 mg 1 AL Up to 64 yrs old

DIAZEPAM SOLUTION 1 MG/ML AL Up to 64 yrs old diazepam 1 DIAZEPAM SOLUTION 5 MG/ML AL Up to 64 yrs old diazepam 1

diazepam tab 10 mg 1 AL Up to 64 yrs old

diazepam tab 2 mg 1 AL Up to 64 yrs old

diazepam tab 5 mg 1 AL Up to 64 yrs old

DILANTIN CAP 100 MG phenytoin sodium extended 2 DILANTIN CAP 30 MG phenytoin sodium extended 2

divalproex sodium cap sprink 125 mg 1

divalproex sodium er tab er 24h 250 mg 1

divalproex sodium er tab er 24h 500 mg 1

PAGE 101 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

divalproex sodium tab dr 125 mg 1

divalproex sodium tab dr 250 mg 1

divalproex sodium tab dr 500 mg 1

epitol tab 200 mg 1

ethosuximide cap 250 mg 1

ethosuximide solution 250 mg/5ml 3

felbamate suspension 600 mg/5ml 4

felbamate tab 400 mg 3

felbamate tab 600 mg 3

gabapentin cap 100 mg 1

gabapentin cap 300 mg 1

gabapentin cap 400 mg 1

gabapentin solution 250 mg/5ml 1

gabapentin tab 600 mg 1

gabapentin tab 800 mg 1 GABITRIL TAB 12 MG tiagabine hcl 3 GABITRIL TAB 16 MG tiagabine hcl 3 LAMICTAL ODT KIT 25 & 50 & 100 MG lamotrigine 3 LAMICTAL ODT KIT 25 (21)-50 (7) MG lamotrigine 3 LAMICTAL ODT KIT 50 (42)-100(14) MG lamotrigine 3

lamotrigine chew tab 25 mg 1

lamotrigine chew tab 5 mg 1

lamotrigine er tab er 24h 100 mg 3

lamotrigine er tab er 24h 200 mg 3

lamotrigine er tab er 24h 25 mg 3

lamotrigine er tab er 24h 250 mg 3

lamotrigine er tab er 24h 300 mg 3

lamotrigine er tab er 24h 50 mg 3

PAGE 102 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lamotrigine tab 100 mg 1

lamotrigine tab 150 mg 1

lamotrigine tab 200 mg 1

lamotrigine tab 25 mg 1

levetiracetam er tab er 24h 500 mg 3

levetiracetam er tab er 24h 750 mg 3

levetiracetam solution 100 mg/ml 1

levetiracetam solution 500 mg/5ml 1

levetiracetam tab 1000 mg 1 QL 90 / 30 days

levetiracetam tab 250 mg 1 QL 360 / 30 days

levetiracetam tab 500 mg 1 QL 180 / 30 days

levetiracetam tab 750 mg 1 QL 120 / 30 days

lorazepam conc 2 mg/ml 1 AL Up to 64 yrs old

LORAZEPAM INTENSOL CONC 2 MG/ML AL Up to 64 yrs old lorazepam 1

lorazepam solution 2 mg/ml 1 AL Up to 64 yrs old

lorazepam solution 4 mg/ml 1 AL Up to 64 yrs old

lorazepam tab 0.5 mg 1 AL Up to 64 yrs old

lorazepam tab 1 mg 1 AL Up to 64 yrs old

lorazepam tab 2 mg 1 AL Up to 64 yrs old

LYRICA CAP 100 MG PA pregabalin 3 LYRICA CAP 150 MG PA pregabalin 3 LYRICA CAP 200 MG PA pregabalin 3 LYRICA CAP 225 MG PA pregabalin 3 LYRICA CAP 25 MG PA pregabalin 3 LYRICA CAP 300 MG PA pregabalin 3

PAGE 103 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LYRICA CAP 50 MG PA pregabalin 3 LYRICA CAP 75 MG PA pregabalin 3 LYRICA SOLUTION 20 MG/ML PA pregabalin 3

oxcarbazepine suspension 300 mg/5ml 1

oxcarbazepine tab 150 mg 1

oxcarbazepine tab 300 mg 1

oxcarbazepine tab 600 mg 1 PEGANONE TAB 250 MG ethotoin 3

phenobarbital elixir 20 mg/5ml 1

phenobarbital solution 20 mg/5ml 1

phenobarbital tab 100 mg 1 PHENOBARBITAL TAB 100 MG phenobarbital 1

phenobarbital tab 15 mg 1 PHENOBARBITAL TAB 15 MG phenobarbital 1

phenobarbital tab 16.2 mg 1

phenobarbital tab 30 mg 1 PHENOBARBITAL TAB 30 MG phenobarbital 1

phenobarbital tab 32.4 mg 1

phenobarbital tab 60 mg 1 PHENOBARBITAL TAB 60 MG phenobarbital 1

phenobarbital tab 64.8 mg 1

phenobarbital tab 97.2 mg 1

phenytoin chew tab 50 mg 1

phenytoin infatabs chew tab 50 mg 1

phenytoin sodium extended cap 100 mg 1

phenytoin sodium extended cap 200 mg 1

phenytoin sodium extended cap 300 mg 1

PAGE 104 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

phenytoin sodium solution 50 mg/ml 1

phenytoin suspension 125 mg/5ml 1 POTIGA TAB 200 MG ezogabine 3 POTIGA TAB 300 MG ezogabine 3 POTIGA TAB 400 MG ezogabine 3 POTIGA TAB 50 MG ezogabine 3

primidone tab 250 mg 1

primidone tab 50 mg 1 SABRIL PACKET 500 MG PA vigabatrin 4 STAVZOR CAP DR 125 MG PA valproic acid 3 TEGRETOL-XR TAB ER 12H 100 MG carbamazepine 2

tiagabine hcl tab 2 mg 3

tiagabine hcl tab 4 mg 3

topiragen tab 100 mg 1

topiragen tab 200 mg 1

topiragen tab 25 mg 1

topiragen tab 50 mg 1

topiramate cap sprink 15 mg 1

topiramate cap sprink 25 mg 1

topiramate tab 100 mg 1

topiramate tab 200 mg 1

topiramate tab 25 mg 1

topiramate tab 50 mg 1

valproic acid cap 250 mg 1

valproic acid solution 250 mg/5ml 1

valproic acid syrup 250 mg/5ml 1

zonisamide cap 100 mg 1 QL 180 / 30 days

PAGE 105 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

zonisamide cap 25 mg 1 QL 360 / 30 days

zonisamide cap 50 mg 1 QL 360 / 30 days

Antimigraine Agents

acetaminophen extra strength tab 500 mg 1

QL 60 / 30 days adult aspirin ec low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspir-low tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin adult low strength chew tab 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin adult low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin chew tab 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec lo-dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin ec tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days aspirin low strength chew tab 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days aspirin tab 325 mg 5 AL 40 to 79 yrs old

PAGE 106 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 days aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

AXERT TAB 12.5 MG QL 9 / 23 days 3 almotriptan malate ST

AXERT TAB 6.25 MG QL 9 / 23 days 3 almotriptan malate ST

QL 60 / 30 days bayer aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer aspirin tab 325 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer aspirin tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days bayer low dose chew tab 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days bayer low dose tab dr 81 mg 5 AL 40 to 79 yrs old

butorphanol tartrate solution 1 mg/ml 3

butorphanol tartrate solution 10 mg/ml 3

butorphanol tartrate solution 2 mg/ml 3 CAFERGOT TAB 1-100 MG ergotamine w/ caffeine 2

caffeine citrate solution 20 mg/ml 1

caffeine citrate solution 60 mg/3ml 1

caffeine citrate solution 60 mg/3ml 1 CAFFEINE-SODIUM BENZOATE SOLUTION 125-125 MG/ML caffeine & sodium benzoate 1

childrens ibuprofen 100 suspension 100 mg/5ml 1

childrens ibuprofen suspension 100 mg/5ml 1

childrens medi-profen suspension 100 mg/5ml 1

childs ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days cvs aspirin adult low strength tab dr 81 mg 5 AL 40 to 79 yrs old

PAGE 107 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cvs childrens ibuprofen suspension 100 mg/5ml 1

cvs ibuprofen infants suspension 50 mg/1.25ml 5 QL 60 / 30 days

DIHYDROERGOTAMINE MESYLATE SOLUTION 4 MG/ML dihydroergotamine mesylate 3

divalproex sodium cap sprink 125 mg 1

divalproex sodium er tab er 24h 250 mg 1

divalproex sodium er tab er 24h 500 mg 1

divalproex sodium tab dr 125 mg 1

divalproex sodium tab dr 250 mg 1

divalproex sodium tab dr 500 mg 1

QL 60 / 30 days ec-81 aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days ecotrin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days ecpirin tab dr 325 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eq adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eq aspirin adult low dose tab dr 81 mg 5 AL 40 to 79 yrs old

eq childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days eql adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days eql aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

eql childrens ibuprofen suspension 100 mg/5ml 1

FROVA TAB 2.5 MG QL 9 / 23 days 3 frovatriptan succinate ST

QL 60 / 30 days gnp adult aspirin low strength tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days gnp aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

PAGE 108 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gnp childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days goodsense aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 60 / 30 days hm aspirin ec low dose tab dr 81 mg 5 AL 40 to 79 yrs old

QL 30 / 30 days hm aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

hm ibuprofen childrens suspension 100 mg/5ml 1

ibuprofen childrens suspension 100 mg/5ml 1

ibuprofen suspension 100 mg/5ml 1

ibuprofen tab 400 mg 1

ibuprofen tab 600 mg 1

ibuprofen tab 800 mg 1

isometheptene-caffeine-apap tab 65-20-325 mg 1

ketoprofen cap 50 mg 1 QL 180 / 30 days

ketoprofen cap 75 mg 1 QL 120 / 30 days

KETOPROFEN ER CAP ER 24H 200 MG QL 30 / 30 days ketoprofen 1

naproxen dr tab dr 375 mg 1

naproxen dr tab dr 500 mg 1

naproxen sodium tab 275 mg 1

naproxen sodium tab 550 mg 1

naproxen suspension 125 mg/5ml 1 NAPROXEN SUSPENSION 125 MG/5ML naproxen 1

naproxen tab 250 mg 1

naproxen tab 375 mg 1

naproxen tab 500 mg 1

QL 9 / 23 days naratriptan hcl tab 1 mg 1 ST

QL 9 / 23 days naratriptan hcl tab 2.5 mg 1 ST

PAGE 109 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

propranolol hcl er cap er 24h 120 mg 1 ST

propranolol hcl er cap er 24h 160 mg 1 ST

propranolol hcl er cap er 24h 60 mg 1 ST

propranolol hcl er cap er 24h 80 mg 1 ST

PROPRANOLOL HCL SOLUTION 20 MG/5ML propranolol hcl 1 PROPRANOLOL HCL SOLUTION 40 MG/5ML propranolol hcl 1

propranolol hcl tab 10 mg 1

propranolol hcl tab 20 mg 1

propranolol hcl tab 40 mg 1

propranolol hcl tab 60 mg 1

propranolol hcl tab 80 mg 1

px childrens profen ib suspension 100 mg/5ml 1

QL 60 / 30 days qc aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

qc childrens ibuprofen suspension 100 mg/5ml 1

ra ibuprofen childrens suspension 100 mg/5ml 1

ra ibuprofen suspension 100 mg/5ml 1

RELPAX TAB 20 MG QL 9 / 23 days 3 eletriptan hydrobromide ST

RELPAX TAB 40 MG QL 9 / 23 days 3 eletriptan hydrobromide ST

rizatriptan benzoate tab 10 mg 1

rizatriptan benzoate tab 5 mg 1

QL 60 / 30 days sb aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

sb childrens ibuprofen suspension 100 mg/5ml 1

QL 60 / 30 days sb low dose asa ec tab dr 81 mg 5 AL 40 to 79 yrs old

sm childrens ibuprofen suspension 100 mg/5ml 1

PAGE 110 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 days st joseph aspirin tab dr 81 mg 5 AL 40 to 79 yrs old

STAVZOR CAP DR 125 MG PA valproic acid 3 SUMATRIPTAN SOLUTION 20 MG/ACT sumatriptan 3 SUMATRIPTAN SOLUTION 5 MG/ACT sumatriptan 3

QL 10 / 23 days sumatriptan succinate refill soln cart 4 mg/0.5ml 3 PA

QL 10 / 23 days sumatriptan succinate refill soln cart 6 mg/0.5ml 3 PA

QL 10 / 23 days sumatriptan succinate soln a-inj 4 mg/0.5ml 3 PA

QL 10 / 23 days sumatriptan succinate soln a-inj 6 mg/0.5ml 3 PA

QL 10 / 23 days sumatriptan succinate soln prsyr 6 mg/0.5ml 3 PA

SUMATRIPTAN SUCCINATE SOLN PRSYR 6 MG/0.5ML QL 10 / 23 days 3 sumatriptan succinate PA

QL 10 / 23 days sumatriptan succinate solution 4 mg/0.5ml 3 PA

SUMATRIPTAN SUCCINATE SOLUTION 4 MG/0.5ML QL 10 / 23 days 3 sumatriptan succinate PA

QL 10 / 23 days sumatriptan succinate solution 6 mg/0.5ml 3 PA

sumatriptan succinate tab 100 mg 1 QL 9 / 23 days

sumatriptan succinate tab 25 mg 1 QL 9 / 23 days

sumatriptan succinate tab 50 mg 1 QL 9 / 23 days

QL 30 / 30 days tgt aspirin ec tab dr 325 mg 5 AL 40 to 79 yrs old

PAGE 111 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 days tgt aspirin low dose tab dr 81 mg 5 AL 40 to 79 yrs old

tgt childrens ibuprofen suspension 100 mg/5ml 1

tgt ibuprofen childrens suspension 100 mg/5ml 1 TIMOLOL MALEATE TAB 10 MG timolol maleate 1 TIMOLOL MALEATE TAB 20 MG timolol maleate 1 TIMOLOL MALEATE TAB 5 MG timolol maleate 1

topiragen tab 100 mg 1

topiragen tab 200 mg 1

topiragen tab 25 mg 1

topiragen tab 50 mg 1

topiramate cap sprink 15 mg 1

topiramate cap sprink 25 mg 1

topiramate tab 100 mg 1

topiramate tab 200 mg 1

topiramate tab 25 mg 1

topiramate tab 50 mg 1

valproic acid cap 250 mg 1

valproic acid solution 250 mg/5ml 1

valproic acid syrup 250 mg/5ml 1

wal-profen tab 200 mg 1 Antiparkinsonian Agents

altaryl syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

amantadine hcl cap 100 mg 1

amantadine hcl syrup 50 mg/5ml 1 AMANTADINE HCL TAB 100 MG amantadine hcl 1 AZILECT TAB 0.5 MG rasagiline mesylate 3 AZILECT TAB 1 MG rasagiline mesylate 3

PAGE 112 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

benztropine mesylate solution 1 mg/ml 3

benztropine mesylate tab 0.5 mg 1 AL Up to 64 yrs old

benztropine mesylate tab 1 mg 1 AL Up to 64 yrs old

benztropine mesylate tab 2 mg 1 AL Up to 64 yrs old

bromocriptine mesylate cap 5 mg 3

bromocriptine mesylate tab 2.5 mg 1

cabergoline tab 0.5 mg 1

carbidopa-levodopa er tab er 25-100 mg 1

carbidopa-levodopa er tab er 50-200 mg 1

carbidopa-levodopa tab 10-100 mg 1

carbidopa-levodopa tab 25-100 mg 1

carbidopa-levodopa tab 25-250 mg 1

carbidopa-levodopa tab disp 10-100 mg 1

carbidopa-levodopa tab disp 25-100 mg 1

carbidopa-levodopa tab disp 25-250 mg 1

diphenhydramine hcl cap 50 mg 1 AL Up to 64 yrs old

diphenhydramine hcl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

diphenhydramine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

EMSAM PATCH 24HR 12 MG/24HR ST selegiline 3 EMSAM PATCH 24HR 6 MG/24HR ST selegiline 3 EMSAM PATCH 24HR 9 MG/24HR ST selegiline 3

entacapone tab 200 mg 3

eq allergy relief childrens elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

LODOSYN TAB 25 MG carbidopa 3

medi-phedryl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

MIRAPEX ER TAB ER 24H 0.375 MG PA pramipexole dihydrochloride 3 MIRAPEX ER TAB ER 24H 0.75 MG PA pramipexole dihydrochloride 3

PAGE 113 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MIRAPEX ER TAB ER 24H 1.5 MG PA pramipexole dihydrochloride 3 MIRAPEX ER TAB ER 24H 2.25 MG PA pramipexole dihydrochloride 3 MIRAPEX ER TAB ER 24H 3 MG PA pramipexole dihydrochloride 3 MIRAPEX ER TAB ER 24H 3.75 MG PA pramipexole dihydrochloride 3 MIRAPEX ER TAB ER 24H 4.5 MG PA pramipexole dihydrochloride 3 NEUPRO PATCH 24HR 1 MG/24HR PA rotigotine 3 NEUPRO PATCH 24HR 2 MG/24HR PA rotigotine 3 NEUPRO PATCH 24HR 3 MG/24HR PA rotigotine 3 NEUPRO PATCH 24HR 4 MG/24HR PA rotigotine 3 NEUPRO PATCH 24HR 6 MG/24HR PA rotigotine 3 NEUPRO PATCH 24HR 8 MG/24HR PA rotigotine 3

orphenadrine citrate er tab er 12h 100 mg 1 AL Up to 64 yrs old

pramipexole dihydrochloride tab 0.125 mg 1

pramipexole dihydrochloride tab 0.25 mg 1

pramipexole dihydrochloride tab 0.5 mg 1

pramipexole dihydrochloride tab 0.75 mg 1

pramipexole dihydrochloride tab 1 mg 1

pramipexole dihydrochloride tab 1.5 mg 1

quenalin syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

ropinirole hcl er tab er 24h 12 mg 1 ST

ropinirole hcl er tab er 24h 2 mg 1 ST

ropinirole hcl er tab er 24h 4 mg 1 ST

ropinirole hcl er tab er 24h 6 mg 1 ST

ropinirole hcl er tab er 24h 8 mg 1 ST

PAGE 114 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ropinirole hcl tab 0.25 mg 1

ropinirole hcl tab 0.5 mg 1

ropinirole hcl tab 1 mg 1

ropinirole hcl tab 2 mg 1

ropinirole hcl tab 3 mg 1

ropinirole hcl tab 4 mg 1

ropinirole hcl tab 5 mg 1

selegiline hcl cap 5 mg 1

selegiline hcl tab 5 mg 1

silphen cough syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

TASMAR TAB 100 MG PA tolcapone 4 Anxiolytics, Sedatives, and Hypnotics

alprazolam er tab er 24h 0.5 mg 3 AL Up to 64 yrs old

alprazolam er tab er 24h 1 mg 3 AL Up to 64 yrs old

alprazolam er tab er 24h 2 mg 3 AL Up to 64 yrs old

alprazolam er tab er 24h 3 mg 3 AL Up to 64 yrs old

alprazolam tab 0.25 mg 1 AL Up to 64 yrs old

alprazolam tab 0.5 mg 1 AL Up to 64 yrs old

alprazolam tab 1 mg 1 AL Up to 64 yrs old

alprazolam tab 2 mg 1 AL Up to 64 yrs old

alprazolam tab disp 0.25 mg 3 AL Up to 64 yrs old

alprazolam tab disp 0.5 mg 3 AL Up to 64 yrs old

alprazolam tab disp 1 mg 3 AL Up to 64 yrs old

alprazolam tab disp 2 mg 3 AL Up to 64 yrs old

alprazolam xr tab er 24h 0.5 mg 3 AL Up to 64 yrs old

alprazolam xr tab er 24h 1 mg 3 AL Up to 64 yrs old

alprazolam xr tab er 24h 2 mg 3 AL Up to 64 yrs old

PAGE 115 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

alprazolam xr tab er 24h 3 mg 3 AL Up to 64 yrs old

altaryl syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

ascomp-codeine cap 50-325-40-30 mg 1

buspirone hcl tab 10 mg 1

buspirone hcl tab 15 mg 1

buspirone hcl tab 30 mg 1

buspirone hcl tab 5 mg 1

buspirone hcl tab 7.5 mg 1

butalbital-acetaminophen tab 50-325 mg 1

butalbital-apap-caff-cod cap 50-300-40-30 mg 1

butalbital-apap-caff-cod cap 50-325-40-30 mg 1

butalbital-apap-caffeine cap 50-300-40 mg 1

butalbital-apap-caffeine cap 50-325-40 mg 1

butalbital-apap-caffeine tab 50-325-40 mg 1

butalbital-asa-caff-codeine cap 50-325-40-30 mg 1

butalbital-aspirin-caffeine cap 50-325-40 mg 1

capacet cap 50-325-40 mg 1

chlordiazepoxide hcl cap 10 mg 1 AL Up to 64 yrs old

chlordiazepoxide hcl cap 25 mg 1 AL Up to 64 yrs old

chlordiazepoxide hcl cap 5 mg 1 AL Up to 64 yrs old

CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 10-25 MG chlordiazepoxide-amitriptyline 1 CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 5-12.5 MG chlordiazepoxide-amitriptyline 1

chlordiazepoxide-clidinium cap 5-2.5 mg 1

clonazepam tab 0.5 mg 1

clonazepam tab 1 mg 1

clonazepam tab 2 mg 1

clonazepam tab disp 0.125 mg 1

clonazepam tab disp 0.25 mg 1

clonazepam tab disp 0.5 mg 1

PAGE 116 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clonazepam tab disp 1 mg 1

clonazepam tab disp 2 mg 1

clorazepate dipotassium tab 15 mg 1 AL Up to 64 yrs old

clorazepate dipotassium tab 3.75 mg 1 AL Up to 64 yrs old

clorazepate dipotassium tab 7.5 mg 1 AL Up to 64 yrs old

DIAZEPAM SOLUTION 1 MG/ML AL Up to 64 yrs old diazepam 1 DIAZEPAM SOLUTION 5 MG/ML AL Up to 64 yrs old diazepam 1

diazepam tab 10 mg 1 AL Up to 64 yrs old

diazepam tab 2 mg 1 AL Up to 64 yrs old

diazepam tab 5 mg 1 AL Up to 64 yrs old

diphenhydramine hcl cap 50 mg 1 AL Up to 64 yrs old

diphenhydramine hcl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

diphenhydramine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

droperidol solution 2.5 mg/ml 1

eq allergy relief childrens elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

estazolam tab 1 mg 1

estazolam tab 2 mg 1

flurazepam hcl cap 15 mg 1 AL Up to 64 yrs old

FLURAZEPAM HCL CAP 15 MG AL Up to 64 yrs old flurazepam hcl 1

flurazepam hcl cap 30 mg 1 AL Up to 64 yrs old

FLURAZEPAM HCL CAP 30 MG AL Up to 64 yrs old flurazepam hcl 1

hydroxyzine hcl solution 10 mg/5ml 1 AL Up to 64 yrs old

HYDROXYZINE HCL SOLUTION 25 MG/ML AL Up to 64 yrs old hydroxyzine hcl 1

hydroxyzine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

hydroxyzine hcl syrup 10 mg/5ml 1 AL Up to 64 yrs old

PAGE 117 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydroxyzine hcl tab 10 mg 1 AL Up to 64 yrs old

hydroxyzine hcl tab 25 mg 1 AL Up to 64 yrs old

hydroxyzine hcl tab 50 mg 1 AL Up to 64 yrs old

HYDROXYZINE PAMOATE CAP 100 MG AL Up to 64 yrs old hydroxyzine pamoate 1

hydroxyzine pamoate cap 25 mg 1 AL Up to 64 yrs old

hydroxyzine pamoate cap 50 mg 1 AL Up to 64 yrs old

lorazepam conc 2 mg/ml 1 AL Up to 64 yrs old

LORAZEPAM INTENSOL CONC 2 MG/ML AL Up to 64 yrs old lorazepam 1

lorazepam solution 2 mg/ml 1 AL Up to 64 yrs old

lorazepam solution 4 mg/ml 1 AL Up to 64 yrs old

lorazepam tab 0.5 mg 1 AL Up to 64 yrs old

lorazepam tab 1 mg 1 AL Up to 64 yrs old

lorazepam tab 2 mg 1 AL Up to 64 yrs old

LUNESTA TAB 1 MG PA 3 eszopiclone AL Up to 64 yrs old

LUNESTA TAB 2 MG PA 3 eszopiclone AL Up to 64 yrs old

LUNESTA TAB 3 MG PA 3 eszopiclone AL Up to 64 yrs old

margesic cap 50-325-40 mg 1

marten-tab tab 50-325 mg 1

medi-phedryl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

meprobamate tab 200 mg 1 AL Up to 64 yrs old

meprobamate tab 400 mg 1 AL Up to 64 yrs old

oxazepam cap 10 mg 1 AL Up to 64 yrs old

oxazepam cap 15 mg 1 AL Up to 64 yrs old

oxazepam cap 30 mg 1 AL Up to 64 yrs old

PAGE 118 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

phenadoz suppos 12.5 mg 1 AL Up to 64 yrs old

phenadoz suppos 25 mg 1 AL Up to 64 yrs old

phenergan suppos 50 mg 1 AL Up to 64 yrs old

phenobarbital elixir 20 mg/5ml 1

phenobarbital solution 20 mg/5ml 1

phenobarbital tab 100 mg 1 PHENOBARBITAL TAB 100 MG phenobarbital 1

phenobarbital tab 15 mg 1 PHENOBARBITAL TAB 15 MG phenobarbital 1

phenobarbital tab 16.2 mg 1

phenobarbital tab 30 mg 1 PHENOBARBITAL TAB 30 MG phenobarbital 1

phenobarbital tab 32.4 mg 1

phenobarbital tab 60 mg 1 PHENOBARBITAL TAB 60 MG phenobarbital 1

phenobarbital tab 64.8 mg 1

phenobarbital tab 97.2 mg 1

promethazine hcl solution 25 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl suppos 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 25 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 50 mg 1 AL Up to 64 yrs old

promethazine hcl syrup 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl tab 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl tab 25 mg 1 AL Up to 64 yrs old

promethazine hcl tab 50 mg 1 AL Up to 64 yrs old

PAGE 119 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

promethegan suppos 12.5 mg 1 AL Up to 64 yrs old

promethegan suppos 25 mg 1 AL Up to 64 yrs old

promethegan suppos 50 mg 1 AL Up to 64 yrs old

quenalin syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

ROZEREM TAB 8 MG QL 30 / 30 days 3 ramelteon ST

silphen cough syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

temazepam cap 15 mg 1 AL Up to 64 yrs old

temazepam cap 22.5 mg 3 AL Up to 64 yrs old

temazepam cap 30 mg 1 AL Up to 64 yrs old

temazepam cap 7.5 mg 3 AL Up to 64 yrs old

triazolam tab 0.125 mg 1 AL Up to 64 yrs old

triazolam tab 0.25 mg 1 AL Up to 64 yrs old

zaleplon cap 10 mg 1 AL Up to 64 yrs old

zaleplon cap 5 mg 1 AL Up to 64 yrs old

QL 30 / 30 days zolpidem tartrate er tab er 12.5 mg 3 AL Up to 64 yrs old

QL 30 / 30 days zolpidem tartrate er tab er 6.25 mg 3 AL Up to 64 yrs old

zolpidem tartrate tab 10 mg 1 QL 30 / 30 days

zolpidem tartrate tab 5 mg 1 QL 30 / 30 days

ABILIFY DISCMELT TAB DISP 10 MG PA aripiprazole 4 ABILIFY DISCMELT TAB DISP 15 MG PA aripiprazole 4 ABILIFY MAINTENA RECON SUSP 300 MG PA aripiprazole 4 ABILIFY SOLUTION 1 MG/ML PA aripiprazole 4 ABILIFY SOLUTION 9.75 MG/1.3ML PA aripiprazole 4

PAGE 120 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ABILIFY TAB 10 MG PA aripiprazole 4 ABILIFY TAB 15 MG PA aripiprazole 4 ABILIFY TAB 2 MG PA aripiprazole 4 ABILIFY TAB 20 MG PA aripiprazole 4 ABILIFY TAB 30 MG PA aripiprazole 4 ABILIFY TAB 5 MG PA aripiprazole 4

QL 90 / 30 days buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 3 PA

QL 90 / 30 days buprenorphine hcl-naloxone hcl sl tab 8-2 mg 3 PA

carbamazepine chew tab 100 mg 1

carbamazepine er cap er 12h 100 mg 1

carbamazepine er cap er 12h 200 mg 1

carbamazepine er cap er 12h 300 mg 1

carbamazepine er tab er 12h 200 mg 1

carbamazepine er tab er 12h 400 mg 1

carbamazepine suspension 100 mg/5ml 1

carbamazepine tab 200 mg 1 CYMBALTA CP DR PART 20 MG PA duloxetine hcl 3 CYMBALTA CP DR PART 30 MG PA duloxetine hcl 3 CYMBALTA CP DR PART 60 MG PA duloxetine hcl 3

divalproex sodium cap sprink 125 mg 1

divalproex sodium er tab er 24h 250 mg 1

divalproex sodium er tab er 24h 500 mg 1

divalproex sodium tab dr 125 mg 1

divalproex sodium tab dr 250 mg 1

PAGE 121 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

divalproex sodium tab dr 500 mg 1

duloxetine hcl cp dr part 20 mg 3 QL 30 / 30 days

duloxetine hcl cp dr part 30 mg 3 QL 30 / 30 days

duloxetine hcl cp dr part 60 mg 3 QL 30 / 30 days

epitol tab 200 mg 1

guanfacine hcl tab 1 mg 1

guanfacine hcl tab 2 mg 1 LAMICTAL ODT KIT 25 & 50 & 100 MG lamotrigine 3 LAMICTAL ODT KIT 25 (21)-50 (7) MG lamotrigine 3 LAMICTAL ODT KIT 50 (42)-100(14) MG lamotrigine 3

lamotrigine chew tab 25 mg 1

lamotrigine chew tab 5 mg 1

lamotrigine er tab er 24h 100 mg 3

lamotrigine er tab er 24h 200 mg 3

lamotrigine er tab er 24h 25 mg 3

lamotrigine er tab er 24h 250 mg 3

lamotrigine er tab er 24h 300 mg 3

lamotrigine er tab er 24h 50 mg 3

lamotrigine tab 100 mg 1

lamotrigine tab 150 mg 1

lamotrigine tab 200 mg 1

lamotrigine tab 25 mg 1

lithium carbonate cap 150 mg 1 LITHIUM CARBONATE CAP 150 MG lithium carbonate 1

lithium carbonate cap 300 mg 1

lithium carbonate cap 600 mg 1 LITHIUM CARBONATE CAP 600 MG lithium carbonate 1

lithium carbonate er tab er 300 mg 1

PAGE 122 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lithium carbonate er tab er 450 mg 1

lithium carbonate tab 300 mg 1 LITHIUM SOLUTION 8 MEQ/5ML lithium 1 LYRICA CAP 100 MG PA pregabalin 3 LYRICA CAP 150 MG PA pregabalin 3 LYRICA CAP 200 MG PA pregabalin 3 LYRICA CAP 225 MG PA pregabalin 3 LYRICA CAP 25 MG PA pregabalin 3 LYRICA CAP 300 MG PA pregabalin 3 LYRICA CAP 50 MG PA pregabalin 3 LYRICA CAP 75 MG PA pregabalin 3 LYRICA SOLUTION 20 MG/ML PA pregabalin 3

naltrexone hcl tab 50 mg 1 NAMENDA SOLUTION 10 MG/5ML PA memantine hcl 3 NAMENDA TAB 10 MG PA memantine hcl 3 NAMENDA TAB 5 MG PA memantine hcl 3 NAMENDA TITRATION PAK TAB 5 (28)-10 (21) MG PA memantine hcl 3 NUEDEXTA CAP 20-10 MG PA dextromethorphan hbr-quinidine sulfate 4

olanzapine recon soln 10 mg 3 PA

olanzapine tab 10 mg 3 ST

olanzapine tab 15 mg 3 ST

olanzapine tab 2.5 mg 3 ST

PAGE 123 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

olanzapine tab 20 mg 3 ST

olanzapine tab 5 mg 3 ST

olanzapine tab 7.5 mg 3 ST

olanzapine tab disp 10 mg 3 PA

olanzapine tab disp 15 mg 3 PA

olanzapine tab disp 20 mg 3 PA

olanzapine tab disp 5 mg 3 PA

pentazocine-naloxone hcl tab 50-0.5 mg 1

quetiapine fumarate tab 100 mg 1

quetiapine fumarate tab 200 mg 1

quetiapine fumarate tab 25 mg 1

quetiapine fumarate tab 300 mg 1

quetiapine fumarate tab 400 mg 1

quetiapine fumarate tab 50 mg 1 RILUTEK TAB 50 MG riluzole 4

risperidone m-tab tab disp 0.5 mg 3

risperidone m-tab tab disp 1 mg 3

risperidone m-tab tab disp 2 mg 3

risperidone m-tab tab disp 3 mg 3

risperidone m-tab tab disp 4 mg 3

risperidone solution 1 mg/ml 3

risperidone tab 0.25 mg 1

risperidone tab 0.5 mg 1

risperidone tab 1 mg 1

risperidone tab 2 mg 1

risperidone tab 3 mg 1

risperidone tab 4 mg 1

risperidone tab disp 0.25 mg 3

risperidone tab disp 0.5 mg 3

PAGE 124 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

risperidone tab disp 1 mg 3

risperidone tab disp 2 mg 3

risperidone tab disp 3 mg 3

risperidone tab disp 4 mg 3 SAPHRIS SL TAB 10 MG ST asenapine maleate 3 SAPHRIS SL TAB 5 MG ST asenapine maleate 3 SAVELLA TAB 100 MG PA milnacipran hcl 3 SAVELLA TAB 12.5 MG PA milnacipran hcl 3 SAVELLA TAB 25 MG PA milnacipran hcl 3 SAVELLA TAB 50 MG PA milnacipran hcl 3 SEROQUEL XR TAB ER 24H 150 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 200 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 300 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 400 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 50 MG ST quetiapine fumarate 3 STAVZOR CAP DR 125 MG PA valproic acid 3

STRATTERA CAP 10 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

STRATTERA CAP 100 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

STRATTERA CAP 18 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

STRATTERA CAP 25 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

PAGE 125 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

STRATTERA CAP 40 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

STRATTERA CAP 60 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

STRATTERA CAP 80 MG PA 3 atomoxetine hcl AL 6 to 17 yrs old

SUBOXONE FILM 12-3 MG QL 30 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

SUBOXONE FILM 2-0.5 MG QL 90 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

SUBOXONE FILM 4-1 MG QL 90 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

SUBOXONE FILM 8-2 MG QL 60 / 30 days 3 buprenorphine hcl-naloxone hcl dihydrate PA

TEGRETOL-XR TAB ER 12H 100 MG carbamazepine 2

valproic acid cap 250 mg 1

valproic acid solution 250 mg/5ml 1

valproic acid syrup 250 mg/5ml 1 VIVITROL RECON SUSP 380 MG PA naltrexone 4 XENAZINE TAB 12.5 MG PA tetrabenazine 4 XENAZINE TAB 25 MG PA tetrabenazine 4 XYREM SOLUTION 500 MG/ML PA sodium oxybate 4

ziprasidone hcl cap 20 mg 3 ST

ziprasidone hcl cap 40 mg 3 ST

ziprasidone hcl cap 60 mg 3 ST

ziprasidone hcl cap 80 mg 3 ST

PAGE 126 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Psychotherapeutic Agents

ABILIFY DISCMELT TAB DISP 10 MG PA aripiprazole 4 ABILIFY DISCMELT TAB DISP 15 MG PA aripiprazole 4 ABILIFY MAINTENA RECON SUSP 300 MG PA aripiprazole 4 ABILIFY SOLUTION 1 MG/ML PA aripiprazole 4 ABILIFY SOLUTION 9.75 MG/1.3ML PA aripiprazole 4 ABILIFY TAB 10 MG PA aripiprazole 4 ABILIFY TAB 15 MG PA aripiprazole 4 ABILIFY TAB 2 MG PA aripiprazole 4 ABILIFY TAB 20 MG PA aripiprazole 4 ABILIFY TAB 30 MG PA aripiprazole 4 ABILIFY TAB 5 MG PA aripiprazole 4

amitriptyline hcl tab 10 mg 1 AL Up to 64 yrs old

amitriptyline hcl tab 100 mg 1 AL Up to 64 yrs old

amitriptyline hcl tab 150 mg 1 AL Up to 64 yrs old

amitriptyline hcl tab 25 mg 1 AL Up to 64 yrs old

amitriptyline hcl tab 50 mg 1 AL Up to 64 yrs old

amitriptyline hcl tab 75 mg 1 AL Up to 64 yrs old

AMOXAPINE TAB 100 MG AL Up to 64 yrs old amoxapine 1 AMOXAPINE TAB 150 MG AL Up to 64 yrs old amoxapine 1 AMOXAPINE TAB 25 MG AL Up to 64 yrs old amoxapine 1 AMOXAPINE TAB 50 MG AL Up to 64 yrs old amoxapine 1

PAGE 127 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AZILECT TAB 0.5 MG rasagiline mesylate 3 AZILECT TAB 1 MG rasagiline mesylate 3

buproban tab er 12h 150 mg 5

bupropion hcl er (sr) tab er 12h 100 mg 1

bupropion hcl er (sr) tab er 12h 150 mg 5

bupropion hcl er (sr) tab er 12h 200 mg 1

bupropion hcl er (xl) tab er 24h 150 mg 1

bupropion hcl er (xl) tab er 24h 300 mg 1

bupropion hcl tab 100 mg 1

bupropion hcl tab 75 mg 1 CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 10-25 MG chlordiazepoxide-amitriptyline 1 CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 5-12.5 MG chlordiazepoxide-amitriptyline 1

chlorpromazine hcl tab 10 mg 1

chlorpromazine hcl tab 100 mg 1

chlorpromazine hcl tab 200 mg 1

chlorpromazine hcl tab 25 mg 1

chlorpromazine hcl tab 50 mg 1

citalopram hydrobromide solution 10 mg/5ml 1

citalopram hydrobromide tab 10 mg 1 QL 51 / 30 days

citalopram hydrobromide tab 20 mg 1 QL 51 / 30 days

citalopram hydrobromide tab 40 mg 1 QL 51 / 30 days

clomipramine hcl cap 25 mg 1 AL Up to 64 yrs old

clomipramine hcl cap 50 mg 1 AL Up to 64 yrs old

clomipramine hcl cap 75 mg 1 AL Up to 64 yrs old

clozapine tab 100 mg 1

clozapine tab 200 mg 1

clozapine tab 25 mg 1

clozapine tab 50 mg 1

PAGE 128 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLOZAPINE TAB DISP 100 MG clozapine 3 CLOZAPINE TAB DISP 12.5 MG clozapine 3 CLOZAPINE TAB DISP 25 MG clozapine 3

compro suppos 25 mg 1 CYMBALTA CP DR PART 20 MG PA duloxetine hcl 3 CYMBALTA CP DR PART 30 MG PA duloxetine hcl 3 CYMBALTA CP DR PART 60 MG PA duloxetine hcl 3

desipramine hcl tab 10 mg 1 QL 60 / 30 days

desipramine hcl tab 100 mg 1 QL 60 / 30 days

desipramine hcl tab 150 mg 1 QL 60 / 30 days

desipramine hcl tab 25 mg 1 QL 60 / 30 days

desipramine hcl tab 50 mg 1 QL 60 / 30 days

desipramine hcl tab 75 mg 1 QL 60 / 30 days

DESVENLAFAXINE ER TAB ER 24H 100 MG desvenlafaxine 1 DESVENLAFAXINE ER TAB ER 24H 50 MG desvenlafaxine 1 DESVENLAFAXINE FUMARATE ER TAB ER 24H 100 MG desvenlafaxine fumarate 1 DESVENLAFAXINE FUMARATE ER TAB ER 24H 50 MG desvenlafaxine fumarate 1

doxepin hcl cap 10 mg 1 AL Up to 64 yrs old

doxepin hcl cap 100 mg 1 AL Up to 64 yrs old

doxepin hcl cap 150 mg 1 AL Up to 64 yrs old

doxepin hcl cap 25 mg 1 AL Up to 64 yrs old

doxepin hcl cap 50 mg 1 AL Up to 64 yrs old

DOXEPIN HCL CAP 75 MG AL Up to 64 yrs old doxepin hcl 1

PAGE 129 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

doxepin hcl conc 10 mg/ml 1 AL Up to 64 yrs old

duloxetine hcl cp dr part 20 mg 3 QL 30 / 30 days

duloxetine hcl cp dr part 30 mg 3 QL 30 / 30 days

duloxetine hcl cp dr part 60 mg 3 QL 30 / 30 days

EMSAM PATCH 24HR 12 MG/24HR ST selegiline 3 EMSAM PATCH 24HR 6 MG/24HR ST selegiline 3 EMSAM PATCH 24HR 9 MG/24HR ST selegiline 3

escitalopram oxalate solution 5 mg/5ml 1 ST

escitalopram oxalate tab 10 mg 1 QL 45 / 30 days

escitalopram oxalate tab 20 mg 1 QL 30 / 30 days

escitalopram oxalate tab 5 mg 1 QL 45 / 30 days

FANAPT TAB 1 MG PA iloperidone 4 FANAPT TAB 10 MG PA iloperidone 4 FANAPT TAB 12 MG PA iloperidone 4 FANAPT TAB 2 MG PA iloperidone 4 FANAPT TAB 4 MG PA iloperidone 4 FANAPT TAB 6 MG PA iloperidone 4 FANAPT TAB 8 MG PA iloperidone 4

fluoxetine hcl (pmdd) cap 10 mg 1

fluoxetine hcl (pmdd) cap 20 mg 1

fluoxetine hcl cap 10 mg 1

fluoxetine hcl cap 20 mg 1

fluoxetine hcl cap 40 mg 1

fluoxetine hcl cap dr 90 mg 1 QL 4 / 28 days

PAGE 130 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluoxetine hcl solution 20 mg/5ml 1

fluoxetine hcl tab 10 mg 1

fluoxetine hcl tab 20 mg 1

fluphenazine decanoate solution 25 mg/ml 3 FLUPHENAZINE HCL CONC 5 MG/ML fluphenazine hcl 3 FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML fluphenazine hcl 1 FLUPHENAZINE HCL SOLUTION 2.5 MG/ML fluphenazine hcl 3

fluphenazine hcl tab 1 mg 1

fluphenazine hcl tab 10 mg 1

fluphenazine hcl tab 2.5 mg 1

fluphenazine hcl tab 5 mg 1

fluvoxamine maleate tab 100 mg 1

fluvoxamine maleate tab 25 mg 1

fluvoxamine maleate tab 50 mg 1

haloperidol decanoate solution 100 mg/ml 3

haloperidol decanoate solution 50 mg/ml 3

haloperidol lactate conc 2 mg/ml 1

haloperidol lactate solution 5 mg/ml 3

haloperidol tab 0.5 mg 1

haloperidol tab 1 mg 1

haloperidol tab 10 mg 1

haloperidol tab 2 mg 1

haloperidol tab 20 mg 1

haloperidol tab 5 mg 1

imipramine hcl tab 10 mg 1 AL Up to 64 yrs old

imipramine hcl tab 25 mg 1 AL Up to 64 yrs old

imipramine hcl tab 50 mg 1 AL Up to 64 yrs old

imipramine pamoate cap 100 mg 3 AL Up to 64 yrs old

imipramine pamoate cap 125 mg 3 AL Up to 64 yrs old

PAGE 131 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

imipramine pamoate cap 150 mg 3 AL Up to 64 yrs old

imipramine pamoate cap 75 mg 3 AL Up to 64 yrs old

INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML PA paliperidone palmitate 4 INVEGA SUSTENNA SUSPENSION 156 MG/ML PA paliperidone palmitate 4 INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML PA paliperidone palmitate 4 INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML PA paliperidone palmitate 4 INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML PA paliperidone palmitate 4 INVEGA TAB ER 24H 1.5 MG PA paliperidone 4 INVEGA TAB ER 24H 3 MG PA paliperidone 4 INVEGA TAB ER 24H 6 MG PA paliperidone 4 INVEGA TAB ER 24H 9 MG PA paliperidone 4 LATUDA TAB 120 MG PA lurasidone hcl 3 LATUDA TAB 20 MG PA lurasidone hcl 3 LATUDA TAB 40 MG PA lurasidone hcl 3 LATUDA TAB 80 MG PA lurasidone hcl 3

loxapine succinate cap 10 mg 1

loxapine succinate cap 25 mg 1

loxapine succinate cap 5 mg 1

loxapine succinate cap 50 mg 1 MAPROTILINE HCL TAB 25 MG maprotiline hcl 1 MAPROTILINE HCL TAB 50 MG maprotiline hcl 1 MAPROTILINE HCL TAB 75 MG maprotiline hcl 1

PAGE 132 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MARPLAN TAB 10 MG isocarboxazid 3

mirtazapine tab 15 mg 1 AL Up to 64 yrs old

mirtazapine tab 30 mg 1 AL Up to 64 yrs old

mirtazapine tab 45 mg 1 AL Up to 64 yrs old

mirtazapine tab 7.5 mg 1 AL Up to 64 yrs old

mirtazapine tab disp 15 mg 3 AL Up to 64 yrs old

mirtazapine tab disp 30 mg 3 AL Up to 64 yrs old

mirtazapine tab disp 45 mg 3 AL Up to 64 yrs old

NEFAZODONE HCL TAB 100 MG nefazodone hcl 1 NEFAZODONE HCL TAB 150 MG nefazodone hcl 1 NEFAZODONE HCL TAB 200 MG nefazodone hcl 1

nefazodone hcl tab 250 mg 1 NEFAZODONE HCL TAB 50 MG nefazodone hcl 1

nortriptyline hcl cap 10 mg 1

nortriptyline hcl cap 25 mg 1

nortriptyline hcl cap 50 mg 1

nortriptyline hcl cap 75 mg 1

nortriptyline hcl solution 10 mg/5ml 1 NORTRIPTYLINE HCL SOLUTION 10 MG/5ML nortriptyline hcl 1

olanzapine recon soln 10 mg 3 PA

olanzapine tab 10 mg 3 ST

olanzapine tab 15 mg 3 ST

olanzapine tab 2.5 mg 3 ST

olanzapine tab 20 mg 3 ST

olanzapine tab 5 mg 3 ST

PAGE 133 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

olanzapine tab 7.5 mg 3 ST

olanzapine tab disp 10 mg 3 PA

olanzapine tab disp 15 mg 3 PA

olanzapine tab disp 20 mg 3 PA

olanzapine tab disp 5 mg 3 PA

olanzapine-fluoxetine hcl cap 12-25 mg 3

olanzapine-fluoxetine hcl cap 12-50 mg 3

olanzapine-fluoxetine hcl cap 3-25 mg 3

olanzapine-fluoxetine hcl cap 6-25 mg 3

olanzapine-fluoxetine hcl cap 6-50 mg 3 ORAP TAB 1 MG PA pimozide 3 ORAP TAB 2 MG PA pimozide 3

paroxetine hcl er tab er 24h 12.5 mg 3

paroxetine hcl er tab er 24h 25 mg 3

paroxetine hcl er tab er 24h 37.5 mg 3

paroxetine hcl tab 10 mg 1

paroxetine hcl tab 20 mg 1

paroxetine hcl tab 30 mg 1

paroxetine hcl tab 40 mg 1 PAXIL SUSPENSION 10 MG/5ML PA paroxetine hcl 2

perphenazine tab 16 mg 1

perphenazine tab 2 mg 1

perphenazine tab 4 mg 1

perphenazine tab 8 mg 1 PERPHENAZINE-AMITRIPTYLINE TAB 2-10 MG perphenazine-amitriptyline 1 PERPHENAZINE-AMITRIPTYLINE TAB 2-25 MG perphenazine-amitriptyline 1 PERPHENAZINE-AMITRIPTYLINE TAB 4-10 MG perphenazine-amitriptyline 1

PAGE 134 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PERPHENAZINE-AMITRIPTYLINE TAB 4-25 MG perphenazine-amitriptyline 1 PERPHENAZINE-AMITRIPTYLINE TAB 4-50 MG perphenazine-amitriptyline 1

phenelzine sulfate tab 15 mg 1 PRISTIQ TAB ER 24H 100 MG PA desvenlafaxine succinate 3 PRISTIQ TAB ER 24H 50 MG PA desvenlafaxine succinate 3

prochlorperazine edisylate solution 5 mg/ml 3

prochlorperazine maleate tab 10 mg 1

prochlorperazine maleate tab 5 mg 1

prochlorperazine suppos 25 mg 1

quetiapine fumarate tab 100 mg 1

quetiapine fumarate tab 200 mg 1

quetiapine fumarate tab 25 mg 1

quetiapine fumarate tab 300 mg 1

quetiapine fumarate tab 400 mg 1

quetiapine fumarate tab 50 mg 1

risperidone m-tab tab disp 0.5 mg 3

risperidone m-tab tab disp 1 mg 3

risperidone m-tab tab disp 2 mg 3

risperidone m-tab tab disp 3 mg 3

risperidone m-tab tab disp 4 mg 3

risperidone solution 1 mg/ml 3

risperidone tab 0.25 mg 1

risperidone tab 0.5 mg 1

risperidone tab 1 mg 1

risperidone tab 2 mg 1

risperidone tab 3 mg 1

risperidone tab 4 mg 1

risperidone tab disp 0.25 mg 3

risperidone tab disp 0.5 mg 3

PAGE 135 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

risperidone tab disp 1 mg 3

risperidone tab disp 2 mg 3

risperidone tab disp 3 mg 3

risperidone tab disp 4 mg 3 SAPHRIS SL TAB 10 MG ST asenapine maleate 3 SAPHRIS SL TAB 5 MG ST asenapine maleate 3 SAVELLA TAB 100 MG PA milnacipran hcl 3 SAVELLA TAB 12.5 MG PA milnacipran hcl 3 SAVELLA TAB 25 MG PA milnacipran hcl 3 SAVELLA TAB 50 MG PA milnacipran hcl 3

selegiline hcl cap 5 mg 1

selegiline hcl tab 5 mg 1 SEROQUEL XR TAB ER 24H 150 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 200 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 300 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 400 MG ST quetiapine fumarate 3 SEROQUEL XR TAB ER 24H 50 MG ST quetiapine fumarate 3

sertraline hcl conc 20 mg/ml 1 PA

sertraline hcl tab 100 mg 1

sertraline hcl tab 25 mg 1

sertraline hcl tab 50 mg 1

thiothixene cap 1 mg 1

thiothixene cap 10 mg 1

thiothixene cap 2 mg 1

thiothixene cap 5 mg 1

PAGE 136 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tranylcypromine sulfate tab 10 mg 1

trazodone hcl tab 100 mg 1

trazodone hcl tab 150 mg 1

trazodone hcl tab 300 mg 1

trazodone hcl tab 50 mg 1

trifluoperazine hcl tab 1 mg 1

trifluoperazine hcl tab 10 mg 1

trifluoperazine hcl tab 2 mg 1

trifluoperazine hcl tab 5 mg 1

trimipramine maleate cap 100 mg 3

trimipramine maleate cap 25 mg 3

trimipramine maleate cap 50 mg 3

venlafaxine hcl er cap er 24h 150 mg 1

venlafaxine hcl er cap er 24h 37.5 mg 1

venlafaxine hcl er cap er 24h 75 mg 1

venlafaxine hcl er tab er 24h 150 mg 3 VENLAFAXINE HCL ER TAB ER 24H 150 MG venlafaxine hcl 3 VENLAFAXINE HCL ER TAB ER 24H 225 MG venlafaxine hcl 3

venlafaxine hcl er tab er 24h 37.5 mg 3 VENLAFAXINE HCL ER TAB ER 24H 37.5 MG venlafaxine hcl 3

venlafaxine hcl er tab er 24h 75 mg 3 VENLAFAXINE HCL ER TAB ER 24H 75 MG venlafaxine hcl 3

venlafaxine hcl tab 100 mg 1

venlafaxine hcl tab 25 mg 1

venlafaxine hcl tab 37.5 mg 1

venlafaxine hcl tab 50 mg 1

venlafaxine hcl tab 75 mg 1 VIIBRYD KIT 10 & 20 & 40 MG PA vilazodone hcl 3

PAGE 137 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIIBRYD TAB 10 MG PA vilazodone hcl 3 VIIBRYD TAB 20 MG PA vilazodone hcl 3 VIIBRYD TAB 40 MG PA vilazodone hcl 3

ziprasidone hcl cap 20 mg 3 ST

ziprasidone hcl cap 40 mg 3 ST

ziprasidone hcl cap 60 mg 3 ST

ziprasidone hcl cap 80 mg 3 ST

Electrolytic, Caloric, and Water Balance

Diuretics

acetazolamide er cap er 12h 500 mg 1 ACETAZOLAMIDE TAB 125 MG acetazolamide 1

acetazolamide tab 250 mg 1

amiloride hcl tab 5 mg 1

amiloride-hydrochlorothiazide tab 5-50 mg 1

atenolol-chlorthalidone tab 100-25 mg 1

atenolol-chlorthalidone tab 50-25 mg 1

benazepril-hydrochlorothiazide tab 10-12.5 mg 1

benazepril-hydrochlorothiazide tab 20-12.5 mg 1

benazepril-hydrochlorothiazide tab 20-25 mg 1

benazepril-hydrochlorothiazide tab 5-6.25 mg 1 BENICAR HCT TAB 20-12.5 MG ST olmesartan medoxomil-hydrochlorothiazide 3 BENICAR HCT TAB 40-12.5 MG ST olmesartan medoxomil-hydrochlorothiazide 3 BENICAR HCT TAB 40-25 MG ST olmesartan medoxomil-hydrochlorothiazide 3

bisoprolol-hydrochlorothiazide tab 10-6.25 mg 1

bisoprolol-hydrochlorothiazide tab 2.5-6.25 mg 1

bisoprolol-hydrochlorothiazide tab 5-6.25 mg 1

PAGE 138 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bumetanide solution 0.25 mg/ml 1

bumetanide tab 0.5 mg 1

bumetanide tab 1 mg 1

bumetanide tab 2 mg 1

candesartan cilexetil-hctz tab 16-12.5 mg 1

candesartan cilexetil-hctz tab 32-12.5 mg 1

candesartan cilexetil-hctz tab 32-25 mg 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-15 MG captopril & hydrochlorothiazide 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-25 MG captopril & hydrochlorothiazide 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 50-15 MG captopril & hydrochlorothiazide 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 50-25 MG captopril & hydrochlorothiazide 1

chlorothiazide tab 250 mg 1 CHLOROTHIAZIDE TAB 250 MG chlorothiazide 1

chlorothiazide tab 500 mg 1 CHLORTHALIDONE TAB 25 MG chlorthalidone 1 CHLORTHALIDONE TAB 50 MG chlorthalidone 1 DYRENIUM CAP 100 MG triamterene 3 EDECRIN TAB 25 MG ethacrynic acid 3 ELIXOPHYLLIN ELIXIR 80 MG/15ML theophylline 2

enalapril-hydrochlorothiazide tab 10-25 mg 1

enalapril-hydrochlorothiazide tab 5-12.5 mg 1

eplerenone tab 25 mg 3

eplerenone tab 50 mg 3

fosinopril sodium-hctz tab 10-12.5 mg 1

fosinopril sodium-hctz tab 20-12.5 mg 1

PAGE 139 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

furosemide solution 10 mg/ml 1

furosemide solution 10 mg/ml 1 FUROSEMIDE SOLUTION 8 MG/ML furosemide 1

furosemide tab 20 mg 1

furosemide tab 40 mg 1

furosemide tab 80 mg 1

hydrochlorothiazide cap 12.5 mg 1

hydrochlorothiazide tab 12.5 mg 1

hydrochlorothiazide tab 25 mg 1

hydrochlorothiazide tab 50 mg 1

indapamide tab 1.25 mg 1

indapamide tab 2.5 mg 1

irbesartan-hydrochlorothiazide tab 150-12.5 mg 1

irbesartan-hydrochlorothiazide tab 300-12.5 mg 1

lisinopril-hydrochlorothiazide tab 10-12.5 mg 1

lisinopril-hydrochlorothiazide tab 20-12.5 mg 1

lisinopril-hydrochlorothiazide tab 20-25 mg 1

losartan potassium-hctz tab 100-12.5 mg 1 QL 30 / 30 days

losartan potassium-hctz tab 100-25 mg 1 QL 30 / 30 days

losartan potassium-hctz tab 50-12.5 mg 1 QL 30 / 30 days

METHYCLOTHIAZIDE TAB 5 MG methyclothiazide 1

metolazone tab 10 mg 1

metolazone tab 2.5 mg 1

metolazone tab 5 mg 1

metoprolol-hydrochlorothiazide tab 100-25 mg 1

metoprolol-hydrochlorothiazide tab 100-50 mg 1

metoprolol-hydrochlorothiazide tab 50-25 mg 1 MICARDIS HCT TAB 40-12.5 MG ST telmisartan-hydrochlorothiazide 3 MICARDIS HCT TAB 80-12.5 MG ST telmisartan-hydrochlorothiazide 3

PAGE 140 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MICARDIS HCT TAB 80-25 MG ST telmisartan-hydrochlorothiazide 3

moexipril-hydrochlorothiazide tab 15-12.5 mg 1

moexipril-hydrochlorothiazide tab 15-25 mg 1

moexipril-hydrochlorothiazide tab 7.5-12.5 mg 1

nadolol-bendroflumethiazide tab 40-5 mg 1

nadolol-bendroflumethiazide tab 80-5 mg 1 PROPRANOLOL-HCTZ TAB 40-25 MG propranolol & hydrochlorothiazide 1 PROPRANOLOL-HCTZ TAB 80-25 MG propranolol & hydrochlorothiazide 1

quinapril-hydrochlorothiazide tab 10-12.5 mg 1

quinapril-hydrochlorothiazide tab 20-12.5 mg 1

quinapril-hydrochlorothiazide tab 20-25 mg 1 SAMSCA TAB 15 MG PA tolvaptan 4 SAMSCA TAB 30 MG PA tolvaptan 4

spironolactone tab 100 mg 1

spironolactone tab 25 mg 1

spironolactone tab 50 mg 1

spironolactone-hctz tab 25-25 mg 1 TEKTURNA HCT TAB 150-12.5 MG aliskiren-hydrochlorothiazide 3 TEKTURNA HCT TAB 150-25 MG aliskiren-hydrochlorothiazide 3 TEKTURNA HCT TAB 300-12.5 MG aliskiren-hydrochlorothiazide 3 TEKTURNA HCT TAB 300-25 MG aliskiren-hydrochlorothiazide 3

theochron tab er 12h 100 mg 1

theochron tab er 12h 200 mg 1

theochron tab er 12h 300 mg 1

theophylline er tab er 12h 100 mg 1

theophylline er tab er 12h 200 mg 1

PAGE 141 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

theophylline er tab er 12h 300 mg 1

theophylline er tab er 12h 450 mg 1

theophylline er tab er 24h 400 mg 1

theophylline er tab er 24h 600 mg 1

theophylline solution 80 mg/15ml 1

torsemide tab 10 mg 1

torsemide tab 100 mg 1

torsemide tab 20 mg 1

torsemide tab 5 mg 1

triamterene-hctz cap 37.5-25 mg 1

triamterene-hctz tab 37.5-25 mg 1

triamterene-hctz tab 75-50 mg 1

valsartan-hydrochlorothiazide tab 160-12.5 mg 1

valsartan-hydrochlorothiazide tab 160-25 mg 1

valsartan-hydrochlorothiazide tab 320-12.5 mg 1

valsartan-hydrochlorothiazide tab 320-25 mg 1

valsartan-hydrochlorothiazide tab 80-12.5 mg 1

acetic acid solution 0.25 % 1

aminoacetic acid solution 1.5 % 1

argyle sterile saline solution 0.9 % 1 AVORIA CAL+D PACKET 500-40-60-400 calcium-magnesium-vitamin c-vitamin d 5 AVORIA GC+ PACKET glucosamine-chondroitin-calcium-magnesium-vit c-vit d 5 BP FOLINATAL PLUS B TAB 1 MG prenatal w/ calcium carbonate-vit b6-vit b12-folic acid 1

calcium acetate (phos binder) tab 667 mg 1

calcium acetate cap 667 mg 1

citric acid-sodium citrate solution 334-500 mg/5ml 1

colchicine-probenecid tab 0.5-500 mg 1

constulose solution 10 gm/15ml 1

curity sterile saline solution 0.9 % 1

cytra-2 solution 500-334 mg/5ml 1

PAGE 142 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYTRA-3 SYRUP 550-500-334 MG/5ML pot & sod citrates w/citric ac 1 EFFER-K EFFER TAB 10 MEQ potassium bicarbonate-citric acid 3 EFFER-K EFFER TAB 20 MEQ potassium bicarbonate-citric acid 3

effer-k effer tab 25 meq 1

effervescent pot chloride effer tab 25 meq 1

enulose solution 10 gm/15ml 1

generlac solution 10 gm/15ml 1

glycine solution 1.5 % 1

glycine urologic solution 1.5 % 1

k-effervescent effer tab 25 meq 1

k-sol solution 20 meq/15ml (10%) 1

k-sol solution 40 meq/15ml (20%) 1

k-vescent effer tab 25 meq 1

k-vescent packet 20 meq 1

klor-con 10 tab er 10 meq 1 KLOR-CON M15 TAB ER 15 MEQ potassium chloride microencapsulated crystals cr 3

klor-con m20 tab er 20 meq 1

klor-con packet 20 meq 1 PA

klor-con tab er 8 meq 1

klor-con/ef effer tab 25 meq 1 KRISTALOSE PACKET 10 GM PA lactulose 3 KRISTALOSE PACKET 20 GM PA lactulose 3

lactulose encephalopathy solution 10 gm/15ml 1

lactulose solution 10 gm/15ml 1

n-acetyl-l-cysteine cap 600 mg 1

nac 600 cap 600 mg 1

nac cap 600 mg 1

nf formulas nac cap 600 mg 1

PAGE 143 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

normal saline flush solution 0.9 % 3

one daily mens tab 1

one daily womens tab 1 PHOSLYRA SOLUTION 667 MG/5ML calcium acetate (phosphate binder) 3

phospha 250 neutral tab 155-852-130 mg 1

pot bicarb-pot chloride effer tab 25 meq 1

potassium bicarbonate effer tab 25 meq 1

potassium chloride crys er tab er 10 meq 1

potassium chloride crys er tab er 20 meq 1

potassium chloride er cap er 10 meq 1

potassium chloride er cap er 8 meq 1

potassium chloride er tab er 10 meq 1

potassium chloride er tab er 8 meq 1 POTASSIUM CHLORIDE ER TAB ER 8 MEQ potassium chloride 1

potassium chloride liquid 20 meq/15ml (10%) 1

potassium chloride liquid 40 meq/15ml (20%) 1

potassium chloride packet 20 meq 1

potassium chloride solution 20 meq/15ml (10%) 1

potassium citrate er tab er 10 meq (1080 mg) 1

potassium citrate er tab er 5 meq (540 mg) 1

potassium citrate-citric acid solution 1100-334 mg/5ml 1 PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5

probenecid tab 500 mg 1 RX SUPPORT HB/REFLUX/ALOE TAB folic acid-cyanocobalamin-vit b6-vit d-calcium-aloe 5

sodium chloride flush solution 0.9 % 1

sodium chloride solution 0.9 % 1

sodium chloride solution 0.9 % 1

sodium chloride solution 0.9 % 1 SORBITOL SOLUTION 3 % sorbitol irrigation 1

PAGE 144 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SORBITOL SOLUTION 3.3 % sorbitol irrigation 1 SORBITOL-MANNITOL SOLUTION 2.7-0.54 GM/100ML sorbitol-mannitol 1 UROCIT-K 10 TAB ER 10 MEQ (1080 MG) potassium citrate (alkalinizer) 2 UROCIT-K 15 TAB ER 15 MEQ (1620 MG) potassium citrate (alkalinizer) 3 UROCIT-K 5 TAB ER 5 MEQ (540 MG) potassium citrate (alkalinizer) 2

zinc sulfate cap 220 mg 1 Ion-removing Agents

calcium acetate (phos binder) tab 667 mg 1

calcium acetate cap 667 mg 1 FOSRENOL CHEW TAB 1000 MG PA lanthanum carbonate 3 FOSRENOL CHEW TAB 500 MG PA lanthanum carbonate 3 FOSRENOL CHEW TAB 750 MG PA lanthanum carbonate 3

kionex suspension 15 gm/60ml 1 PHOSLYRA SOLUTION 667 MG/5ML calcium acetate (phosphate binder) 3 RENAGEL TAB 400 MG PA sevelamer hcl 3 RENAGEL TAB 800 MG PA sevelamer hcl 3 RENVELA PACKET 0.8 GM PA sevelamer carbonate 3 RENVELA PACKET 2.4 GM PA sevelamer carbonate 3 RENVELA TAB 800 MG PA sevelamer carbonate 3

sodium polystyrene sulfonate suspension 15 gm/60ml 1

sodium polystyrene sulfonate suspension 30 gm/120ml 1

sodium polystyrene sulfonate suspension 50 gm/200ml 1

PAGE 145 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Eye, Ear, Nose & Throat Preparations

Anti-infectives

ak-poly-bac ointment 500-10000 unit/gm 1 AZASITE SOLUTION 1 % PA azithromycin (ophth) 3

bacitra-neomycin-polymyxin-hc ointment 1 % 1 BACITRACIN OINTMENT 500 UNIT/GM bacitracin (ophthalmic) 1 BESIVANCE SUSPENSION 0.6 % besifloxacin hcl 3 BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % sulfacetamide sod-prednisolone 2

chlorhexidine gluconate solution 0.12 % 1 CILOXAN OINTMENT 0.3 % ciprofloxacin hcl (ophth) 3 CIPRO HC SUSPENSION 0.2-1 % PA ciprofloxacin-hydrocortisone 3 CIPRODEX SUSPENSION 0.3-0.1 % ciprofloxacin-dexamethasone 3 CIPROFLOXACIN HCL SOLUTION 0.2 % ciprofloxacin hcl (otic) 1

ciprofloxacin hcl solution 0.3 % 1 COLY-MYCIN S SUSPENSION 3.3-3-10-0.5 MG/ML neomycin-colistin-hc-thonzonium 3 CORTISPORIN-TC SUSPENSION 3.3-3-10-0.5 MG/ML neomycin-colistin-hc-thonzonium 3

erythromycin ointment 5 mg/gm 1

gentak ointment 0.3 % 1

gentamicin sulfate ointment 0.3 % 1

gentamicin sulfate solution 0.3 % 1

levofloxacin solution 0.5 % 1 PA

MOXEZA SOLUTION 0.5 % moxifloxacin hcl (ophth) 3 NATACYN SUSPENSION 5 % PA natamycin 3

neo-polycin hc ointment 1 % 1

PAGE 146 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

neo-polycin ointment 3.5-400-10000 1

neomycin-bacitracin zn-polymyx ointment 5-400-10000 1

neomycin-polymyxin-dexameth ointment 3.5-10000-0.1 1

neomycin-polymyxin-dexameth suspension 3.5-10000-0.1 1

neomycin-polymyxin-gramicidin solution 1.75-10000-.025 1

neomycin-polymyxin-hc solution 1 % 1

neomycin-polymyxin-hc solution 3.5-10000-1 1 NEOMYCIN-POLYMYXIN-HC SUSPENSION 3.5-10000-1 neomycin-polymyxin-hc (ophth) 1

neomycin-polymyxin-hc suspension 3.5-10000-1 1

ofloxacin solution 0.3 % 1

ofloxacin solution 0.3 % 1

periogard solution 0.12 % 1

poly-dex ointment 3.5-10000-0.1 1

polycin b ointment 500-10000 unit/gm 1

polymyxin b-trimethoprim solution 10000-0.1 unit/ml-% 1

romycin ointment 5 mg/gm 1 SILVER NITRATE OINTMENT 10 % silver nitrate 1 SILVER NITRATE SOLUTION 0.5 % silver nitrate 1 SILVER NITRATE SOLUTION 10 % silver nitrate 1 SILVER NITRATE SOLUTION 25 % silver nitrate 1 SILVER NITRATE SOLUTION 50 % silver nitrate 1

sulfacetamide sodium solution 10 % 1

sulfacetamide-prednisolone solution 10-0.23 % 1 TOBRADEX OINTMENT 0.3-0.1 % QL 3.5 / 10 days tobramycin-dexamethasone 3 TOBRADEX ST SUSPENSION 0.3-0.05 % QL 1 / 10 days tobramycin-dexamethasone 2

tobramycin solution 0.3 % 1

tobramycin-dexamethasone suspension 0.3-0.1 % 1 QL 5 / 10 days

PAGE 147 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TOBREX OINTMENT 0.3 % tobramycin (ophth) 2

trifluridine solution 1 % 3 VIGAMOX SOLUTION 0.5 % moxifloxacin hcl (ophth) 3 ZIRGAN GEL 0.15 % ganciclovir ophthalmic 3 ZYMAXID SOLUTION 0.5 % gatifloxacin (ophth) 3 Anti-inflammatory Agents

acetasol hc solution 2-1 % 3 ACUVAIL SOLUTION 0.45 % ketorolac tromethamine (ophth) 3

antipyrine-benzocaine solution 5.4-1.4 % 1

antipyrine-benzocaine solution 54-14 mg/ml 1

bacitra-neomycin-polymyxin-hc ointment 1 % 1 BECONASE AQ SUSPENSION 42 MCG/SPRAY ST beclomethasone diprop monohyd 3 BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % sulfacetamide sod-prednisolone 2

bromfenac sodium (once-daily) solution 0.09 % 3

bromfenac sodium solution 0.09 % 3 CIPRO HC SUSPENSION 0.2-1 % PA ciprofloxacin-hydrocortisone 3 CIPRODEX SUSPENSION 0.3-0.1 % ciprofloxacin-dexamethasone 3 COLY-MYCIN S SUSPENSION 3.3-3-10-0.5 MG/ML neomycin-colistin-hc-thonzonium 3 CORTISPORIN-TC SUSPENSION 3.3-3-10-0.5 MG/ML neomycin-colistin-hc-thonzonium 3

dexamethasone sodium phosphate solution 0.1 % 1

diclofenac sodium solution 0.1 % 1 DUREZOL EMULSION 0.05 % difluprednate 3 FLAREX SUSPENSION 0.1 % fluorometholone acetate 3

PAGE 148 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

flunisolide solution 25 mcg/act (0.025%) 1 QL 50 / 25 days

FLUNISOLIDE SOLUTION 25 MCG/ACT (0.025%) QL 50 / 25 days flunisolide (nasal) 1

fluocinolone acetonide oil 0.01 % 3

fluorometholone suspension 0.1 % 1

flurbiprofen sodium solution 0.03 % 1

fluticasone propionate suspension 50 mcg/act 1 QL 16 / 25 days

FML OINTMENT 0.1 % fluorometholone (ophth) 2

hydrocortisone-acetic acid solution 1-2 % 3

ketorolac tromethamine solution 0.4 % 1

ketorolac tromethamine solution 0.5 % 1 LOTEMAX OINTMENT 0.5 % loteprednol etabonate 3 LOTEMAX SUSPENSION 0.5 % loteprednol etabonate 3 NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT triamcinolone acetonide (nasal) 1 NASONEX SUSPENSION 50 MCG/ACT ST mometasone furoate (nasal) 3

neo-polycin hc ointment 1 % 1

neomycin-polymyxin-dexameth ointment 3.5-10000-0.1 1

neomycin-polymyxin-dexameth suspension 3.5-10000-0.1 1

neomycin-polymyxin-hc solution 1 % 1

neomycin-polymyxin-hc solution 3.5-10000-1 1 NEOMYCIN-POLYMYXIN-HC SUSPENSION 3.5-10000-1 neomycin-polymyxin-hc (ophth) 1

neomycin-polymyxin-hc suspension 3.5-10000-1 1 NEVANAC SUSPENSION 0.1 % nepafenac 3

poly-dex ointment 3.5-10000-0.1 1 PRED MILD SUSPENSION 0.12 % prednisolone acetate (ophth) 2

prednisolone acetate suspension 1 % 1 PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 % prednisolone sodium phosphate (ophth) 1

PAGE 149 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QNASL AERO SOLN 80 MCG/ACT ST beclomethasone dipropionate (nasal) 3 RHINOCORT AQUA SUSPENSION 32 MCG/ACT ST budesonide (nasal) 3

sulfacetamide-prednisolone solution 10-0.23 % 1 TOBRADEX OINTMENT 0.3-0.1 % QL 3.5 / 10 days tobramycin-dexamethasone 3 TOBRADEX ST SUSPENSION 0.3-0.05 % QL 1 / 10 days tobramycin-dexamethasone 2

tobramycin-dexamethasone suspension 0.3-0.1 % 1 QL 5 / 10 days

VERAMYST SUSPENSION 27.5 MCG/SPRAY ST fluticasone furoate 3 VEXOL SUSPENSION 1 % PA rimexolone 3 Antiglaucoma Agents

acetazolamide er cap er 12h 500 mg 1 ACETAZOLAMIDE TAB 125 MG acetazolamide 1

acetazolamide tab 250 mg 1 ALPHAGAN P SOLUTION 0.1 % brimonidine tartrate 3

betaxolol hcl solution 0.5 % 1 BETOPTIC-S SUSPENSION 0.25 % PA betaxolol hcl (ophth) 2

brimonidine tartrate solution 0.15 % 3

brimonidine tartrate solution 0.2 % 1

carteolol hcl solution 1 % 1 COMBIGAN SOLUTION 0.2-0.5 % brimonidine tartrate-timolol maleate 3

dorzolamide hcl solution 2 % 1

dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml 3 ISOPTO CARBACHOL SOLUTION 1.5 % carbachol (ophth) 2 ISOPTO CARBACHOL SOLUTION 3 % carbachol (ophth) 2

latanoprost solution 0.005 % 1 QL 5 / 23 days

PAGE 150 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVOBUNOLOL HCL SOLUTION 0.25 % levobunolol hcl 1

levobunolol hcl solution 0.5 % 1 LUMIGAN SOLUTION 0.01 % ST bimatoprost 3

metipranolol solution 0.3 % 1 METIPRANOLOL SOLUTION 0.3 % metipranolol 1 PHOSPHOLINE IODIDE RECON SOLN 0.125 % PA echothiophate iodide 2

pilocarpine hcl solution 1 % 1

pilocarpine hcl solution 2 % 1

pilocarpine hcl solution 4 % 1

timolol maleate gel f soln 0.25 % 3

timolol maleate gel f soln 0.5 % 3

timolol maleate solution 0.25 % 1

timolol maleate solution 0.5 % 1 TRAVATAN Z SOLUTION 0.004 % ST travoprost 3 ZIOPTAN SOLUTION 0.0015 % ST tafluprost 3

acetasol hc solution 2-1 % 3

acetic acid solution 2 % 1 ALOCRIL SOLUTION 2 % PA nedocromil sodium (ophth) 3 ALOMIDE SOLUTION 0.1 % PA lodoxamide tromethamine 3

altacaine solution 0.5 % 1

antipyrine-benzocaine solution 5.4-1.4 % 1

antipyrine-benzocaine solution 54-14 mg/ml 1

apraclonidine hcl solution 0.5 % 3

artificial tears solution 0.1-0.3 % 5 QL 30 / 30 days

ASTEPRO SOLUTION 0.15 % ST azelastine hcl 3 ATROPINE SULFATE OINTMENT 1 % atropine sulfate (ophthalmic) 1

PAGE 151 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

atropine sulfate solution 1 % 1

azelastine hcl solution 0.05 % 3

azelastine hcl solution 137 mcg/spray 1 ST

balanced salt solution 1 BEPREVE SOLUTION 1.5 % PA bepotastine besilate 3

bss solution 1

cromolyn sodium conc 100 mg/5ml 1

cromolyn sodium solution 4 % 1

cyclopentolate hcl solution 1 % 1

cyclopentolate hcl solution 2 % 1 CYSTARAN SOLUTION 0.44 % cysteamine hcl 4

epinastine hcl solution 0.05 % 3

eye wash solution 1 QL 50 / 30 days

homatropaire solution 5 % 1

homatropine hbr solution 5 % 1

hydrocortisone-acetic acid solution 1-2 % 3 IOPIDINE SOLUTION 1 % apraclonidine hcl 3 LACRISERT INSERT 5 MG PA artificial tear insert 3 LASTACAFT SOLUTION 0.25 % PA alcaftadine 3

lidocaine hcl solution 4 % 1 QL 100 / 23 days

lidocaine viscous solution 2 % 1 QL 100 / 23 days

mydral solution 0.5 % 1

mydral solution 1 % 1 NAPHAZOLINE HCL SOLUTION 0.1 % naphazoline hcl 1

olopatadine hcl solution 0.6 % 3 ST

parcaine solution 0.5 % 1 PATADAY SOLUTION 0.2 % PA olopatadine hcl 3

PAGE 152 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PATANOL SOLUTION 0.1 % PA olopatadine hcl 3

proparacaine hcl solution 0.5 % 1

redness reliever eye drops solution 0.05 % 5 QL 30 / 30 days

tetracaine hcl solution 0.5 % 1

tropicamide solution 0.5 % 1

tropicamide solution 1 % 1 Gastrointestinal Drugs

Antiemetics

ANZEMET TAB 100 MG ST dolasetron mesylate 3 ANZEMET TAB 50 MG ST dolasetron mesylate 3 CESAMET CAP 1 MG PA nabilone 3

compro suppos 25 mg 1 DIMENHYDRINATE SOLUTION 50 MG/ML dimenhydrinate 3

dronabinol cap 10 mg 4 PA

dronabinol cap 2.5 mg 3 PA

dronabinol cap 5 mg 3 PA

granisetron hcl tab 1 mg 3 QL 10 / 23 days

meclizine hcl tab 12.5 mg 1

meclizine hcl tab 25 mg 1

ondansetron hcl solution 4 mg/5ml 1

ondansetron hcl tab 24 mg 1 QL 5 / 23 days

ondansetron hcl tab 4 mg 1 QL 15 / 23 days

ondansetron hcl tab 8 mg 1 QL 15 / 23 days

ondansetron tab disp 4 mg 1 QL 10 / 23 days

ondansetron tab disp 8 mg 1 QL 10 / 23 days

phenadoz suppos 12.5 mg 1 AL Up to 64 yrs old

PAGE 153 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

phenadoz suppos 25 mg 1 AL Up to 64 yrs old

phenergan suppos 50 mg 1 AL Up to 64 yrs old

prochlorperazine edisylate solution 5 mg/ml 3

prochlorperazine maleate tab 10 mg 1

prochlorperazine maleate tab 5 mg 1

prochlorperazine suppos 25 mg 1

promethazine hcl solution 25 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl suppos 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 25 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 50 mg 1 AL Up to 64 yrs old

promethazine hcl syrup 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl tab 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl tab 25 mg 1 AL Up to 64 yrs old

promethazine hcl tab 50 mg 1 AL Up to 64 yrs old

promethegan suppos 12.5 mg 1 AL Up to 64 yrs old

promethegan suppos 25 mg 1 AL Up to 64 yrs old

promethegan suppos 50 mg 1 AL Up to 64 yrs old

trimethobenzamide hcl cap 300 mg 1

acid control maximum strength tab 20 mg 1

acid controller max st tab 20 mg 1

acid reducer maximum strength tab 20 mg 1

acid relief tab 200 mg 1 AMITIZA CAP 24 MCG PA lubiprostone 3 AMITIZA CAP 8 MCG PA lubiprostone 3

amoxicillin cap 250 mg 1

PAGE 154 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

amoxicillin cap 500 mg 1 AMOXICILLIN CHEW TAB 125 MG amoxicillin 1 AMOXICILLIN CHEW TAB 250 MG amoxicillin 1

amoxicillin recon susp 125 mg/5ml 1

amoxicillin recon susp 200 mg/5ml 1

amoxicillin recon susp 250 mg/5ml 1

amoxicillin recon susp 400 mg/5ml 1

amoxicillin tab 500 mg 1

amoxicillin tab 875 mg 1

anti-diarrheal cap 2 mg 1

anti-diarrheal liquid 1 mg/5ml 1

anti-diarrheal tab 2 mg 1 APRISO CAP ER 24H 0.375 GM mesalamine 3 ASACOL HD TAB DR 800 MG ST mesalamine 3

balsalazide disodium cap 750 mg 1 BIOGAIA CHEW TAB lactobacillus reuteri 5 BIOGAIA PROBIOTIC LIQUID lactobacillus reuteri 5 BIOGAIA PROBIOTIC MISC lactobacillus reuteri 5 BIOGAIA PROTECTIS/VITAMIN D LIQUID lactobacillus reuteri-vitamin d 5 CANASA SUPPOS 1000 MG mesalamine 4 CARAFATE SUSPENSION 1 GM/10ML PA sucralfate 3

cimetidine 200 tab 200 mg 1

cimetidine acid reducer tab 200 mg 1

cimetidine hcl solution 300 mg/5ml 1

cimetidine tab 200 mg 1

PAGE 155 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cimetidine tab 300 mg 1

cimetidine tab 400 mg 1

cimetidine tab 800 mg 1

clarithromycin er tab er 24h 500 mg 1

clarithromycin recon susp 125 mg/5ml 1

clarithromycin recon susp 250 mg/5ml 1

clarithromycin tab 250 mg 1

clarithromycin tab 500 mg 1 COLYTE WITH FLAVOR PACKS RECON SOLN 227.1 GM peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 3 CREON CP DR PART 12000 UNIT pancrelipase (lipase-protease-amylase) 2 CREON CP DR PART 24000 UNIT pancrelipase (lipase-protease-amylase) 2 CREON CP DR PART 3000-9500 UNIT pancrelipase (lipase-protease-amylase) 2 CREON CP DR PART 6000 UNIT pancrelipase (lipase-protease-amylase) 2

cvs acid controller max st tab 20 mg 1

cvs anti-diarrheal cap 2 mg 1

cvs anti-diarrheal tab 2 mg 1

cvs heartburn relief tab 200 mg 1

cvs lansoprazole cap dr 15 mg 3 QL 60 / 30 days

DELZICOL CAP DR 400 MG mesalamine 2

diamode tab 2 mg 1

diclofenac-misoprostol tab dr 50-0.2 mg 3

diclofenac-misoprostol tab dr 75-0.2 mg 3 DIPENTUM CAP 250 MG PA olsalazine sodium 3 DIPHENOXYLATE-ATROPINE LIQUID 2.5-0.025 MG/5ML diphenoxylate w/ atropine 1

diphenoxylate-atropine tab 2.5-0.025 mg 1

eq acid reducer max st tab 20 mg 1

PAGE 156 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

eq acid reducer tab 200 mg 1

eq anti-diarrheal cap 2 mg 1

eq anti-diarrheal liquid 1 mg/5ml 1

eq anti-diarrheal tab 2 mg 1

eq heartburn relief tab 200 mg 1

eq lansoprazole cap dr 15 mg 3 QL 60 / 30 days

eql acid reducer tab 200 mg 1

eql anti-diarrheal liquid 1 mg/5ml 1

eql anti-diarrheal tab 2 mg 1

eql heartburn prevention tab 20 mg 1

famotidine recon susp 40 mg/5ml 1

famotidine tab 20 mg 1

famotidine tab 40 mg 1 FERRAPLUS 90 TAB 90-1 MG iron-folic acid-vitamin b12-vitamin c-docusate sodium 1 FIRST-LANSOPRAZOLE SUSPENSION 3 MG/ML QL 150 / 30 days lansoprazole 3 FLAGYL ER TAB ER 24H 750 MG ST metronidazole 3

gavilyte-c recon soln 240 gm 1

gavilyte-g recon soln 236 gm 1

gavilyte-n with flavor pack recon soln 420 gm 1

gnp acid reducer max st tab 20 mg 1

gnp anti-diarrheal cap 2 mg 1

gnp anti-diarrheal liquid 1 mg/5ml 1

gnp anti-diarrheal tab 2 mg 1

gnp heartburn relief 200 tab 200 mg 1

gnp heartburn relief tab 200 mg 1

gnp lansoprazole cap dr 15 mg 3 QL 60 / 30 days

heartburn relief 24 hour cap dr 15 mg 3 QL 60 / 30 days

heartburn relief max st tab 20 mg 1

heartburn relief tab 200 mg 1

PAGE 157 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

heartburn treatment 24 hour cap dr 15 mg 3 QL 60 / 30 days

hm anti-diarrheal tab 2 mg 1

hm famotidine tab 20 mg 1

hm lansoprazole cap dr 15 mg 3 QL 60 / 30 days

hm loperamide hcl cap 2 mg 1 HUMIRA PEDIATRIC CROHNS START PREF SY KT 40 MG/0.8ML 4 PA adalimumab HUMIRA PEN-CROHNS STARTER PEN KIT 40 MG/0.8ML PA adalimumab 4 HUMIRA PREF SY KT 20 MG/0.4ML PA adalimumab 4 HUMIRA PREF SY KT 40 MG/0.8ML PA adalimumab 4

kls acid controller max st tab 20 mg 1

kls anti-diarrheal tab 2 mg 1

kls lansoprazole cap dr 15 mg 3 QL 60 / 30 days

lansoprazole cap dr 15 mg 3 QL 60 / 30 days

lansoprazole cap dr 30 mg 3 QL 30 / 30 days

LINZESS CAP 145 MCG PA linaclotide 3 LINZESS CAP 290 MCG PA linaclotide 3

lonox tab 2.5-0.025 mg 1

loperamide a-d tab 2 mg 1

loperamide hcl cap 2 mg 1

loperamide hcl liquid 1 mg/5ml 1

meijer anti-diarrheal tab 2 mg 1

mesalamine enema 4 gm 1

metoclopramide hcl solution 10 mg/10ml 1

metoclopramide hcl solution 5 mg/5ml 1

metoclopramide hcl tab 10 mg 1

metoclopramide hcl tab 5 mg 1

PAGE 158 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metronidazole cap 375 mg 1

metronidazole tab 250 mg 1

metronidazole tab 500 mg 1

misoprostol tab 100 mcg 1

misoprostol tab 200 mcg 1 NEXIUM 24HR CAP DR 20 MG QL 60 / 30 days esomeprazole magnesium 1

nizatidine cap 150 mg 1

nizatidine cap 300 mg 1

nizatidine solution 15 mg/ml 1

octreotide acetate solution 100 mcg/ml 4 PA

octreotide acetate solution 1000 mcg/5ml 4 PA

octreotide acetate solution 1000 mcg/ml 4 PA

octreotide acetate solution 200 mcg/ml 4 PA

octreotide acetate solution 50 mcg/ml 4 PA

octreotide acetate solution 500 mcg/ml 4 PA

omeprazole cap dr 10 mg 1 QL 60 / 30 days

omeprazole cap dr 20 mg 1 QL 60 / 30 days

omeprazole cap dr 40 mg 1 QL 60 / 30 days

QL 30 / 30 days omeprazole-sodium bicarbonate cap 20-1100 mg 3 PA

QL 30 / 30 days omeprazole-sodium bicarbonate cap 40-1100 mg 3 PA

OSMOPREP TAB 1.102-0.398 GM sodium phosphate monobasic-sodium phosphate dibasic 3

pantoprazole sodium tab dr 20 mg 1 QL 60 / 30 days

pantoprazole sodium tab dr 40 mg 1 QL 60 / 30 days

peg 3350-kcl-na bicarb-nacl recon soln 420 gm 1

peg 3350/electrolytes recon soln 240 gm 1

peg-3350/electrolytes recon soln 236 gm 1

PAGE 159 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PENTASA CAP ER 250 MG ST mesalamine 3 PENTASA CAP ER 500 MG ST mesalamine 3 PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1

polyethylene glycol 3350 packet 1

polyethylene glycol 3350 powder 1 POLYETHYLENE GLYCOL 3350 POWDER polyethylene glycol 3350 (bulk) 1 PRENATAL 19 TAB prenatal vit w/ docusate-fe fumarate-folic acid 1 PRENATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1 PREPOPIK PACKET 10-3.5-12 MG-GM-GM PA sodium picosulfate-magnesium oxide-anhydrous citric acid 3

px acid reducer max st tab 20 mg 1

px acid reducer tab 200 mg 1

px anti-diarrheal tab 2 mg 1

qc acid controller max st tab 20 mg 1

qc anti-diarrheal tab 2 mg 1

ra acid reducer max st tab 20 mg 1

ra acid reducer tab 200 mg 1

ra anti-diarrheal cap 2 mg 1

ra anti-diarrheal liquid 1 mg/5ml 1

ra anti-diarrheal tab 2 mg 1

ra lansoprazole cap dr 15 mg 3 QL 60 / 30 days

QL 30 / 30 days ra omeprazole-sodium bicarb cap 20-1100 mg 3 PA

ranitidine hcl cap 150 mg 3

ranitidine hcl cap 300 mg 3

ranitidine hcl syrup 15 mg/ml 1

ranitidine hcl syrup 150 mg/10ml 1

ranitidine hcl syrup 75 mg/5ml 1

PAGE 160 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ranitidine hcl tab 150 mg 1

ranitidine hcl tab 300 mg 1 SANDOSTATIN LAR DEPOT KIT 10 MG PA octreotide acetate 4 SANDOSTATIN LAR DEPOT KIT 20 MG PA octreotide acetate 4 SANDOSTATIN LAR DEPOT KIT 30 MG PA octreotide acetate 4

sb acid controller max st tab 20 mg 1

sb anti-diarrhea tab 2 mg 1 SE-NATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1

sm acid reducer max st tab 20 mg 1

sm acid reducer tab 200 mg 1

sm anti-diarrheal cap 2 mg 1

sm anti-diarrheal liquid 1 mg/5ml 1

sm anti-diarrheal tab 2 mg 1

sm lansoprazole cap dr 15 mg 3 QL 60 / 30 days

sucralfate tab 1 gm 1

sulfasalazine tab 500 mg 1

sulfasalazine tab dr 500 mg 1

sulfazine ec tab dr 500 mg 1

sulfazine tab 500 mg 1 SUPREP BOWEL PREP SOLUTION sodium sulfate-potassium sulfate-magnesium sulfate 3 TARON-PREX CAP 30-1.2-265 MG prenatal w/o vit a w/ fe fumarate-dss-fa-dha 1

tetracycline hcl cap 250 mg 1 TETRACYCLINE HCL CAP 250 MG tetracycline hcl 1

tetracycline hcl cap 500 mg 1 TETRACYCLINE HCL CAP 500 MG tetracycline hcl 1

tgt acid reducer tab 200 mg 1

PAGE 161 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tgt anti-diarrheal tab 2 mg 1

tgt loperamide hcl cap 2 mg 1

th anti-diarrheal tab 2 mg 1

trilyte recon soln 420 gm 1

ursodiol cap 300 mg 1

ursodiol tab 250 mg 3

ursodiol tab 500 mg 3 ZENPEP CP DR PART 25000 UNIT pancrelipase (lipase-protease-amylase) 2 Hormones and Synthetic Substitutes

Antidiabetic Agents

acarbose tab 100 mg 1

acarbose tab 25 mg 1

acarbose tab 50 mg 1 APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML PA insulin glulisine 3 APIDRA SOLUTION 100 UNIT/ML insulin glulisine 2 AVANDIA TAB 2 MG PA rosiglitazone maleate 3

BYDUREON RECON SUSP 2 MG QL 4 / 30 days 3 exenatide PA

BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML QL 2.4 / 30 days 3 exenatide PA

BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML QL 1.2 / 30 days 3 exenatide PA

CHLORPROPAMIDE TAB 100 MG chlorpropamide 1 CHLORPROPAMIDE TAB 250 MG chlorpropamide 1 CYCLOSET TAB 0.8 MG bromocriptine mesylate (diabetes) 3

glimepiride tab 1 mg 1

glimepiride tab 2 mg 1

PAGE 162 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

glimepiride tab 4 mg 1

glipizide er tab er 24h 10 mg 1 QL 60 / 30 days

glipizide er tab er 24h 2.5 mg 1 QL 60 / 30 days

glipizide er tab er 24h 5 mg 1 QL 60 / 30 days

glipizide tab 10 mg 1

glipizide tab 5 mg 1

glipizide xl tab er 24h 10 mg 1 QL 60 / 30 days

glipizide xl tab er 24h 2.5 mg 1 QL 60 / 30 days

glipizide xl tab er 24h 5 mg 1 QL 60 / 30 days

glipizide-metformin hcl tab 2.5-250 mg 1

glipizide-metformin hcl tab 2.5-500 mg 1

glipizide-metformin hcl tab 5-500 mg 1 GLUMETZA TAB ER 24H 500 MG metformin hcl 3

glyburide micronized tab 1.5 mg 1

glyburide micronized tab 3 mg 1

glyburide micronized tab 6 mg 1

glyburide tab 1.25 mg 1 GLYBURIDE TAB 1.25 MG glyburide 1

glyburide tab 2.5 mg 1 GLYBURIDE TAB 2.5 MG glyburide 1

glyburide tab 5 mg 1 GLYBURIDE TAB 5 MG glyburide 1

glyburide-metformin tab 1.25-250 mg 1

glyburide-metformin tab 2.5-500 mg 1

glyburide-metformin tab 5-500 mg 1 GLYSET TAB 25 MG miglitol 3 HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100 UNIT/ML 3 PA insulin lispro protamine & lispro (human)

PAGE 163 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HUMALOG MIX 50/50 SUSPENSION (50-50) 100 UNIT/ML insulin lispro protamine & lispro (human) 3 HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100 UNIT/ML 3 PA insulin lispro protamine & lispro (human) HUMALOG MIX 75/25 SUSPENSION (75-25) 100 UNIT/ML ST insulin lispro protamine & lispro (human) 3 HUMALOG SOLN CART 100 UNIT/ML ST insulin lispro (human) 3 HUMALOG SOLUTION 100 UNIT/ML ST insulin lispro (human) 3 HUMULIN N SUSPENSION 100 UNIT/ML ST insulin isophane (human) 3 HUMULIN R SOLUTION 100 UNIT/ML ST insulin regular (human) 3 HUMULIN R U-500 (CONCENTRATED) SOLUTION 500 UNIT/ML 4 PA insulin regular (human) JANUMET XR TAB ER 24H 100-1000 MG QL 30 / 30 days sitagliptin-metformin hcl 3 JANUMET XR TAB ER 24H 50-1000 MG QL 30 / 30 days sitagliptin-metformin hcl 3 JANUMET XR TAB ER 24H 50-500 MG QL 30 / 30 days sitagliptin-metformin hcl 3 JANUVIA TAB 100 MG QL 30 / 30 days sitagliptin phosphate 3 JANUVIA TAB 25 MG QL 30 / 30 days sitagliptin phosphate 3 JANUVIA TAB 50 MG QL 30 / 30 days sitagliptin phosphate 3

JENTADUETO TAB 2.5-1000 MG QL 60 / 30 days 3 linagliptin-metformin hcl PA

JENTADUETO TAB 2.5-500 MG QL 60 / 30 days 3 linagliptin-metformin hcl PA

JENTADUETO TAB 2.5-850 MG QL 60 / 30 days 3 linagliptin-metformin hcl PA

LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML PA insulin glargine 3

PAGE 164 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LANTUS SOLUTION 100 UNIT/ML insulin glargine 2 LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML PA insulin detemir 3 LEVEMIR SOLUTION 100 UNIT/ML insulin detemir 2

metformin hcl er (osm) tab er 24h 1000 mg 1

metformin hcl er (osm) tab er 24h 500 mg 1

metformin hcl er tab er 24h 500 mg 1

metformin hcl er tab er 24h 750 mg 1

metformin hcl tab 1000 mg 1

metformin hcl tab 500 mg 1

metformin hcl tab 850 mg 1

nateglinide tab 120 mg 1

nateglinide tab 60 mg 1 NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) 2 NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) 2 NOVOLIN N RELION SUSPENSION 100 UNIT/ML insulin isophane (human) 2 NOVOLIN N SUSPENSION 100 UNIT/ML insulin isophane (human) 2 NOVOLIN R RELION SOLUTION 100 UNIT/ML insulin regular (human) 2 NOVOLIN R SOLUTION 100 UNIT/ML insulin regular (human) 2 NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100 UNIT/ML 3 PA insulin aspart protamine & aspart (human) NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin aspart protamine & aspart (human) 3 NOVOLOG PENFILL SOLN CART 100 UNIT/ML insulin aspart 3 NOVOLOG SOLUTION 100 UNIT/ML insulin aspart 3

ONGLYZA TAB 2.5 MG QL 30 / 30 days 3 saxagliptin hcl ST

PAGE 165 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ONGLYZA TAB 5 MG QL 30 / 30 days 3 saxagliptin hcl ST

pioglitazone hcl tab 15 mg 3 QL 30 / 30 days

pioglitazone hcl tab 30 mg 3 QL 30 / 30 days

pioglitazone hcl tab 45 mg 3 QL 30 / 30 days

pioglitazone hcl-glimepiride tab 30-2 mg 3

pioglitazone hcl-glimepiride tab 30-4 mg 3

pioglitazone hcl-metformin hcl tab 15-500 mg 3

pioglitazone hcl-metformin hcl tab 15-850 mg 3 PRANDIN TAB 0.5 MG repaglinide 2 PRANDIN TAB 1 MG repaglinide 2 PRANDIN TAB 2 MG repaglinide 2 SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML PA pramlintide acetate 3 SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML PA pramlintide acetate 3

tolazamide tab 250 mg 1 TOLAZAMIDE TAB 500 MG tolazamide 1 TOLBUTAMIDE TAB 500 MG tolbutamide 1

TRADJENTA TAB 5 MG QL 30 / 30 days 3 linagliptin ST

VICTOZA SOLN PEN 18 MG/3ML QL 6 / 30 days 3 liraglutide PA

WELCHOL PACKET 3.75 GM PA colesevelam hcl 3 WELCHOL TAB 625 MG PA colesevelam hcl 3 Antihypoglycemic Agents

GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG QL 2 / 30 days glucagon hcl rdna (diagnostic) 3

PAGE 166 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLUCAGEN HYPOKIT RECON SOLN 1 MG QL 2 / 30 days glucagon hcl (rdna) 3 GLUCAGON EMERGENCY KIT 1 MG QL 2 / 30 days glucagon (rdna) 3 Estrogens and Antiestrogens

QL 28 / 28 days altavera tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days alyacen 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

QL 28 / 28 days apri tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days aviane tab 0.1-20 mg-mcg 5 GL Female

QL 28 / 28 days caziant tab 0.1/0.125/0.15 -0.025 mg 5 GL Female

QL 28 / 28 days cesia tab 0.1/0.125/0.15 -0.025 mg 5 GL Female

QL 28 / 28 days chateal tab 0.15-30 mg-mcg 5 GL Female

COMBIPATCH PATCH TW 0.05-0.14 MG/DAY estradiol & norethindrone acetate 3 COMBIPATCH PATCH TW 0.05-0.25 MG/DAY estradiol & norethindrone acetate 3

covaryx hs tab 0.625-1.25 mg 1

covaryx tab 1.25-2.5 mg 1

QL 28 / 28 days cryselle-28 tab 0.3-30 mg-mcg 5 GL Female

QL 28 / 28 days cyclafem 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

PAGE 167 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days dasetta 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

QL 28 / 28 days elinest tab 0.3-30 mg-mcg 5 GL Female

QL 28 / 28 days emoquette tab 0.15-30 mg-mcg 5 GL Female

ENJUVIA TAB 0.3 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 0.45 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 0.625 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 0.9 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 1.25 MG GL Female estrogens, conjugated synthetic b 2

QL 28 / 28 days enpresse-28 tab 5 GL Female

QL 28 / 28 days estarylla tab 0.25-35 mg-mcg 5 GL Female

ESTRACE CREAM 0.1 MG/GM estradiol vaginal 2

QL 8 / 28 days estradiol patch tw 0.025 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.0375 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.05 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.075 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.1 mg/24hr 1 GL Female

PAGE 168 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / 28 days estradiol patch wk 0.025 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.0375 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.05 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.06 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.075 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.1 mg/24hr 1 GL Female

estradiol tab 0.5 mg 1 GL Female

estradiol tab 1 mg 1 GL Female

estradiol tab 2 mg 1 GL Female

estradiol valerate oil 20 mg/ml 1 GL Female

estradiol valerate oil 40 mg/ml 1 GL Female

estradiol-norethindrone acet tab 0.5-0.1 mg 1

estradiol-norethindrone acet tab 1-0.5 mg 1 ESTRING RING 2 MG estradiol vaginal 3 ESTROGEL GEL 0.75 MG/1.25 GM (0.06%) GL Female estradiol 3

estropipate tab 0.75 mg 1 GL Female

estropipate tab 1.5 mg 1 GL Female

ESTROPIPATE TAB 3 MG GL Female estropipate 1 EVAMIST SOLUTION 1.53 MG/SPRAY GL Female estradiol 3 EVISTA TAB 60 MG PA raloxifene hcl 3

PAGE 169 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days falmina tab 0.1-20 mg-mcg 5 GL Female

FARESTON TAB 60 MG PA toremifene citrate 4

gildess 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

gildess 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days gildess fe 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

QL 28 / 28 days gildess fe 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days jinteli tab 1-5 mg-mcg 1 GL Female

QL 28 / 28 days junel 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

QL 28 / 28 days junel 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days junel fe 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

QL 28 / 28 days junel fe 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days kelnor 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days kurvelo tab 0.15-30 mg-mcg 5 GL Female

larin fe 1/20 tab 1-20 mg-mcg 5

QL 28 / 28 days lessina tab 0.1-20 mg-mcg 5 GL Female

QL 28 / 28 days levonest tab 5 GL Female

QL 28 / 28 days levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg 5 GL Female

PAGE 170 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days levonorgest-eth estrad 91-day tab 0.15-0.03 mg 5 GL Female

QL 28 / 28 days levonorgestrel-ethinyl estrad tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days levora 0.15/30 (28) tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days low-ogestrel tab 0.3-30 mg-mcg 5 GL Female

QL 28 / 28 days lutera tab 0.1-20 mg-mcg 5 GL Female

QL 28 / 28 days marlissa tab 0.15-30 mg-mcg 5 GL Female

MENEST TAB 0.3 MG GL Female esterified estrogens 3 MENEST TAB 0.625 MG GL Female esterified estrogens 3 MENEST TAB 1.25 MG GL Female esterified estrogens 3 MENEST TAB 2.5 MG GL Female esterified estrogens 3

microgestin fe 1/20 tab 1-20 mg-mcg 5 GL Female

mimvey tab 1-0.5 mg 1

QL 28 / 28 days mono-linyah tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days mononessa tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days myzilra tab 5 GL Female

QL 28 / 28 days necon 0.5/35 (28) tab 0.5-35 mg-mcg 5 GL Female

QL 28 / 28 days necon 1/35 (28) tab 1-35 mg-mcg 5 GL Female

PAGE 171 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

norethin ace-eth estrad-fe tab 1-20 mg-mcg 5

norethin ace-eth estrad-fe tab 1-20 mg-mcg(24) 5

QL 28 / 28 days norgestim-eth estrad triphasic tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days norgestimate-eth estradiol tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 0.5/35 (28) tab 0.5-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 1/35 (21) tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 1/35 (28) tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

NUVARING RING 0.12-0.015 MG/24HR PA etonogestrel-ethinyl estradiol 5

QL 28 / 28 days orsythia tab 0.1-20 mg-mcg 5 GL Female

ORTHO EVRA PATCH WK 150-35 MCG/24HR PA norelgestromin-ethinyl estradiol 5

QL 28 / 28 days portia-28 tab 0.15-30 mg-mcg 5 GL Female

PREMARIN TAB 0.3 MG GL Female estrogens, conjugated 2 PREMARIN TAB 0.45 MG GL Female estrogens, conjugated 3 PREMARIN TAB 0.625 MG GL Female estrogens, conjugated 3 PREMARIN TAB 0.9 MG GL Female estrogens, conjugated 3 PREMARIN TAB 1.25 MG GL Female estrogens, conjugated 3

PAGE 172 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREMPHASE TAB 0.625-5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.3-1.5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.45-1.5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.625-2.5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.625-5 MG conjugated estrogens-medroxyprogesterone acetate 2

QL 28 / 28 days previfem tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days reclipsen tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days solia tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days sprintec 28 tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days sronyx tab 0.1-20 mg-mcg 5 GL Female

tamoxifen citrate tab 10 mg 1

tamoxifen citrate tab 20 mg 1

tarina fe 1/20 tab 1-20 mg-mcg 5

QL 28 / 28 days tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days tri-linyah tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days tri-previfem tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

PAGE 173 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days trivora (28) tab 5 GL Female

VAGIFEM TAB 10 MCG estradiol vaginal 3

QL 28 / 28 days velivet tab 0.1/0.125/0.15 -0.025 mg 5 GL Female

QL 28 / 28 days wera tab 0.5-35 mg-mcg 5 GL Female

xulane patch wk 150-35 mcg/24hr 5 PA

QL 28 / 28 days zovia 1/35e (28) tab 1-35 mg-mcg 5 GL Female

A-HYDROCORT RECON SOLN 100 MG hydrocortisone sod succinate 1 ADVAIR DISKUS AER POW BA 100-50 MCG/DOSE QL 60 / 30 days fluticasone-salmeterol 2 ADVAIR DISKUS AER POW BA 250-50 MCG/DOSE ST fluticasone-salmeterol 3 ADVAIR DISKUS AER POW BA 500-50 MCG/DOSE ST fluticasone-salmeterol 3 ADVAIR HFA AEROSOL 115-21 MCG/ACT ST fluticasone-salmeterol 3 ADVAIR HFA AEROSOL 230-21 MCG/ACT ST fluticasone-salmeterol 3 ADVAIR HFA AEROSOL 45-21 MCG/ACT ST fluticasone-salmeterol 3

QL 28 / 28 days altavera tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days alyacen 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

ANDRODERM PATCH 24HR 2 MG/24HR PA testosterone 3 ANDRODERM PATCH 24HR 4 MG/24HR PA testosterone 3

PAGE 174 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANDROGEL GEL 20.25 MG/1.25GM (1.62%) PA testosterone 3 ANDROGEL GEL 25 MG/2.5GM (1%) PA testosterone 3 ANDROGEL GEL 40.5 MG/2.5GM (1.62%) PA testosterone 3 ANDROGEL PUMP GEL 20.25 MG/ACT (1.62%) PA testosterone 3 ANDROXY TAB 10 MG PA fluoxymesterone 3

QL 28 / 28 days apri tab 0.15-30 mg-mcg 5 GL Female

ASMANEX 120 METERED DOSES AER POW BA 220 MCG/INH 3 QL 2 / 30 days mometasone furoate (inhalation) ASMANEX 14 METERED DOSES AER POW BA 220 MCG/INH 3 QL 2 / 30 days mometasone furoate (inhalation) ASMANEX 30 METERED DOSES AER POW BA 110 MCG/INH 3 QL 2 / 30 days mometasone furoate (inhalation) ASMANEX 30 METERED DOSES AER POW BA 220 MCG/INH 3 QL 2 / 30 days mometasone furoate (inhalation) ASMANEX 60 METERED DOSES AER POW BA 220 MCG/INH 3 QL 2 / 30 days mometasone furoate (inhalation) ASMANEX 7 METERED DOSES AER POW BA 110 MCG/INH QL 2 / 30 days mometasone furoate (inhalation) 3

QL 28 / 28 days aviane tab 0.1-20 mg-mcg 5 GL Female

AXIRON SOLUTION 30 MG/ACT PA testosterone 3

baycadron elixir 0.5 mg/5ml 1

betamethasone sod phos & acet suspension 6 (3-3) mg/ml 1

budesonide er cap er 24h 3 mg 4

QL 120 / 30 days budesonide suspension 0.25 mg/2ml 1 AL Up to 8 yrs old

PAGE 175 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 120 / 30 days budesonide suspension 0.5 mg/2ml 1 AL Up to 8 yrs old

calcitonin (salmon) solution 200 unit/act 1

QL 28 / 28 days camila tab 0.35 mg 5 GL Female

QL 28 / 28 days caziant tab 0.1/0.125/0.15 -0.025 mg 5 GL Female

QL 28 / 28 days cesia tab 0.1/0.125/0.15 -0.025 mg 5 GL Female

QL 28 / 28 days chateal tab 0.15-30 mg-mcg 5 GL Female

chorionic gonadotropin recon soln 10000 unit 4 PA

COMBIPATCH PATCH TW 0.05-0.14 MG/DAY estradiol & norethindrone acetate 3 COMBIPATCH PATCH TW 0.05-0.25 MG/DAY estradiol & norethindrone acetate 3 CORTISONE ACETATE TAB 25 MG cortisone acetate 1

covaryx hs tab 0.625-1.25 mg 1

covaryx tab 1.25-2.5 mg 1 CRINONE GEL 4 % PA progesterone (vaginal) 4 CRINONE GEL 8 % PA progesterone (vaginal) 4

QL 28 / 28 days cryselle-28 tab 0.3-30 mg-mcg 5 GL Female

QL 28 / 28 days cyclafem 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

QL 28 / 28 days dasetta 1/35 tab 1-35 mg-mcg 5 GL Female

PAGE 176 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

DEPO-MEDROL SUSPENSION 20 MG/ML methylprednisolone acetate 3 DEPO-PROVERA SUSPENSION 400 MG/ML medroxyprogesterone acetate (antineoplastic) 3

DEPO-SUBQ PROVERA 104 SUSPENSION 104 MG/0.65ML QL 1 / 90 days 3 medroxyprogesterone acetate (contraceptive) GL Female

desmopressin ace rhinal tube solution 0.01 % 1

desmopressin ace spray refrig solution 0.01 % 3

desmopressin acetate solution 4 mcg/ml 4 PA

desmopressin acetate spray solution 0.01 % 1

desmopressin acetate tab 0.1 mg 1

desmopressin acetate tab 0.2 mg 1 DEXAMETHASONE INTENSOL CONC 1 MG/ML dexamethasone 3 DEXAMETHASONE SOD PHOSPHATE PF SOLUTION 10 MG/ML 1 dexamethasone sodium phosphate DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MG/ML 1 dexamethasone sodium phosphate

dexamethasone sodium phosphate solution 100 mg/10ml 1

dexamethasone sodium phosphate solution 120 mg/30ml 1

dexamethasone sodium phosphate solution 20 mg/5ml 1

dexamethasone sodium phosphate solution 4 mg/ml 1 DEXAMETHASONE SOLUTION 0.5 MG/5ML dexamethasone 1

dexamethasone tab 0.5 mg 1

dexamethasone tab 0.75 mg 1 DEXAMETHASONE TAB 1 MG dexamethasone 1

dexamethasone tab 1.5 mg 1 DEXAMETHASONE TAB 2 MG dexamethasone 1

PAGE 177 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

dexamethasone tab 4 mg 1

dexamethasone tab 6 mg 1 DEXPAK 10 DAY TAB 1.5 MG dexamethasone 3 DEXPAK 13 DAY TAB 1.5 MG dexamethasone 3 DEXPAK 6 DAY TAB 1.5 MG dexamethasone 3

DULERA AEROSOL 100-5 MCG/ACT QL 13 / 25 days 2 mometasone furoate-formoterol fumarate dihydrate ST

DULERA AEROSOL 200-5 MCG/ACT QL 13 / 25 days 2 mometasone furoate-formoterol fumarate dihydrate ST

ELIGARD KIT 22.5 MG PA leuprolide acetate (3 month) 4 ELIGARD KIT 30 MG PA leuprolide acetate (4 month) 4 ELIGARD KIT 45 MG PA leuprolide acetate (6 month) 4 ELIGARD KIT 7.5 MG PA leuprolide acetate 4

QL 28 / 28 days elinest tab 0.3-30 mg-mcg 5 GL Female

ELLA TAB 30 MG GL Female ulipristal acetate 3

QL 28 / 28 days emoquette tab 0.15-30 mg-mcg 5 GL Female

ENDOMETRIN INSERT 100 MG progesterone (vaginal) 3

QL 28 / 28 days enpresse-28 tab 5 GL Female

QL 28 / 28 days errin tab 0.35 mg 5 GL Female

QL 28 / 28 days estarylla tab 0.25-35 mg-mcg 5 GL Female

PAGE 178 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

estradiol-norethindrone acet tab 0.5-0.1 mg 1

estradiol-norethindrone acet tab 1-0.5 mg 1

QL 28 / 28 days falmina tab 0.1-20 mg-mcg 5 GL Female

FLOVENT DISKUS AER POW BA 100 MCG/BLIST QL 60 / 30 days fluticasone propionate (inhalation) 3

fludrocortisone acetate tab 0.1 mg 1

flunisolide solution 25 mcg/act (0.025%) 1 QL 50 / 25 days

FLUNISOLIDE SOLUTION 25 MCG/ACT (0.025%) QL 50 / 25 days flunisolide (nasal) 1

fluticasone propionate suspension 50 mcg/act 1 QL 16 / 25 days

FORTEO SOLUTION 600 MCG/2.4ML PA teriparatide (recombinant) 4 GENOTROPIN MINIQUICK RECON SOLN 0.2 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 0.4 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 0.6 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 0.8 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.2 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.4 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.6 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.8 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 2 MG PA somatropin 4 GENOTROPIN RECON SOLN 12 MG PA somatropin 4 GENOTROPIN RECON SOLN 5 MG PA somatropin 4

PAGE 179 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gildess 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

gildess 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days gildess fe 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

QL 28 / 28 days gildess fe 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days heather tab 0.35 mg 5 GL Female

hydrocortisone tab 10 mg 1

hydrocortisone tab 20 mg 1

hydrocortisone tab 5 mg 1 HYDROXYPROGESTERONE CAPROATE POWDER hydroxyprogesterone caproate (bulk) 1

QL 28 / 28 days jinteli tab 1-5 mg-mcg 1 GL Female

QL 28 / 28 days jolivette tab 0.35 mg 5 GL Female

QL 28 / 28 days junel 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

QL 28 / 28 days junel 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days junel fe 1.5/30 tab 1.5-30 mg-mcg 5 GL Female

QL 28 / 28 days junel fe 1/20 tab 1-20 mg-mcg 5 GL Female

QL 28 / 28 days kelnor 1/35 tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days kurvelo tab 0.15-30 mg-mcg 5 GL Female

larin fe 1/20 tab 1-20 mg-mcg 5

PAGE 180 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days lessina tab 0.1-20 mg-mcg 5 GL Female

leuprolide acetate kit 1 mg/0.2ml 4 PA

QL 28 / 28 days levonest tab 5 GL Female

QL 28 / 28 days levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg 5 GL Female

QL 28 / 28 days levonorgest-eth estrad 91-day tab 0.15-0.03 mg 5 GL Female

LEVONORGESTREL TAB 0.75 MG QL 2 / 30 days 5 levonorgestrel (emergency oc) GL Female

QL 28 / 28 days levonorgestrel-ethinyl estrad tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days levora 0.15/30 (28) tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days low-ogestrel tab 0.3-30 mg-mcg 5 GL Female

LUPRON DEPOT KIT 11.25 MG PA leuprolide acetate (3 month) 4 LUPRON DEPOT KIT 22.5 MG PA leuprolide acetate (3 month) 4 LUPRON DEPOT KIT 3.75 MG PA leuprolide acetate 4 LUPRON DEPOT KIT 30 MG PA leuprolide acetate (4 month) 4 LUPRON DEPOT KIT 45 MG PA leuprolide acetate (6 month) 4

QL 28 / 28 days lutera tab 0.1-20 mg-mcg 5 GL Female

QL 28 / 28 days marlissa tab 0.15-30 mg-mcg 5 GL Female

QL 1 / 90 days medroxyprogesterone acetate suspension 150 mg/ml 5 GL Female

PAGE 181 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

medroxyprogesterone acetate tab 10 mg 1

medroxyprogesterone acetate tab 2.5 mg 1

medroxyprogesterone acetate tab 5 mg 1

megestrol acetate suspension 40 mg/ml 1

megestrol acetate suspension 400 mg/10ml 1

megestrol acetate tab 20 mg 1

megestrol acetate tab 40 mg 1 METHITEST TAB 10 MG methyltestosterone 3

methylprednisolone (pak) tab 4 mg 1

methylprednisolone tab 16 mg 1

methylprednisolone tab 32 mg 1

methylprednisolone tab 4 mg 1

methylprednisolone tab 8 mg 1 MIACALCIN SOLUTION 200 UNIT/ML ST calcitonin (salmon) 3

microgestin fe 1/20 tab 1-20 mg-mcg 5 GL Female

MILLIPRED TAB 5 MG prednisolone 3

mimvey tab 1-0.5 mg 1

QL 28 / 28 days mono-linyah tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days mononessa tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days myzilra tab 5 GL Female

NASONEX SUSPENSION 50 MCG/ACT ST mometasone furoate (nasal) 3

QL 28 / 28 days necon 0.5/35 (28) tab 0.5-35 mg-mcg 5 GL Female

QL 28 / 28 days necon 1/35 (28) tab 1-35 mg-mcg 5 GL Female

PAGE 182 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 28 / 28 days necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

QL 28 / 28 days nora-be tab 0.35 mg 5 GL Female

NORDITROPIN FLEXPRO SOLUTION 10 MG/1.5ML PA somatropin 4 NORDITROPIN FLEXPRO SOLUTION 15 MG/1.5ML PA somatropin 4 NORDITROPIN FLEXPRO SOLUTION 5 MG/1.5ML PA somatropin 4 NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML PA somatropin 4

norethin ace-eth estrad-fe tab 1-20 mg-mcg 5

norethin ace-eth estrad-fe tab 1-20 mg-mcg(24) 5

norethindrone acetate tab 5 mg 1

QL 28 / 28 days norethindrone tab 0.35 mg 5 GL Female

QL 28 / 28 days norgestim-eth estrad triphasic tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days norgestimate-eth estradiol tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 0.5/35 (28) tab 0.5-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 1/35 (21) tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 1/35 (28) tab 1-35 mg-mcg 5 GL Female

QL 28 / 28 days nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg 5 GL Female

NUTROPIN AQ NUSPIN 10 SOLUTION 10 MG/2ML PA somatropin 4 NUTROPIN AQ NUSPIN 20 SOLUTION 20 MG/2ML PA somatropin 4

PAGE 183 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NUTROPIN AQ NUSPIN 5 SOLUTION 5 MG/2ML PA somatropin 4 NUTROPIN AQ PEN SOLUTION 10 MG/2ML PA somatropin 4 NUTROPIN AQ PEN SOLUTION 20 MG/2ML PA somatropin 4 NUVARING RING 0.12-0.015 MG/24HR PA etonogestrel-ethinyl estradiol 5

QL 28 / 28 days orsythia tab 0.1-20 mg-mcg 5 GL Female

ORTHO EVRA PATCH WK 150-35 MCG/24HR PA norelgestromin-ethinyl estradiol 5

QL 28 / 28 days portia-28 tab 0.15-30 mg-mcg 5 GL Female

prednisolone sodium phosphate solution 15 mg/5ml 1 PREDNISOLONE SODIUM PHOSPHATE SOLUTION 25 MG/5ML 1 prednisolone sodium phosphate

prednisolone sodium phosphate solution 6.7 (5 base) mg/5ml 1

prednisolone solution 15 mg/5ml 1

prednisolone syrup 15 mg/5ml 1

prednisone (pak) tab 10 mg 1 PREDNISONE (PAK) TAB 10 MG prednisone 1

prednisone (pak) tab 5 mg 1 PREDNISONE (PAK) TAB 5 MG prednisone 1 PREDNISONE INTENSOL CONC 5 MG/ML prednisone 3 PREDNISONE SOLUTION 5 MG/5ML prednisone 1

prednisone tab 1 mg 1

prednisone tab 10 mg 1

prednisone tab 2.5 mg 1

prednisone tab 20 mg 1

prednisone tab 5 mg 1

PAGE 184 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREDNISONE TAB 50 MG prednisone 1 PREMPHASE TAB 0.625-5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.3-1.5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.45-1.5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.625-2.5 MG conjugated estrogens-medroxyprogesterone acetate 2 PREMPRO TAB 0.625-5 MG conjugated estrogens-medroxyprogesterone acetate 2

QL 28 / 28 days previfem tab 0.25-35 mg-mcg 5 GL Female

PULMICORT FLEXHALER AER POW BA 180 MCG/ACT QL 1 / 30 days budesonide (inhalation) 3 PULMICORT FLEXHALER AER POW BA 90 MCG/ACT QL 1 / 30 days budesonide (inhalation) 3

PULMICORT SUSPENSION 1 MG/2ML QL 120 / 30 days 4 budesonide (inhalation) AL Up to 8 yrs old

QVAR AERO SOLN 40 MCG/ACT QL 8.7 / 30 days beclomethasone dipropionate 2 QVAR AERO SOLN 80 MCG/ACT beclomethasone dipropionate 2

QL 28 / 28 days reclipsen tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days solia tab 0.15-30 mg-mcg 5 GL Female

QL 28 / 28 days sprintec 28 tab 0.25-35 mg-mcg 5 GL Female

QL 28 / 28 days sronyx tab 0.1-20 mg-mcg 5 GL Female

STIMATE SOLUTION 1.5 MG/ML PA desmopressin acetate 4

SYMBICORT AEROSOL 160-4.5 MCG/ACT QL 10.2 / 25 days 2 budesonide-formoterol fumarate dihydrate ST

PAGE 185 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SYMBICORT AEROSOL 80-4.5 MCG/ACT QL 10.2 / 25 days 2 budesonide-formoterol fumarate dihydrate ST

tarina fe 1/20 tab 1-20 mg-mcg 5 TESTOSTERONE GEL 25 MG/2.5GM (1%) PA testosterone 3 TEV-TROPIN RECON SOLN 5 MG PA somatropin 4

QL 28 / 28 days tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days tri-linyah tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days tri-previfem tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg 5 GL Female

QL 28 / 28 days trivora (28) tab 5 GL Female

QL 28 / 28 days velivet tab 0.1/0.125/0.15 -0.025 mg 5 GL Female

VERAMYST SUSPENSION 27.5 MCG/SPRAY ST fluticasone furoate 3

QL 28 / 28 days wera tab 0.5-35 mg-mcg 5 GL Female

xulane patch wk 150-35 mcg/24hr 5 PA

ZOLADEX IMPLANT 10.8 MG PA goserelin acetate 3 ZOLADEX IMPLANT 3.6 MG PA goserelin acetate 3

QL 28 / 28 days zovia 1/35e (28) tab 1-35 mg-mcg 5 GL Female

PAGE 186 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Somatostatin Agonists and Antagonists

octreotide acetate solution 100 mcg/ml 4 PA

octreotide acetate solution 1000 mcg/5ml 4 PA

octreotide acetate solution 1000 mcg/ml 4 PA

octreotide acetate solution 200 mcg/ml 4 PA

octreotide acetate solution 50 mcg/ml 4 PA

octreotide acetate solution 500 mcg/ml 4 PA

SANDOSTATIN LAR DEPOT KIT 10 MG PA octreotide acetate 4 SANDOSTATIN LAR DEPOT KIT 20 MG PA octreotide acetate 4 SANDOSTATIN LAR DEPOT KIT 30 MG PA octreotide acetate 4 SOMATULINE DEPOT SOLUTION 120 MG/0.5ML PA lanreotide acetate 4 SOMATULINE DEPOT SOLUTION 60 MG/0.2ML PA lanreotide acetate 4 SOMATULINE DEPOT SOLUTION 90 MG/0.3ML PA lanreotide acetate 4 Somatotropin Agonists and Antagonists

GENOTROPIN MINIQUICK RECON SOLN 0.2 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 0.4 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 0.6 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 0.8 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.2 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.4 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 1.6 MG PA somatropin 4

PAGE 187 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GENOTROPIN MINIQUICK RECON SOLN 1.8 MG PA somatropin 4 GENOTROPIN MINIQUICK RECON SOLN 2 MG PA somatropin 4 GENOTROPIN RECON SOLN 12 MG PA somatropin 4 GENOTROPIN RECON SOLN 5 MG PA somatropin 4 INCRELEX SOLUTION 40 MG/4ML PA mecasermin 4 NORDITROPIN FLEXPRO SOLUTION 10 MG/1.5ML PA somatropin 4 NORDITROPIN FLEXPRO SOLUTION 15 MG/1.5ML PA somatropin 4 NORDITROPIN FLEXPRO SOLUTION 5 MG/1.5ML PA somatropin 4 NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML PA somatropin 4 NUTROPIN AQ NUSPIN 10 SOLUTION 10 MG/2ML PA somatropin 4 NUTROPIN AQ NUSPIN 20 SOLUTION 20 MG/2ML PA somatropin 4 NUTROPIN AQ NUSPIN 5 SOLUTION 5 MG/2ML PA somatropin 4 NUTROPIN AQ PEN SOLUTION 10 MG/2ML PA somatropin 4 NUTROPIN AQ PEN SOLUTION 20 MG/2ML PA somatropin 4 SOMAVERT RECON SOLN 10 MG PA pegvisomant 4 SOMAVERT RECON SOLN 15 MG PA pegvisomant 4 SOMAVERT RECON SOLN 20 MG PA pegvisomant 4 TEV-TROPIN RECON SOLN 5 MG PA somatropin 4 Thyroid and Antithyroid Agents

levothyroxine sodium tab 100 mcg 1

PAGE 188 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

levothyroxine sodium tab 112 mcg 1

levothyroxine sodium tab 125 mcg 1

levothyroxine sodium tab 137 mcg 1

levothyroxine sodium tab 150 mcg 1

levothyroxine sodium tab 175 mcg 1

levothyroxine sodium tab 200 mcg 1

levothyroxine sodium tab 25 mcg 1

levothyroxine sodium tab 300 mcg 1

levothyroxine sodium tab 50 mcg 1

levothyroxine sodium tab 75 mcg 1

levothyroxine sodium tab 88 mcg 1

levoxyl tab 100 mcg 1

levoxyl tab 112 mcg 1

levoxyl tab 125 mcg 1

levoxyl tab 137 mcg 1

levoxyl tab 150 mcg 1

levoxyl tab 175 mcg 1

levoxyl tab 200 mcg 1

levoxyl tab 25 mcg 1

levoxyl tab 50 mcg 1

levoxyl tab 75 mcg 1

levoxyl tab 88 mcg 1

liothyronine sodium tab 25 mcg 1

liothyronine sodium tab 5 mcg 1

liothyronine sodium tab 50 mcg 1

methimazole tab 10 mg 1

methimazole tab 5 mg 1 NATURE-THROID TAB 130 MG thyroid 1 NATURE-THROID TAB 16.25 MG thyroid 1 NATURE-THROID TAB 195 MG thyroid 1

PAGE 189 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NATURE-THROID TAB 32.5 MG thyroid 1 NATURE-THROID TAB 65 MG thyroid 1

propylthiouracil tab 50 mg 1 SYNTHROID TAB 100 MCG levothyroxine sodium 2 SYNTHROID TAB 112 MCG levothyroxine sodium 2 SYNTHROID TAB 125 MCG levothyroxine sodium 2 SYNTHROID TAB 137 MCG levothyroxine sodium 2 SYNTHROID TAB 150 MCG levothyroxine sodium 2 SYNTHROID TAB 175 MCG levothyroxine sodium 2 SYNTHROID TAB 200 MCG levothyroxine sodium 2 SYNTHROID TAB 25 MCG levothyroxine sodium 2 SYNTHROID TAB 300 MCG levothyroxine sodium 2 SYNTHROID TAB 50 MCG levothyroxine sodium 2 SYNTHROID TAB 75 MCG levothyroxine sodium 2 SYNTHROID TAB 88 MCG levothyroxine sodium 2 THYROLAR-1 TAB 60 (12.5-50) MG (MCG) liotrix (t3-t4) 3 THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG) liotrix (t3-t4) 3 THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG) liotrix (t3-t4) 3 THYROLAR-2 TAB 120 (25-100) MG (MCG) liotrix (t3-t4) 3 THYROLAR-3 TAB 180 (37.5-150) MG (MCG) liotrix (t3-t4) 3

PAGE 190 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

unithroid direct tab 100 mcg 1

unithroid direct tab 112 mcg 1

unithroid direct tab 125 mcg 1

unithroid direct tab 150 mcg 1

unithroid direct tab 175 mcg 1

unithroid direct tab 200 mcg 1

unithroid direct tab 25 mcg 1

unithroid direct tab 300 mcg 1

unithroid direct tab 50 mcg 1

unithroid direct tab 75 mcg 1

unithroid direct tab 88 mcg 1

unithroid tab 100 mcg 1

unithroid tab 112 mcg 1

unithroid tab 125 mcg 1

unithroid tab 150 mcg 1

unithroid tab 175 mcg 1

unithroid tab 200 mcg 1

unithroid tab 25 mcg 1

unithroid tab 300 mcg 1

unithroid tab 50 mcg 1

unithroid tab 75 mcg 1

unithroid tab 88 mcg 1 WESTHROID TAB 130 MG thyroid 1 WESTHROID TAB 32.5 MG thyroid 1 WESTHROID TAB 65 MG thyroid 1 Miscellaneous Therapeutic Agents

acetylcysteine solution 10 % 1

acetylcysteine solution 20 % 1

acetylcysteine solution 200 mg/ml 1

PAGE 191 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ACTEMRA SOLN PRSYR 162 MG/0.9ML PA tocilizumab 4 ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML PA interferon gamma-1b 4 ACTONEL TAB 150 MG ST risedronate sodium 2

ACTONEL TAB 30 MG QL 30 / 30 days 2 risedronate sodium ST

ACTONEL TAB 35 MG ST risedronate sodium 2

ACTONEL TAB 5 MG QL 30 / 30 days 2 risedronate sodium ST

alendronate sodium tab 10 mg 1 QL 4 / 28 days

alendronate sodium tab 35 mg 1 QL 4 / 28 days

ALENDRONATE SODIUM TAB 40 MG QL 4 / 28 days 1 alendronate sodium PA

alendronate sodium tab 5 mg 1 QL 4 / 28 days

alendronate sodium tab 70 mg 1 QL 4 / 28 days

allopurinol tab 100 mg 1

allopurinol tab 300 mg 1

alpha-lipoic acid tab 200 mg 5 AMPYRA TAB ER 12H 10 MG PA dalfampridine 4 ARCALYST RECON SOLN 220 MG PA rilonacept 4

ATELVIA TAB DR 35 MG QL 4 / 30 days 3 risedronate sodium ST

AVODART CAP 0.5 MG ST dutasteride 3 AVONEX KIT 30 MCG PA interferon beta-1a 4 AVONEX PEN KIT 30 MCG/0.5ML PA interferon beta-1a 4 AVONEX PREFILLED KIT 30 MCG/0.5ML PA interferon beta-1a 4

PAGE 192 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AVORIA GC+ PACKET glucosamine-chondroitin-calcium-magnesium-vit c-vit d 5 AZASAN TAB 100 MG PA azathioprine 3 AZASAN TAB 75 MG PA azathioprine 3

azathioprine tab 50 mg 1 BERINERT KIT 500 UNIT PA c1 esterase inhibitor (human) 4 BETASERON KIT 0.3 MG PA interferon beta-1b 4

calcitonin (salmon) solution 200 unit/act 1

cavirinse solution 0.2 % 1 CELLCEPT RECON SUSP 200 MG/ML mycophenolate mofetil 4 CHEMET CAP 100 MG succimer 3

clinpro 5000 paste 1.1 % 1 COENZYME Q10 TAB 100 MG coenzyme q10 (ubidecarenone) 5 COLCHICINE TAB 0.6 MG QL 20 / 30 days colchicine 3

colchicine-probenecid tab 0.5-500 mg 1

controlrx paste 1.1 % 1 COPAXONE SOLN PRSYR 20 MG/ML PA glatiramer acetate 4

cranberry tab 400 mg 5

cyclosporine cap 100 mg 3

cyclosporine cap 25 mg 3

cyclosporine modified cap 100 mg 3

cyclosporine modified cap 25 mg 1 CYCLOSPORINE MODIFIED CAP 50 MG cyclosporine modified (for microemulsion) 1

cyclosporine modified solution 100 mg/ml 3 CYSTADANE POWDER PA betaine 4

PAGE 193 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

deferoxamine mesylate recon soln 500 mg 1

denta 5000 plus cream 1.1 % 1

dentagel gel 1.1 % 1 DEPEN TITRATABS TAB 250 MG penicillamine 4

disulfiram tab 250 mg 1

disulfiram tab 500 mg 1 DYSPORT RECON SOLN 500 UNIT PA abobotulinumtoxina 4 ELIDEL CREAM 1 % QL 100 / 30 days pimecrolimus 3 ELMIRON CAP 100 MG PA pentosan polysulfate sodium 4 ENBREL KIT 25 MG PA etanercept 4 ENJUVIA TAB 0.3 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 0.45 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 0.625 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 0.9 MG GL Female estrogens, conjugated synthetic b 2 ENJUVIA TAB 1.25 MG GL Female estrogens, conjugated synthetic b 2 ESTRACE CREAM 0.1 MG/GM estradiol vaginal 2

QL 8 / 28 days estradiol patch tw 0.025 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.0375 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.05 mg/24hr 1 GL Female

QL 8 / 28 days estradiol patch tw 0.075 mg/24hr 1 GL Female

PAGE 194 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 8 / 28 days estradiol patch tw 0.1 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.025 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.0375 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.05 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.06 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.075 mg/24hr 1 GL Female

QL 4 / 28 days estradiol patch wk 0.1 mg/24hr 1 GL Female

estradiol tab 0.5 mg 1 GL Female

estradiol tab 1 mg 1 GL Female

estradiol tab 2 mg 1 GL Female

estradiol valerate oil 20 mg/ml 1 GL Female

estradiol valerate oil 40 mg/ml 1 GL Female

ESTRING RING 2 MG estradiol vaginal 3 ESTROGEL GEL 0.75 MG/1.25 GM (0.06%) GL Female estradiol 3

estropipate tab 0.75 mg 1 GL Female

estropipate tab 1.5 mg 1 GL Female

ESTROPIPATE TAB 3 MG GL Female estropipate 1 ETIDRONATE DISODIUM TAB 200 MG etidronate disodium 3 ETIDRONATE DISODIUM TAB 400 MG etidronate disodium 3

PAGE 195 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EVAMIST SOLUTION 1.53 MG/SPRAY GL Female estradiol 3 EVISTA TAB 60 MG PA raloxifene hcl 3 EXTAVIA KIT 0.3 MG PA interferon beta-1b 4

finasteride tab 1 mg 1

finasteride tab 5 mg 1 FIRAZYR SOLUTION 30 MG/3ML PA icatibant acetate 4

fluoridex sensitivity relief paste 1.1-5 % 1

fluoritab chew tab 1.1 (0.5 f) mg 5

fluoritab chew tab 2.2 (1 f) mg 5

fomepizole solution 1 gm/ml 1

fomepizole solution 1.5 gm/1.5ml 1 FOSAMAX PLUS D TAB 70-2800 MG-UNIT PA alendronate sodium-cholecalciferol 3 FOSAMAX PLUS D TAB 70-5600 MG-UNIT PA alendronate sodium-cholecalciferol 3 FOSRENOL CHEW TAB 1000 MG PA lanthanum carbonate 3 FOSRENOL CHEW TAB 500 MG PA lanthanum carbonate 3 FOSRENOL CHEW TAB 750 MG PA lanthanum carbonate 3 GANIRELIX ACETATE SOLUTION 250 MCG/0.5ML PA ganirelix acetate 4

gengraf cap 100 mg 3

gengraf cap 25 mg 1

gengraf solution 100 mg/ml 3 GILENYA CAP 0.5 MG PA fingolimod hcl 4 GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG QL 2 / 30 days glucagon hcl rdna (diagnostic) 3 GLUCAGEN HYPOKIT RECON SOLN 1 MG QL 2 / 30 days glucagon hcl (rdna) 3 GLUCAGON EMERGENCY KIT 1 MG QL 2 / 30 days glucagon (rdna) 3

PAGE 196 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLUCOSAMINE HCL TAB 500 MG glucosamine hydrochloride 5

hecoria cap 0.5 mg 1

hecoria cap 1 mg 1

hecoria cap 5 mg 3 HUMIRA PEDIATRIC CROHNS START PREF SY KT 40 MG/0.8ML 4 PA adalimumab HUMIRA PEN-CROHNS STARTER PEN KIT 40 MG/0.8ML PA adalimumab 4 HUMIRA PREF SY KT 20 MG/0.4ML PA adalimumab 4 HUMIRA PREF SY KT 40 MG/0.8ML PA adalimumab 4

hydroxychloroquine sulfate tab 200 mg 1

ibandronate sodium tab 150 mg 3 ST

indomethacin cap 25 mg 1 AL Up to 64 yrs old

indomethacin cap 50 mg 1 AL Up to 64 yrs old

indomethacin er cap er 75 mg 1 AL Up to 64 yrs old

INTRON A RECON SOLN 10000000 UNIT PA interferon alfa-2b 4 INTRON A RECON SOLN 18000000 UNIT PA interferon alfa-2b 4 INTRON A RECON SOLN 50000000 UNIT PA interferon alfa-2b 4 INTRON A SOLUTION 6000000 UNIT/ML PA interferon alfa-2b 4 KALBITOR SOLUTION 10 MG/ML PA ecallantide 4 KINERET SOLN PRSYR 100 MG/0.67ML PA anakinra 4

kionex suspension 15 gm/60ml 1

leflunomide tab 10 mg 1

leflunomide tab 20 mg 1 LEUCOVORIN CALCIUM TAB 10 MG PA leucovorin calcium 4

PAGE 197 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEUCOVORIN CALCIUM TAB 15 MG PA leucovorin calcium 4

leucovorin calcium tab 25 mg 4 PA

leucovorin calcium tab 5 mg 4 PA

levocarnitine solution 1 gm/10ml 3

levocarnitine tab 330 mg 3 LOZI-FLUR LOZENGE 2.2 (1 F) MG sodium fluoride 5

ludent chew tab 1.1 (0.5 f) mg 5

ludent chew tab 2.2 (1 f) mg 5 MENEST TAB 0.3 MG GL Female esterified estrogens 3 MENEST TAB 0.625 MG GL Female esterified estrogens 3 MENEST TAB 1.25 MG GL Female esterified estrogens 3 MENEST TAB 2.5 MG GL Female esterified estrogens 3 MEPHYTON TAB 5 MG PA phytonadione 2

mercaptopurine tab 50 mg 1 MESNEX TAB 400 MG PA mesna 4

methotrexate sodium (pf) solution 1 gm/40ml 1

methotrexate sodium (pf) solution 100 mg/4ml 1

methotrexate sodium (pf) solution 25 mg/ml 1

methotrexate sodium (pf) solution 250 mg/10ml 1

methotrexate sodium (pf) solution 50 mg/2ml 1

methotrexate sodium recon soln 1 gm 1

methotrexate tab 2.5 mg 1 MIACALCIN SOLUTION 200 UNIT/ML ST calcitonin (salmon) 3

multi-vit/fluoride solution 0.25 mg/ml 1

multi-vitamin/fluoride solution 0.25 mg/ml 1

mycophenolate mofetil cap 250 mg 1

PAGE 198 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

mycophenolate mofetil recon susp 200 mg/ml 4

mycophenolate mofetil tab 500 mg 1 MYFORTIC TAB DR 180 MG PA mycophenolate sodium 3 MYFORTIC TAB DR 360 MG PA mycophenolate sodium 3

naltrexone hcl tab 50 mg 1

naproxen dr tab dr 375 mg 1

naproxen dr tab dr 500 mg 1

naproxen sodium tab 275 mg 1

naproxen sodium tab 550 mg 1

naproxen suspension 125 mg/5ml 1 NAPROXEN SUSPENSION 125 MG/5ML naproxen 1

naproxen tab 250 mg 1

naproxen tab 375 mg 1

naproxen tab 500 mg 1 OMEGA-3-6-9 CAP omega 3 fatty acids-omega 6 fatty acids-omega 9 fatty acids 5 ORFADIN CAP 10 MG PA nitisinone 4 ORFADIN CAP 2 MG PA nitisinone 4 ORFADIN CAP 5 MG PA nitisinone 4

perio med conc 0.63 % 1

periomed conc 0.63 % 1

phos-flur gel 1.1 % 1

phosphasal tab 81.6 mg 1 PHYSOSTIGMINE SALICYLATE SOLUTION 1 MG/ML physostigmine salicylate 1 POMALYST CAP 1 MG PA pomalidomide 4 POMALYST CAP 2 MG PA pomalidomide 4

PAGE 199 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POMALYST CAP 3 MG PA pomalidomide 4 POMALYST CAP 4 MG PA pomalidomide 4 PREMARIN TAB 0.3 MG GL Female estrogens, conjugated 2 PREMARIN TAB 0.45 MG GL Female estrogens, conjugated 3 PREMARIN TAB 0.625 MG GL Female estrogens, conjugated 3 PREMARIN TAB 0.9 MG GL Female estrogens, conjugated 3 PREMARIN TAB 1.25 MG GL Female estrogens, conjugated 3

probenecid tab 500 mg 1 PROLIA SOLUTION 60 MG/ML PA denosumab 4 RAPAMUNE SOLUTION 1 MG/ML PA sirolimus 4 RAPAMUNE TAB 0.5 MG PA sirolimus 4 REBIF REBIDOSE SOLUTION 22 MCG/0.5ML PA interferon beta-1a 4 REBIF REBIDOSE SOLUTION 44 MCG/0.5ML PA interferon beta-1a 4 REBIF REBIDOSE TITRATION PACK SOLUTION 6X8.8 & 6X22 MCG 4 PA interferon beta-1a REBIF SOLUTION 22 MCG/0.5ML PA interferon beta-1a 4 REBIF SOLUTION 44 MCG/0.5ML PA interferon beta-1a 4 REBIF TITRATION PACK SOLUTION 6X8.8 & 6X22 MCG PA interferon beta-1a 4 RENAGEL TAB 400 MG PA sevelamer hcl 3 RENAGEL TAB 800 MG PA sevelamer hcl 3 RENVELA PACKET 0.8 GM PA sevelamer carbonate 3

PAGE 200 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RENVELA PACKET 2.4 GM PA sevelamer carbonate 3 RENVELA TAB 800 MG PA sevelamer carbonate 3 REVLIMID CAP 10 MG PA lenalidomide 4 REVLIMID CAP 15 MG PA lenalidomide 4 REVLIMID CAP 2.5 MG PA lenalidomide 4 REVLIMID CAP 25 MG PA lenalidomide 4 REVLIMID CAP 5 MG PA lenalidomide 4 RIDAURA CAP 3 MG PA auranofin 4 RX SUPPORT HB/REFLUX/ALOE TAB folic acid-cyanocobalamin-vit b6-vit d-calcium-aloe 5 SANDIMMUNE SOLUTION 100 MG/ML PA cyclosporine 4 SENSIPAR TAB 30 MG PA cinacalcet hcl 4 SENSIPAR TAB 60 MG PA cinacalcet hcl 4 SENSIPAR TAB 90 MG PA cinacalcet hcl 4

sf gel 1.1 % 1

sodium fluoride chew tab 2.2 (1 f) mg 5

sodium fluoride solution 1.1 (0.5 f) mg/ml 5

sodium polystyrene sulfonate suspension 15 gm/60ml 1

sodium polystyrene sulfonate suspension 30 gm/120ml 1

sodium polystyrene sulfonate suspension 50 gm/200ml 1 SODIUM SULFACETAMIDE WASH LIQUID 10 % sulfacetamide sodium in bakuchiol vehicle 3

stannous fluoride conc 0.63 % 1 STRIBILD TAB 150-150-200-300 MG QL 30 / 30 days elvitegravir-cobicistat-emtricitabine-tenofovir 2

PAGE 201 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sulfasalazine tab 500 mg 1

sulfasalazine tab dr 500 mg 1

sulfazine ec tab dr 500 mg 1

sulfazine tab 500 mg 1 SYLATRON KIT 200 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 300 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 4 X 200 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 4 X 300 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 600 MCG PA peginterferon alfa-2b (antineoplastic) 4

tacrolimus cap 0.5 mg 1

tacrolimus cap 1 mg 1

tacrolimus cap 5 mg 3 TARON-PREX CAP 30-1.2-265 MG prenatal w/o vit a w/ fe fumarate-dss-fa-dha 1

tart cherry advanced cap 5 THALOMID CAP 100 MG PA thalidomide 4 THALOMID CAP 150 MG PA thalidomide 4 THALOMID CAP 200 MG PA thalidomide 4 THALOMID CAP 50 MG PA thalidomide 4 TREXALL TAB 10 MG PA methotrexate sodium 3 TREXALL TAB 15 MG PA methotrexate sodium 3 TREXALL TAB 5 MG PA methotrexate sodium 3 TREXALL TAB 7.5 MG PA methotrexate sodium 3

tri-vit/fluoride solution 0.25 mg/ml 1

PAGE 202 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tri-vit/fluoride solution 0.5 mg/ml 1

tri-vitamin/fluoride solution 0.25 mg/ml 1

tri-vitamin/fluoride solution 0.5 mg/ml 1

triple-vitamin/fluoride solution 0.25 mg/ml 1

uretron d/s tab 1 URETRON D/S TAB methenamine-hyosc-methylene blue-sod phos-phenyl sal 1

ustell cap 120 mg 1

uticap cap 120 mg 1

utira-c tab 81.6 mg 1

utrona-c tab 81.6 mg 1 VAGIFEM TAB 10 MCG estradiol vaginal 3

vitamins acd-fluoride solution 0.25 mg/ml 1 VIVITROL RECON SUSP 380 MG PA naltrexone 4 ZORTRESS TAB 0.25 MG PA everolimus (immunosuppressant) 4 ZORTRESS TAB 0.5 MG PA everolimus (immunosuppressant) 4 ZORTRESS TAB 0.75 MG PA everolimus (immunosuppressant) 4 Respiratory Tract Agents

Anti-inflammatory Agents

ALOCRIL SOLUTION 2 % PA nedocromil sodium (ophth) 3 BECONASE AQ SUSPENSION 42 MCG/SPRAY ST beclomethasone diprop monohyd 3

QL 120 / 30 days budesonide suspension 0.25 mg/2ml 1 AL Up to 8 yrs old

QL 120 / 30 days budesonide suspension 0.5 mg/2ml 1 AL Up to 8 yrs old

cromolyn sodium conc 100 mg/5ml 1

cromolyn sodium solution 4 % 1

PAGE 203 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLOVENT DISKUS AER POW BA 100 MCG/BLIST QL 60 / 30 days fluticasone propionate (inhalation) 3

flunisolide solution 25 mcg/act (0.025%) 1 QL 50 / 25 days

FLUNISOLIDE SOLUTION 25 MCG/ACT (0.025%) QL 50 / 25 days flunisolide (nasal) 1

fluticasone propionate suspension 50 mcg/act 1 QL 16 / 25 days

montelukast sodium chew tab 4 mg 1

montelukast sodium chew tab 5 mg 1

montelukast sodium packet 4 mg 1

montelukast sodium tab 10 mg 1 NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT triamcinolone acetonide (nasal) 1 NASONEX SUSPENSION 50 MCG/ACT ST mometasone furoate (nasal) 3 PULMICORT FLEXHALER AER POW BA 180 MCG/ACT QL 1 / 30 days budesonide (inhalation) 3 PULMICORT FLEXHALER AER POW BA 90 MCG/ACT QL 1 / 30 days budesonide (inhalation) 3

PULMICORT SUSPENSION 1 MG/2ML QL 120 / 30 days 4 budesonide (inhalation) AL Up to 8 yrs old

QNASL AERO SOLN 80 MCG/ACT ST beclomethasone dipropionate (nasal) 3 QVAR AERO SOLN 40 MCG/ACT QL 8.7 / 30 days beclomethasone dipropionate 2 QVAR AERO SOLN 80 MCG/ACT beclomethasone dipropionate 2 RHINOCORT AQUA SUSPENSION 32 MCG/ACT ST budesonide (nasal) 3 VERAMYST SUSPENSION 27.5 MCG/SPRAY ST fluticasone furoate 3

zafirlukast tab 10 mg 3

zafirlukast tab 20 mg 3 ZYFLO TAB 600 MG PA zileuton 4

PAGE 204 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Antihistamines

ALLEGRA ALLERGY CHILDRENS TAB 30 MG QL 50 / 30 days fexofenadine hcl 1

altaryl syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

arbinoxa tab 4 mg 1 AL Up to 64 yrs old

ASTEPRO SOLUTION 0.15 % ST azelastine hcl 3

azelastine hcl solution 0.05 % 3

azelastine hcl solution 137 mcg/spray 1 ST

carbinoxamine maleate tab 4 mg 1 AL Up to 64 yrs old

cetirizine hcl childrens alrgy syrup 1 mg/ml 1 QL 50 / 30 days

cetirizine hcl solution 1 mg/ml 1 QL 50 / 30 days

cetirizine hcl syrup 1 mg/ml 1 QL 50 / 30 days

cetirizine hcl syrup 5 mg/5ml 1

cetirizine hcl tab 10 mg 1 QL 50 / 30 days

cetirizine hcl tab 5 mg 1 QL 50 / 30 days

childrens loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

CLARITIN REDITABS TAB DISP 10 MG QL 50 / 30 days loratadine 1

clemastine fumarate syrup 0.67 mg/5ml 1 AL Up to 64 yrs old

CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML AL Up to 64 yrs old clemastine fumarate 1

clemastine fumarate tab 2.68 mg 1 AL Up to 64 yrs old

cvs allergy relief tab 10 mg 1 QL 50 / 30 days

cvs loratadine tab 10 mg 1 QL 50 / 30 days

cyproheptadine hcl syrup 2 mg/5ml 1 AL Up to 64 yrs old

cyproheptadine hcl tab 4 mg 1 AL Up to 64 yrs old

diphenhydramine hcl cap 50 mg 1 AL Up to 64 yrs old

diphenhydramine hcl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

PAGE 205 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diphenhydramine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

eq allergy relief childrens elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

eq loratadine tab 10 mg 1 QL 50 / 30 days

eql childrens loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

fexofenadine hcl tab 60 mg 1 QL 50 / 30 days

gnp loratadine childrens syrup 5 mg/5ml 1 QL 50 / 30 days

gnp loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

gnp loratadine tab 10 mg 1 QL 50 / 30 days

hm fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

hm fexofenadine hcl tab 60 mg 1 QL 50 / 30 days

hm loratadine childrens syrup 5 mg/5ml 1 QL 50 / 30 days

kp cetirizine hcl tab 10 mg 1 QL 50 / 30 days

kp cetirizine hcl tab 5 mg 1 QL 50 / 30 days

kp fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

loratadine allergy relief tab disp 10 mg 1 QL 50 / 30 days

loratadine tab 10 mg 1 QL 50 / 30 days

medi-phedryl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

phenadoz suppos 12.5 mg 1 AL Up to 64 yrs old

phenadoz suppos 25 mg 1 AL Up to 64 yrs old

phenergan suppos 50 mg 1 AL Up to 64 yrs old

promethazine hcl solution 25 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl suppos 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 25 mg 1 AL Up to 64 yrs old

PAGE 206 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

promethazine hcl suppos 50 mg 1 AL Up to 64 yrs old

promethazine hcl syrup 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl tab 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl tab 25 mg 1 AL Up to 64 yrs old

promethazine hcl tab 50 mg 1 AL Up to 64 yrs old

promethegan suppos 12.5 mg 1 AL Up to 64 yrs old

promethegan suppos 25 mg 1 AL Up to 64 yrs old

promethegan suppos 50 mg 1 AL Up to 64 yrs old

qc loratadine allergy relief tab 10 mg 1 QL 50 / 30 days

quenalin syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

sb loratadine tab 10 mg 1 QL 50 / 30 days

silphen cough syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

sm childrens loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

sm fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

sm fexofenadine hcl tab 60 mg 1 QL 50 / 30 days

sm loratadine allergy relief tab disp 10 mg 1 QL 50 / 30 days

sm loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

sm loratadine tab 10 mg 1 QL 50 / 30 days

sm loratadine tab disp 10 mg 1 QL 50 / 30 days

tgt loratadine childrens syrup 5 mg/5ml 1 QL 50 / 30 days

wal-itin tab 10 mg 1 Bronchodilators

ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML epinephrine 3

albuterol sulfate er tab er 12h 4 mg 1

albuterol sulfate er tab er 12h 8 mg 1

albuterol sulfate nebu soln (2.5 mg/3ml) 0.083% 1

albuterol sulfate nebu soln (5 mg/ml) 0.5% 1

PAGE 207 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

albuterol sulfate nebu soln 0.63 mg/3ml 1

albuterol sulfate nebu soln 1.25 mg/3ml 1

albuterol sulfate syrup 2 mg/5ml 1

ARCAPTA NEOHALER CAP 75 MCG QL 30 / 30 days 3 indacaterol maleate PA

ATROVENT HFA AERO SOLN 17 MCG/ACT QL 26 / 25 days ipratropium bromide hfa 2 AUVI-Q SOLN A-INJ 0.15 MG/0.15ML epinephrine 3 COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT QL 4 / 25 days ipratropium-albuterol 3 ELIXOPHYLLIN ELIXIR 80 MG/15ML theophylline 2

epinephrine hcl soln prsyr 0.1 mg/ml 1

epinephrine hcl solution 1 mg/ml 1 EPINEPHRINE SOLN A-INJ 0.15 MG/0.15ML QL 2 / 90 days epinephrine 1 EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML epinephrine 1 EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML epinephrine 2 EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML QL 2 / 90 days epinephrine 2 FORADIL AEROLIZER CAP 12 MCG QL 60 / 30 days formoterol fumarate 2

ipratropium bromide solution 0.02 % 1

ipratropium bromide solution 0.03 % 1 QL 30 / 25 days

ipratropium bromide solution 0.06 % 1 QL 15 / 25 days

ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml 1

levalbuterol hcl nebu soln 0.31 mg/3ml 1 ST

levalbuterol hcl nebu soln 0.63 mg/3ml 1 ST

levalbuterol hcl nebu soln 1.25 mg/0.5ml 1 ST

metaproterenol sulfate syrup 10 mg/5ml 1 METAPROTERENOL SULFATE SYRUP 10 MG/5ML metaproterenol sulfate 1

PAGE 208 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS METAPROTERENOL SULFATE TAB 10 MG metaproterenol sulfate 1 METAPROTERENOL SULFATE TAB 20 MG metaproterenol sulfate 1 PERFOROMIST NEBU SOLN 20 MCG/2ML PA formoterol fumarate 3 PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate 3 PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT QL 6.7 / 30 days albuterol sulfate 3 SEREVENT DISKUS AER POW BA 50 MCG/DOSE PA salmeterol xinafoate 2 SPIRIVA HANDIHALER CAP 18 MCG QL 30 / 30 days tiotropium bromide monohydrate 2

terbutaline sulfate solution 1 mg/ml 1

terbutaline sulfate tab 2.5 mg 1

terbutaline sulfate tab 5 mg 1

theochron tab er 12h 100 mg 1

theochron tab er 12h 200 mg 1

theochron tab er 12h 300 mg 1

theophylline er tab er 12h 100 mg 1

theophylline er tab er 12h 200 mg 1

theophylline er tab er 12h 300 mg 1

theophylline er tab er 12h 450 mg 1

theophylline er tab er 24h 400 mg 1

theophylline er tab er 24h 600 mg 1

theophylline solution 80 mg/15ml 1 VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate 2

XOPENEX HFA AEROSOL 45 MCG/ACT QL 60 / 30 days 3 levalbuterol tartrate ST

Cystic Fibrosis Transmembrane Conductance Regulator Modulators

KALYDECO TAB 150 MG PA ivacaftor 4

acetylcysteine solution 10 % 1

PAGE 209 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

acetylcysteine solution 20 % 1

altaryl syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

benzonatate cap 100 mg 1

benzonatate cap 200 mg 1

bromfed dm syrup 30-2-10 mg/5ml 1 CODEINE SULFATE SOLUTION 30 MG/5ML codeine sulfate 1

codeine sulfate tab 15 mg 1 CODEINE SULFATE TAB 15 MG codeine sulfate 1

codeine sulfate tab 30 mg 1 CODEINE SULFATE TAB 30 MG codeine sulfate 1

difil-g forte liquid 100-100 mg/5ml 1

diphenhydramine hcl cap 50 mg 1 AL Up to 64 yrs old

diphenhydramine hcl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

diphenhydramine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

eq allergy relief childrens elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

hydrocod polst-cpm polst er liquid er 10-8 mg/5ml 1

hydrocodone-homatropine syrup 5-1.5 mg/5ml 1

hydrocodone-homatropine tab 5-1.5 mg 1

hydromet syrup 5-1.5 mg/5ml 1 IODINE STRONG (LUGOL'S) SOLUTION iodine strong (lugol's) (bulk) 1 IODINE STRONG SOLUTION 5 % iodine strong (lugol's) 1 LETAIRIS TAB 10 MG PA ambrisentan 4 LETAIRIS TAB 5 MG PA ambrisentan 4

medi-phedryl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 1.75-0.75-2.75 MG/ML 1 phenylephrine-chlorphen-dm

PAGE 210 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

phenylephrine-guaifenesin liquid 1.5-20 mg/ml 1 PROMETHAZINE VC/CODEINE SYRUP 6.25-5-10 MG/5ML phenyleph-promethazine w/ cod 1

promethazine-codeine syrup 6.25-10 mg/5ml 1

promethazine-dm syrup 6.25-15 mg/5ml 1

PULMOZYME SOLUTION 1 MG/ML QL 60 / 30 days 4 dornase alfa PA

quenalin syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

sildenafil citrate tab 20 mg 4 PA

silphen cough syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

sodium chloride nebu soln 0.9 % 1

sodium chloride nebu soln 10 % 1

sodium chloride nebu soln 3 % 1

sodium chloride nebu soln 7 % 1 TGQ 15DM/5PEH/2CPM SYRUP 15-5-2 MG/5ML phenylephrine-chlorphen-dm 1 TGQ 30PSE/150GFN/15DM SYRUP 30-150-15 MG/5ML pseudoephedrine w/ dm-gg 1

tussigon tab 5-1.5 mg 1 TYVASO REFILL SOLUTION 0.6 MG/ML PA treprostinil 4 TYVASO SOLUTION 0.6 MG/ML PA treprostinil 4 TYVASO STARTER SOLUTION 0.6 MG/ML PA treprostinil 4 VENTAVIS SOLUTION 10 MCG/ML PA iloprost 4 VENTAVIS SOLUTION 20 MCG/ML PA iloprost 4 XOLAIR RECON SOLN 150 MG PA omalizumab 4 Serums, Toxoids and Vaccines

AFLURIA PRESERVATIVE FREE SUSP PRSYR 0.5 ML influenza virus vaccine split preservative free 5 AFLURIA SUSPENSION influenza virus vaccine split 5

PAGE 211 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLUARIX QUADRIVALENT SUSP PRSYR 0.5 ML influenza virus vaccine split quadrivalent 5 FLUARIX SUSP PRSYR 0.5 ML influenza virus vaccine split preservative free 5 FLUCELVAX SUSP PRSYR 0.5 ML influenza virus vaccine tissue-cultured subunit 5 FLULAVAL QUADRIVALENT SUSP PRSYR 0.5 ML influenza virus vaccine split quadrivalent 5 FLULAVAL SUSPENSION influenza virus vaccine split 5 FLUVIRIN PRESERVATIVE FREE SUSP PRSYR 0.5 ML influenza virus vaccine types a & b preservative free 5 FLUVIRIN SUSP PRSYR 0.5 ML influenza virus vaccine types a & b surface antigen 5 FLUVIRIN SUSPENSION influenza virus vaccine types a & b surface antigen 5 FLUZONE PRESERVATIVE FREE SUSP PRSYR 0.5 ML influenza virus vaccine split preservative free 5 FLUZONE PRESERVATIVE FREE SUSPENSION influenza virus vaccine split preservative free 5 FLUZONE QUADRIVALENT SUSP PRSYR 0.5 ML influenza virus vaccine split quadrivalent 5 FLUZONE QUADRIVALENT SUSPENSION 0.5 ML influenza virus vaccine split quadrivalent 5 FLUZONE SUSP PEN 9 MCG/STRAIN influenza virus vaccine split 5 FLUZONE SUSPENSION influenza virus vaccine split 5 ZOSTAVAX RECON SOLN 19400 UNT/0.65ML zoster vaccine live 5 Skin and Mucous Membrane Preparations

Anti-infectives

acticin cream 5 % 1 QL 120 / 30 days

acyclovir ointment 5 % 4 PA

ALTABAX OINTMENT 1 % ST retapamulin 3

antifungal cream 2 % 1

PAGE 212 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BACTROBAN NASAL OINTMENT 2 % mupirocin calcium 3

baza antifungal cream 2 % 1

benzepro foam 5.3 % 3

benzepro short contact foam 9.8 % 3

benziq wash liquid 5.25 % 1

benzoyl peroxide cleanser lotion 6 % 1

benzoyl peroxide foam 5.3 % 3

benzoyl peroxide gel 10 % 1

benzoyl peroxide gel 5 % 1

benzoyl peroxide wash kit 4 & 5 % 1

benzoyl peroxide wash kit 8 & 5 % 1

benzoyl peroxide-erythromycin gel 5-3 % 1

bp wash liquid 5.25 % 1

bp wash liquid 7 % 3

bpo creamy wash kit 4 & 5 % 1 BPO CREAMY WASH KIT 8 & 5 % benzoyl peroxide 1

carrington antifungal cream 2 % 1

chlorhexidine gluconate solution 0.12 % 1 CHLORHEXIDINE GLUCONATE SOLUTION 20 % chlorhexidine gluconate 3 CLEOCIN SUPPOS 100 MG clindamycin phosphate vaginal 3

clindacin-p swab 1 % 1

clindamax gel 1 % 3

clindamax lotion 1 % 1

clindamycin phos-benzoyl perox gel 1-5 % 3

clindamycin phosphate cream 2 % 1

clindamycin phosphate foam 1 % 3

clindamycin phosphate gel 1 % 3

clindamycin phosphate lotion 1 % 1

clindamycin phosphate solution 1 % 1

PAGE 213 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clindamycin phosphate swab 1 % 1

clotrimazole af cream 1 % 1 QL 50 / 30 days

clotrimazole anti-fungal cream 1 % 1 QL 50 / 30 days

clotrimazole cream 1 % 1 QL 50 / 30 days

clotrimazole cream 1 % 1 QL 50 / 30 days

clotrimazole lozenge 10 mg 1

clotrimazole solution 1 % 1

clotrimazole troche 10 mg 1

clotrimazole-7 cream 1 % 1 QL 50 / 30 days

clotrimazole-betamethasone cream 1-0.05 % 1 QL 90 / 23 days

clotrimazole-betamethasone lotion 1-0.05 % 3 QL 60 / 23 days

CORTISPORIN CREAM 0.5-0.5-10000 neomycin-polymyxin-hc 1 CORTISPORIN OINTMENT 1 % bacitracin-polymyxin-neomycin hc 3 DENAVIR CREAM 1 % penciclovir 3

econazole nitrate cream 1 % 1 QL 85 / 23 days

EPIDUO GEL 0.1-2.5 % adapalene-benzoyl peroxide 3

eql miconazole 3 kit 200-2 mg-% (9gm) 1 ERTACZO CREAM 2 % sertaconazole nitrate 3

ery pad 2 % 1

erythromycin gel 2 % 1

erythromycin pad 2 % 1

erythromycin solution 2 % 1 EURAX CREAM 10 % PA crotamiton 2 EURAX LOTION 10 % PA crotamiton 2

exoderm lotion 25-1 % 1

fungicure intensive/nailguard solution 1 % 1

PAGE 214 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gentamicin sulfate cream 0.1 % 1 GENTAMICIN SULFATE CREAM 0.1 % gentamicin sulfate (topical) 1

gentamicin sulfate ointment 0.1 % 1 GENTAMICIN SULFATE OINTMENT 0.1 % gentamicin sulfate (topical) 1

gnp miconazole 3 kit 1

gnp miconazole 3 kit 200-2 mg-% (9gm) 1 GYNAZOLE-1 CREAM 2 % butoconazole nitrate (one dose) 3 IODINE TINCTURE TINCTURE iodine (topical) 1

ketoconazole cream 2 % 1

ketoconazole shampoo 2 % 1

ketodan foam 2 % 3

kp benzoyl peroxide gel 10 % 1

kp benzoyl peroxide gel 5 % 1

kp clotrimazole cream 1 % 1 QL 50 / 30 days

kp miconazole nitrate cream 2 % 1 LAVOCLEN-4 CREAMY WASH LIQUID 4 % benzoyl peroxide 1 LAVOCLEN-8 CREAMY WASH LIQUID 8 % benzoyl peroxide 1

lindane lotion 1 % 3

lindane shampoo 1 % 3 LUGOLS SOLUTION iodine (topical) 1

mafenide acetate packet 5 % 3

malathion lotion 0.5 % 2 MENTAX CREAM 1 % butenafine hcl 3

metronidazole cream 0.75 % 3

metronidazole gel 0.75 % 3

metronidazole gel 0.75 % 1

PAGE 215 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

metronidazole lotion 0.75 % 1

micaderm cream 2 % 1

miconazole 3 combo pack kit 200-2 mg-% (9gm) 1

miconazole nitrate cream 2 % 1

miconazole nitrate cream 2 % 1

micro guard cream 2 % 1

mupirocin calcium cream 2 % 3

mupirocin ointment 2 % 1 NATROBA SUSPENSION 0.9 % ST spinosad 3

neomycin-polymyxin b gu solution 40-200000 1

nyamyc powder 100000 unit/gm 1

nystatin cream 100000 unit/gm 1

nystatin ointment 100000 unit/gm 1

nystatin powder 100000 unit/gm 1

nystatin-triamcinolone cream 100000-0.1 unit/gm-% 3

nystatin-triamcinolone ointment 100000-0.1 unit/gm-% 1

nystop powder 100000 unit/gm 1

oscion cleanser lotion 6 % 1 OXISTAT CREAM 1 % oxiconazole nitrate 3

periogard solution 0.12 % 1

permethrin cream 5 % 1 QL 120 / 30 days

podactin cream 2 % 1

qc clotrimazole cream 1 % 1 QL 50 / 30 days

ra antifungal cream 2 % 1

ra clotrimazole 7 cream 1 % 1 QL 50 / 30 days

remedy antifungal cream 2 % 1

rosadan cream 0.75 % 3

rosadan gel 0.75 % 3

seb-prev wash liquid 10 % 3

secura antifungal cream 2 % 1

PAGE 216 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

secura antifungal extra thick cream 2 % 1

selenium sulf-pyrithione-urea shampoo 2.25 % 3

selenium sulfide lotion 2.5 % 1 SKLICE LOTION 0.5 % PA ivermectin (pediculicide) 3

sm antifungal clotrimazole cream 1 % 1 QL 50 / 30 days

sm antifungal miconazole cream 2 % 1

sm clotrimazole vaginal cream 1 % 1 QL 50 / 30 days

sm miconazole 3 kit 200-2 mg-% (9gm) 1 SODIUM SULFACETAMIDE WASH LIQUID 10 % sulfacetamide sodium in bakuchiol vehicle 3

soothe & cool inzo antifungal cream 2 % 1

sulfacetamide sodium (acne) lotion 10 % 3

sulfacetamide sodium liquid 10 % 3

sulfacetamide sodium suspension 10 % 3

sulfacetamide sodium-sulfur lotion 10-5 % 3

terconazole cream 0.4 % 1

terconazole cream 0.8 % 1

terconazole suppos 80 mg 3

tgt clotrimazole cream 1 % 1 QL 50 / 30 days

tgt miconazole 3 combo pack kit 200-2 mg-% (9gm) 1

triple antibiotic ointment 3.5-400-5000 1 QL 50 / 30 days

urea emulsion 50 % 3

urea in zn undecyl-lactic acid emulsion 50 % 3

vandazole gel 0.75 % 1 VELTIN GEL 1.2-0.025 % clindamycin phosphate-tretinoin 3

versiclear lotion 25-1 % 1

zazole cream 0.4 % 1

zazole cream 0.8 % 1

zazole suppos 80 mg 3 ZIANA GEL 1.2-0.025 % clindamycin phosphate-tretinoin 3

PAGE 217 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZOVIRAX CREAM 5 % PA acyclovir topical 3 Depigmenting and Pigmenting Agents

alphaquin hp cream 4 % 1

hydroquinone time release cream 4 % 1

melpaque hp cream 4 % 1 MELQUIN 3 SOLUTION 3 % hydroquinone 1

melquin hp cream 4 % 1 OXSORALEN LOTION 1 % methoxsalen (topical) 4 OXSORALEN ULTRA CAP 10 MG PA methoxsalen rapid 3

remergent hq cream 4 % 1

ala cort cream 1 % 1

alclometasone dipropionate cream 0.05 % 1

alclometasone dipropionate ointment 0.05 % 1

amcinonide cream 0.1 % 3 AMCINONIDE CREAM 0.1 % amcinonide 3 AMCINONIDE LOTION 0.1 % amcinonide 3 AMCINONIDE OINTMENT 0.1 % amcinonide 3

ammonium lactate cream 12 % 1 PA

ammonium lactate lotion 12 % 1 PA

ANALPRAM-HC LOTION 1-2.5 % hydrocortisone acetate w/ pramoxine 3

anti-itch intensive healing lotion 1 % 1 QL 240 / 23 days

anti-itch maximum strength cream 1 % 1 QL 120 / 23 days

anucort-hc suppos 25 mg 1

aquanil hc lotion 1 % 1 QL 240 / 23 days

PAGE 218 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

aveeno anti-itch max st cream 1 % 1 QL 120 / 23 days

AVIDOXY DK KIT 100 MG doxycycline w/ suncreen & salicylic acid 1

QL 45 / 23 days avita cream 0.025 % 1 AL Up to 28 yrs old

avita gel 0.025 % 1 AL Up to 28 yrs old

BENZYL ALCOHOL LIQUID benzyl alcohol 1

beta hc lotion 1 % 1 QL 240 / 23 days

betamethasone dipropionate aug cream 0.05 % 1 QL 100 / 23 days

betamethasone dipropionate aug gel 0.05 % 1 QL 100 / 23 days

betamethasone dipropionate aug lotion 0.05 % 1 QL 120 / 23 days

betamethasone dipropionate aug ointment 0.05 % 1 QL 100 / 23 days

betamethasone dipropionate cream 0.05 % 1 QL 90 / 23 days

betamethasone dipropionate lotion 0.05 % 1 QL 120 / 23 days

betamethasone dipropionate ointment 0.05 % 1 QL 90 / 23 days

betamethasone valerate cream 0.1 % 1 QL 90 / 23 days

betamethasone valerate foam 0.12 % 3

betamethasone valerate lotion 0.1 % 1 QL 120 / 23 days

betamethasone valerate ointment 0.1 % 1 QL 90 / 23 days

calahist clear lotion 1-0.1 % 1

calcipotriene cream 0.005 % 3

calcipotriene ointment 0.005 % 3

calcipotriene solution 0.005 % 3 CALCITRIOL OINTMENT 3 MCG/GM PA calcitriol (topical) 3

CAPEX SHAMPOO 0.01 % QL 120 / 23 days 3 fluocinolone acetonide ST

capsaicin cream 0.025 % 1

capsaicin cream 0.1 % 1

PAGE 219 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

capsaicin hp cream 0.1 % 1 CEM-UREA SOLUTION 45 % urea 3

cerovel gel 40 % 3

cerovel lotion 40 % 1

clobetasol propionate cream 0.05 % 1 QL 120 / 23 days

clobetasol propionate emulsion foam 0.05 % 3

clobetasol propionate foam 0.05 % 3

clobetasol propionate gel 0.05 % 1 QL 120 / 23 days

clobetasol propionate lotion 0.05 % 3

clobetasol propionate ointment 0.05 % 1 QL 120 / 23 days

clobetasol propionate shampoo 0.05 % 3

clobetasol propionate solution 0.05 % 1 CLODERM CREAM 0.1 % clocortolone pivalate 3 CLODERM PUMP CREAM 0.1 % clocortolone pivalate 3

clotrimazole-betamethasone cream 1-0.05 % 1 QL 90 / 23 days

clotrimazole-betamethasone lotion 1-0.05 % 3 QL 60 / 23 days

COAL TAR EXTRACT SOLUTION 20 % coal tar (crude) 1 COAL TAR SOLUTION coal tar (crude) 1 COAL TAR SOLUTION 20 % coal tar (crude) 1 COAL TAR SOLUTION 20 % coal tar extract 1

colocort enema 100 mg/60ml 1 CONDYLOX GEL 0.5 % PA podofilox 3 CORDRAN CREAM 0.05 % PA flurandrenolide 3 CORDRAN LOTION 0.05 % PA flurandrenolide 3

PAGE 220 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CORDRAN TAPE 4 MCG/SQCM QL 1 / 23 days 3 flurandrenolide PA

cormax scalp application solution 0.05 % 1 QL 100 / 23 days

cortaid advanced 12 hour cream 1 % 1 QL 120 / 23 days

cortaid maximum strength cream 1 % 1 QL 120 / 23 days

CORTALO GEL 2 % hydrocortisone acetate-aloe vera 1 CORTIFOAM FOAM 90 MG ST hydrocortisone acetate (intrarectal) 3 CORTISPORIN CREAM 0.5-0.5-10000 neomycin-polymyxin-hc 1 CORTISPORIN OINTMENT 1 % bacitracin-polymyxin-neomycin hc 3

cortizone-10 eczema lotion 1 % 1 QL 240 / 23 days

cortizone-10 hydratensive lotion 1 % 1 QL 240 / 23 days

cortizone-10 ointment 1 % 1 QL 90 / 23 days

COTTONSEED OIL OIL cottonseed oil (bulk) 1

cvs anti-itch maximum strength cream 1 % 1 QL 120 / 23 days

cvs capsaicin hp cream 0.1 % 1

cvs cortisone intense healing cream 1 % 1 QL 120 / 23 days

cvs cortisone long-lasting lotion 1 % 1 QL 240 / 23 days

cvs cortisone maximum strength cream 1 % 1 QL 120 / 23 days

cvs cortisone maximum strength ointment 1 % 1 QL 90 / 23 days

cvs eczema anti-itch cream 1 % 1 QL 120 / 23 days

cvs hydrocortisone anti-itch cream 1 % 1 QL 120 / 23 days

cvs hydrocortisone max st cream 1 % 1 QL 120 / 23 days

desonide cream 0.05 % 3 QL 120 / 23 days

desonide lotion 0.05 % 3

desonide ointment 0.05 % 1 QL 120 / 23 days

PAGE 221 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DESOXIMETASONE CREAM 0.05 % QL 200 / 23 days desoximetasone 1

desoximetasone cream 0.25 % 1 QL 200 / 23 days

desoximetasone gel 0.05 % 1 QL 120 / 23 days

DESOXIMETASONE OINTMENT 0.05 % QL 120 / 23 days desoximetasone 3

desoximetasone ointment 0.25 % 1 QL 200 / 23 days

DIFLORASONE DIACETATE CREAM 0.05 % QL 120 / 23 days diflorasone diacetate 1

diflorasone diacetate ointment 0.05 % 1 QL 120 / 23 days

DIFLORASONE DIACETATE OINTMENT 0.05 % QL 120 / 23 days diflorasone diacetate 1 DRITHO-CREME HP CREAM 1 % anthralin 3 ELIDEL CREAM 1 % QL 100 / 30 days pimecrolimus 3 EPIDUO GEL 0.1-2.5 % adapalene-benzoyl peroxide 3

eq anti-itch max strength cream 1 % 1 QL 120 / 23 days

eq hydrocortisone max st cream 1 % 1 QL 120 / 23 days

eq hydrocortisone plus cream 1 % 1 QL 120 / 23 days

eql anti-itch intensive heal cream 1 % 1 QL 120 / 23 days

eql anti-itch maximum strength cream 1 % 1 QL 120 / 23 days

eql anti-itch maximum strength ointment 1 % 1 QL 90 / 23 days

ETHYL CHLORIDE AEROSOL ethyl chloride 1

exoderm lotion 25-1 % 1

finasteride tab 1 mg 1

fluocinolone acetonide cream 0.01 % 1 QL 120 / 23 days

fluocinolone acetonide cream 0.025 % 1 QL 120 / 23 days

fluocinolone acetonide ointment 0.025 % 1 QL 120 / 23 days

fluocinolone acetonide solution 0.01 % 3 QL 120 / 23 days

PAGE 222 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fluocinonide cream 0.05 % 1 QL 120 / 23 days

fluocinonide gel 0.05 % 1 QL 120 / 23 days

fluocinonide ointment 0.05 % 1 QL 120 / 23 days

fluocinonide solution 0.05 % 1 QL 120 / 23 days

fluorouracil cream 5 % 3

fluorouracil solution 2 % 1

fluorouracil solution 5 % 1

fluticasone propionate cream 0.05 % 1 QL 120 / 23 days

fluticasone propionate lotion 0.05 % 3

fluticasone propionate ointment 0.005 % 1 QL 120 / 23 days

geri-hydrolac 12 cream 12 % 1 PA

glydo gel 2 % 1 QL 90 / 23 days

gnp arthritis pain relief cream 0.1 % 1

gnp capsaicin cream 0.1 % 1

gnp hydro-lotion lotion 1 % 1 QL 240 / 23 days

gnp hydrocortisone max st ointment 1 % 1 QL 90 / 23 days

gnp hydrocortisone plus cream 1 % 1 QL 120 / 23 days

HALAC KIT 0.05 & 12 % halobetasol propionate & ammonium lactate 3

halobetasol propionate cream 0.05 % 1 QL 100 / 23 days

halobetasol propionate ointment 0.05 % 1 QL 100 / 23 days

HALOG CREAM 0.1 % QL 100 / 23 days halcinonide 3 HALOG OINTMENT 0.1 % QL 100 / 23 days halcinonide 3

halonate pac kit 0.05 & 12 % 3

hydro skin maximum strength lotion 1 % 1 QL 240 / 23 days

hydrocortisone ace-pramoxine cream 1-1 % 3

hydrocortisone ace-pramoxine cream 2.5-1 % 3

hydrocortisone ace-pramoxine cream 2.5-1 % 1 QL 60 / 23 days

PAGE 223 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydrocortisone ace-pramoxine kit 2.5-1 & 1 % 1

hydrocortisone acetate suppos 25 mg 1

hydrocortisone acetate suppos 30 mg 1

hydrocortisone butyr lipo base cream 0.1 % 1

hydrocortisone butyrate cream 0.1 % 1

hydrocortisone butyrate ointment 0.1 % 1

hydrocortisone butyrate solution 0.1 % 1

hydrocortisone cream 1 % 1 QL 120 / 23 days

hydrocortisone cream 2.5 % 3 QL 90 / 23 days

hydrocortisone enema 100 mg/60ml 1

hydrocortisone intensive heal cream 1 % 1 QL 120 / 23 days

hydrocortisone lotion 1 % 1

hydrocortisone lotion 2.5 % 1 QL 120 / 23 days

hydrocortisone max st cream 1 % 1 QL 120 / 23 days

hydrocortisone max st/12 moist cream 1 % 1

hydrocortisone ointment 0.5 % 1

hydrocortisone ointment 1 % 1 QL 90 / 23 days

hydrocortisone ointment 2.5 % 1 QL 90 / 23 days

hydrocortisone plus cream 1 % 1 QL 120 / 23 days

hydrocortisone valerate cream 0.2 % 1 QL 120 / 23 days

hydrocortisone valerate ointment 0.2 % 1 QL 120 / 23 days

hydroskin cream 1 % 1 QL 120 / 23 days

hygel gel 0.2 % 1

hygienic cleansing pad 50 % 1

hypercare solution 20 % 1

ice blue gel 2 % 1

imiquimod cream 5 % 4 QL 60 / 30 days

KENALOG AERO SOLN PA triamcinolone acetonide (topical) 3

PAGE 224 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

kericort 10 cream 1 % 1 QL 120 / 23 days

kp hydrocortisone cream 1 % 1

kp hydrocortisone max st ointment 1 % 1 QL 90 / 23 days

laclotion lotion 12 % 1 PA

lactic acid e cream 10-3500 %-unt/30gm 1 PA

lactic acid lotion 10 % 1 PA

latrix suspension 50 % 1

lidazone hc cream 3-0.5 % 1

lidocaine hcl cream 3 % 1 QL 85 / 30 days

lidocaine hcl gel 2 % 1 LIDOCAINE HCL LOTION 3 % QL 100 / 23 days lidocaine hcl 1

lidocaine hcl solution 4 % 1 QL 100 / 23 days

lidocaine ointment 5 % 1 QL 70.8 / 23 days

lidocaine-hydrocortisone ace cream 3-0.5 % 1 LIDOCAINE-HYDROCORTISONE ACE GEL 2.8-0.55 % lidocaine-hydrocortisone acetate (rectal) 3

lidocaine-hydrocortisone ace kit 2-2 % 3 PA

lidocaine-hydrocortisone ace kit 3-1 % 1

lidocaine-hydrocortisone ace kit 3-2.5 % 1

lidocaine-prilocaine cream 2.5-2.5 % 1 AL Up to 15 yrs old

LIDODERM PATCH 5 % PA lidocaine 3

lidopin cream 3 % 1 QL 85 / 30 days

lokara lotion 0.05 % 1 PA

lubricating jelly gel 1

PA minocycline hcl er tab er 24h 135 mg 4 ST

PA minocycline hcl er tab er 24h 45 mg 4 ST

PAGE 225 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA minocycline hcl er tab er 24h 90 mg 3 ST

mometasone furoate cream 0.1 % 1

mometasone furoate ointment 0.1 % 1

mometasone furoate solution 0.1 % 1

muscle relief cream 0.075 % 1

neosporin eczema essent max st cream 1 % 1 QL 120 / 23 days

noble formula hc cream 1 % 1 QL 120 / 23 days

nystatin-triamcinolone cream 100000-0.1 unit/gm-% 3

nystatin-triamcinolone ointment 100000-0.1 unit/gm-% 1

oralone paste 0.1 % 3 PETROLEUM JELLY GEL white petrolatum 1

phenazo tab 200 mg 1

phenazopyridine hcl tab 100 mg 1

phenazopyridine hcl tab 200 mg 1 PODOCON SOLUTION 25 % podophyllum resin 3

podofilox solution 0.5 % 1

pramcort cream 1-1 % 1 QL 60 / 23 days

pramegel gel 1 % 1

pramox gel 1 % 1

prednicarbate cream 0.1 % 1 QL 120 / 23 days

prednicarbate ointment 0.1 % 1 QL 120 / 23 days

preparation h hydrocortisone cream 1 % 1 QL 120 / 23 days

PROCTOFOAM HC FOAM 1-1 % hydrocortisone acetate w/ pramoxine 3

proctosol hc cream 2.5 % 1

proctozone-hc cream 2.5 % 1 PRUDOXIN CREAM 5 % doxepin hcl (antipruritic) 3

px hydrocream cream 1 % 1 QL 120 / 23 days

PAGE 226 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PYROGALLIC ACID OINTMENT 25-2 % pyrogallol-chlorobutanol 1

qc hydrocortisone cream 1 % 1 QL 120 / 23 days

qc hydrocortisone max st cream 1 % 1 QL 120 / 23 days

ra anti-itch maximum strength cream 1 % 1 QL 120 / 23 days

ra anti-itch maximum strength ointment 1 % 1 QL 90 / 23 days

ra arthritis pain relief cream 0.075 % 1

ra hydrocortisone max st cream 1 % 1 QL 120 / 23 days

ra hydrocortisone plus 12 cream 1 % 1 QL 120 / 23 days

rea lo 39 cream 39 % 3

recort plus cream 1 % 1 QL 120 / 23 days

RECTIV OINTMENT 0.4 % ST nitroglycerin (intra-anal) 3

regenecare ha gel 2 % 1 QL 90 / 23 days

remeven cream 50 % 1

revina ointment 1

salacyn cream 6 % 1

salacyn lotion 6 % 1

salicylic acid cream 6 % 3

salicylic acid foam 6 % 3

salicylic acid gel 6 % 1 SALICYLIC ACID LIQUID 26 % salicylic acid 1

salicylic acid liquid 27.5 % 1

salicylic acid lotion 6 % 3

salicylic acid shampoo 6 % 1

salicylic acid wart remover liquid 27.5 % 1 SALVAX FOAM 6 % salicylic acid 3 SANTYL OINTMENT 250 UNIT/GM collagenase 3

sarnol-hc lotion 1 % 1 QL 240 / 23 days

PAGE 227 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sb hydrocortisone cream 1 % 1 QL 120 / 23 days

sb hydrocortisone max st ointment 1 % 1 QL 90 / 23 days

scalacort lotion 2 % 3 QL 120 / 23 days

selenium sulf-pyrithione-urea shampoo 2.25 % 3

sm hydrocortisone cream 1 % 1 QL 120 / 23 days

sm hydrocortisone max st ointment 1 % 1 QL 90 / 23 days

sodium hyaluronate gel 0.2 % 1 SORIATANE CAP 10 MG PA acitretin 4 SORIATANE CAP 17.5 MG PA acitretin 4 SORIATANE CAP 25 MG PA acitretin 4 STELARA SOLN PRSYR 45 MG/0.5ML PA ustekinumab 4

sulfacetamide sodium-sulfur lotion 10-5 % 3 SYNALAR CREAM 0.025 % fluocinolone acetonide 3 SYNALAR OINTMENT 0.025 % fluocinolone acetonide 3 TACLONEX OINTMENT 0.005-0.064 % ST calcipotriene-betamethasone dipropionate 3 TACLONEX SUSPENSION 0.005-0.064 % ST calcipotriene-betamethasone dipropionate 3 TAZORAC CREAM 0.05 % PA tazarotene 4 TAZORAC CREAM 0.1 % PA tazarotene 4 TAZORAC GEL 0.05 % PA tazarotene 4 TAZORAC GEL 0.1 % PA tazarotene 4

tgt anti-itch maximum strength cream 1 % 1 QL 120 / 23 days

tgt anti-itch maximum strength ointment 1 % 1 QL 90 / 23 days

tgt anti-itch plus oatmeal cream 1 % 1 QL 120 / 23 days

PAGE 228 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tgt anti-itch/aloe/vit e cream 1 % 1 QL 120 / 23 days

th hydrocortisone cream 1 % 1 QL 120 / 23 days

theracort lotion 1 % 1 QL 240 / 23 days

theragen cream 0.025 % 1

QL 45 / 23 days tretinoin cream 0.025 % 1 AL Up to 28 yrs old

QL 45 / 23 days tretinoin cream 0.05 % 1 AL Up to 28 yrs old

QL 45 / 23 days tretinoin cream 0.1 % 1 AL Up to 28 yrs old

QL 45 / 23 days tretinoin gel 0.01 % 1 AL Up to 28 yrs old

tretinoin gel 0.025 % 1 AL Up to 28 yrs old

tretinoin microsphere gel 0.04 % 3 ST

tretinoin microsphere pump gel 0.04 % 3 ST

triamcinolone acetonide cream 0.025 % 1 QL 160 / 23 days

triamcinolone acetonide cream 0.1 % 1 QL 160 / 23 days

triamcinolone acetonide cream 0.5 % 1 QL 60 / 23 days

triamcinolone acetonide lotion 0.025 % 1 QL 120 / 23 days

triamcinolone acetonide lotion 0.1 % 1 QL 120 / 23 days

triamcinolone acetonide ointment 0.025 % 1 QL 160 / 23 days

triamcinolone acetonide ointment 0.1 % 1 QL 160 / 23 days

TRIAMCINOLONE ACETONIDE OINTMENT 0.5 % QL 60 / 23 days triamcinolone acetonide (topical) 1

triamcinolone acetonide paste 0.1 % 3 TRIANEX OINTMENT 0.05 % QL 60 / 23 days triamcinolone acetonide (topical) 3

triderm cream 0.1 % 1 QL 160 / 23 days

trixaicin hp cream 0.075 % 1

PAGE 229 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

u-kera e cream 40 % 1

umecta mousse foam 40 % 3 URAMAXIN FOAM 20 % urea in ammonium lactate vehicle 3

urea cream 39 % 3

urea cream 40 % 1

urea cream 45 % 3

urea cream 50 % 3

urea emulsion 50 % 3

urea gel 40 % 3

urea in zn undecyl-lactic acid emulsion 50 % 3

urea lotion 40 % 1

urea lotion 45 % 3

urea nail film suspension 40 % 3

urea nail gel 45 % 3 UREA NAIL KIT 40 & 0.2 % urea & hyaluronate sodium 3

urea suspension 40 % 3

vasolex ointment 1 VELTIN GEL 1.2-0.025 % clindamycin phosphate-tretinoin 3 VEREGEN OINTMENT 15 % PA sinecatechins 3

versiclear lotion 25-1 % 1 VOLTAREN GEL 1 % QL 200 / 30 days diclofenac sodium (topical) 3

wal-dryl anti-itch liquid 2-0.1 % 1

x-viate cream 40 % 1

x-viate gel 40 % 1 ZIANA GEL 1.2-0.025 % clindamycin phosphate-tretinoin 3

PAGE 230 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS Smooth Muscle Relaxants

Genitourinary Smooth Muscle Relaxants

DETROL LA CAP ER 24H 2 MG tolterodine tartrate 2 DETROL LA CAP ER 24H 4 MG tolterodine tartrate 2 ENABLEX TAB ER 24H 15 MG ST darifenacin hydrobromide 2 ENABLEX TAB ER 24H 7.5 MG ST darifenacin hydrobromide 2

flavoxate hcl tab 100 mg 1 GELNIQUE GEL 3 (28) % (MG/ACT) oxybutynin 3

oxybutynin chloride er tab er 24h 10 mg 1

oxybutynin chloride er tab er 24h 15 mg 1

oxybutynin chloride er tab er 24h 5 mg 1

oxybutynin chloride syrup 5 mg/5ml 1

oxybutynin chloride tab 5 mg 1 OXYTROL PATCH TW 3.9 MG/24HR oxybutynin 3

tolterodine tartrate tab 1 mg 1 ST

tolterodine tartrate tab 2 mg 1 ST

TOVIAZ TAB ER 24H 4 MG ST fesoterodine fumarate 2 TOVIAZ TAB ER 24H 8 MG ST fesoterodine fumarate 2

trospium chloride er cap er 24h 60 mg 1 ST

trospium chloride tab 20 mg 1 ST

VESICARE TAB 10 MG ST solifenacin succinate 3 VESICARE TAB 5 MG ST solifenacin succinate 3

aminophylline solution 25 mg/ml 1

difil-g forte liquid 100-100 mg/5ml 1

PAGE 231 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ELIXOPHYLLIN ELIXIR 80 MG/15ML theophylline 2

sildenafil citrate tab 20 mg 4 PA

theochron tab er 12h 100 mg 1

theochron tab er 12h 200 mg 1

theochron tab er 12h 300 mg 1

theophylline er tab er 12h 100 mg 1

theophylline er tab er 12h 200 mg 1

theophylline er tab er 12h 300 mg 1

theophylline er tab er 12h 450 mg 1

theophylline er tab er 24h 400 mg 1

theophylline er tab er 24h 600 mg 1

theophylline solution 80 mg/15ml 1 UNCATEGORIZED

1ST CHOICE LANCETS SUPER THIN MISC lancets 1 1ST CHOICE LANCETS THIN MISC lancets 1 1ST CHOICE LANCETS ULTRA THIN MISC lancets 1 1ST CHOICE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS PLUS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1

PAGE 232 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 1ST TIER UNILET COMFORTOUCH MISC lancets 1 ACCU-CHEK ACTIVE GLUCOSE CONT LIQUID blood glucose calibration 1 ACCU-CHEK ACTIVE STRIP glucose blood 1 ACCU-CHEK AVIVA PLUS KIT W/DEVICE blood glucose monitoring supplies 1 ACCU-CHEK AVIVA PLUS STRIP glucose blood 1 ACCU-CHEK AVIVA SOLUTION blood glucose calibration 1 ACCU-CHEK AVIVA STRIP glucose blood 1 ACCU-CHEK COMFORT CURVE LINEAR SOLUTION blood glucose calibration 1 ACCU-CHEK COMFORT CURVE SOLUTION blood glucose calibration 1 ACCU-CHEK COMFORT CURVE STRIP glucose blood 1 ACCU-CHEK COMPACT BLUE CONTROL LIQUID blood glucose calibration 1 ACCU-CHEK COMPACT PLUS CONTROL SOLUTION blood glucose calibration 1 ACCU-CHEK COMPACT PLUS STRIP glucose blood 1 ACCU-CHEK COMPACT TEST DRUM STRIP glucose blood 1 ACCU-CHEK FASTCLIX LANCETS MISC lancets 1 ACCU-CHEK INSTANT CONTROL LIQUID blood glucose calibration 1 ACCU-CHEK MULTICLIX LANCETS MISC lancets 1

PAGE 233 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE blood glucose monitoring supplies 1 ACCU-CHEK SAFE-T PRO LANCETS MISC lancets 1 ACCU-CHEK SMARTVIEW CONTROL LIQUID blood glucose calibration 1 ACCU-CHEK SMARTVIEW STRIP glucose blood 1 ACCU-CHEK SOFT TOUCH LANCETS MISC lancets 1 ACCU-CHEK SOFTCLIX LANCET DEV MISC lancet devices 1 ACCU-CHEK SOFTCLIX LANCETS MISC lancets 1 ACCU-CHEK VOICEMATE KIT blood glucose monitoring supplies 1 ACCUTREND GLUCOSE CONTROL SOLUTION blood glucose calibration 1 ACCUTREND GLUCOSE STRIP glucose blood 1

acid control maximum strength tab 20 mg 1

acid controller max st tab 20 mg 1

acid reducer maximum strength tab 20 mg 1

acid relief tab 200 mg 1 ACTI-LANCE 28G MISC lancets 1 ACTI-LANCE LITE LANCETS 28G MISC lancets 1 ACTI-LANCE SPECIAL LANCETS 17G MISC lancets 1 ACTI-LANCE UNIVERSAL 23G MISC lancets 1 ACURA BLOOD GLUCOSE METER KIT W/DEVICE blood glucose monitoring supplies 1 ACURA BLOOD GLUCOSE STARTER KIT W/DEVICE blood glucose monitoring supplies 1 ACURA BLOOD GLUCOSE TEST STRIP glucose blood 1

PAGE 234 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ACURA CONTROL SOLUTION NORMAL blood glucose calibration 1 ACURA PLUS BLOOD GLUCOSE SYS KIT W/DEVICE blood glucose monitoring supplies 1 ADJUSTABLE LANCING DEVICE MISC lancet devices 1 ADVANCE INTUITION CONTROL LIQUID NORMAL blood glucose calibration 1 ADVANCE INTUITION MONITOR KIT blood glucose monitoring supplies 1 ADVANCE INTUITION TEST STRIP glucose blood 1 ADVOCATE BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 ADVOCATE INSULIN PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 ADVOCATE INSULIN PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 ADVOCATE LANCETS MISC lancets 1 ADVOCATE LANCING DEVICE MISC lancet devices 1

PAGE 235 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADVOCATE REDI-CODE KIT W/DEVICE blood glucose monitoring supplies 1 ADVOCATE REDI-CODE STRIP glucose blood 1 ADVOCATE REDI-CODE+ TALKING KIT W/DEVICE blood glucose monitoring supplies 1 ADVOCATE SAFETY LANCETS MISC lancets 1 ADVOCATE TEST STRIP glucose blood 1 AFINITOR TAB 10 MG PA everolimus 4 AFINITOR TAB 2.5 MG PA everolimus 4 AFINITOR TAB 5 MG PA everolimus 4 AFINITOR TAB 7.5 MG PA everolimus 4 AGAMATRIX AMP TEST STRIP glucose blood 1 AGAMATRIX CONTROL SOLUTION blood glucose calibration 1 AGAMATRIX CONTROL SOLUTION NORMAL blood glucose calibration 1 AGAMATRIX JAZZ KIT W/DEVICE blood glucose monitoring supplies 1 AGAMATRIX JAZZ TEST STRIP glucose blood 1 AGAMATRIX KEYNOTE TEST STRIP glucose blood 1 AGAMATRIX PRESTO KIT W/DEVICE blood glucose monitoring supplies 1 AGAMATRIX PRESTO TEST STRIP glucose blood 1 AGAMATRIX ULTRA-THIN LANCETS MISC lancets 1 ALLEGRA ALLERGY CHILDRENS TAB 30 MG QL 50 / 30 days fexofenadine hcl 1 ALOMIDE SOLUTION 0.1 % PA lodoxamide tromethamine 3

PAGE 236 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

altaryl syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

ALTERNATE SITE LANCING DEVICE MISC lancet devices 1

anastrozole tab 1 mg 1 ANTI-STICK INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 AQUA LANCE ADJUSTABLE LANCING DEVICE lancet devices 1

arbinoxa tab 4 mg 1 AL Up to 64 yrs old

ASCENSIA AUTODISC CONTROL LIQUID NORMAL blood glucose calibration 1 ASCENSIA AUTODISC CONTROLS LIQUID blood glucose calibration 1 ASSURE 3 CONTROL LIQUID blood glucose calibration 1 ASSURE 3 TEST STRIP glucose blood 1 ASSURE 4 CONTROL LEVEL 1 & 2 LIQUID blood glucose calibration 1 ASSURE 4 TEST STRIP glucose blood 1 ASSURE COMFORT LANCETS 28G MISC lancets 1 ASSURE COMFORT LANCETS 30G MISC lancets 1 ASSURE DOSE CONTROL SOLUTION NORMAL blood glucose calibration 1 ASSURE DOSE NORM/HIGH CONTROL SOLUTION blood glucose calibration 1 ASSURE HAEMOLANCE PLUS HIGH MISC lancets 1 ASSURE HAEMOLANCE PLUS LOW MISC lancets 1 ASSURE HAEMOLANCE PLUS MICRO MISC lancets 1 ASSURE HAEMOLANCE PLUS NORMAL MISC lancets 1 ASSURE HAEMOLANCE PLUS PED MISC lancets 1

PAGE 237 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 ASSURE II CHECK STRIP glucose blood 1 ASSURE LANCE LANCETS MISC lancets 1 ASSURE LANCETS MISC lancets 1 ASSURE PLATINUM STRIP glucose blood 1 ASSURE PRISM CONTROL LEVEL 1&2 SOLUTION blood glucose calibration 1 ASSURE PRISM MULTI TEST STRIP glucose blood 1 ASSURE PRO CONTROL LEVEL 1 & 2 LIQUID blood glucose calibration 1 ASSURE PRO TEST STRIP glucose blood 1 AURORA LANCET SUPER THIN 30G MISC lancets 1 AURORA LANCET THIN 23G MISC lancets 1 AURORA PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 AURORA PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 AURORA PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 AURORA UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 AURORA UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 AUTO-LANCET MINI MISC lancet devices 1 AUTO-LANCET MISC lancet devices 1 AUTOLET IMPRESSION MISC lancet devices 1

PAGE 238 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AUTOLET LANCING DEVICE MISC lancet devices 1 AUTOLET MINI MISC lancet devices 1 BAYER BREEZE 2 CONTROL LIQUID NORMAL blood glucose calibration 1 BAYER BREEZE 2 SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR LINK MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR LIQUID NORMAL blood glucose calibration 1 BAYER CONTOUR MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR NEXT CONTROL SOLUTION NORMAL blood glucose calibration 1 BAYER CONTOUR NEXT EZ KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR NEXT LINK KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR NEXT MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR NEXT TEST STRIP glucose blood 1 BAYER CONTOUR NEXT USB MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 BAYER CONTOUR TEST STRIP glucose blood 1 BAYER CONTOUR USB KIT W/DEVICE blood glucose monitoring supplies 1 BAYER MICROLET 2 LANCING DEVIC MISC lancet devices 1 BAYER MICROLET LANCETS MISC lancets 1 BD AUTOSHIELD MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1

PAGE 239 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BD INSULIN SYRINGE HALF-UNIT MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 BD INTEGRA INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 BD LANCET DEVICE MISC lancet devices 1 BD LANCET ULTRAFINE 30G MISC lancets 1

PAGE 240 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BD LANCET ULTRAFINE 33G MISC lancets 1 BD MICROTAINER LANCETS MISC lancets 1 BD PEN NEEDLE MINI U/F MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 BD PEN NEEDLE NANO U/F MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 BD PEN NEEDLE SHORT U/F MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 BD PEN NEEDLE ULTRAFINE MISC 29G X 12.7MM QL 200 / 30 days insulin pen needle 1 BD SAFETY-LOK INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 BD SAFETYGLIDE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 BG STAR TEST STRIP glucose blood 1

bicalutamide tab 50 mg 1 BLOOD GLUCOSE MONITOR SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 BLOOD GLUCOSE SYSTEM PAK KIT blood glucose monitoring supplies 1 BLOOD GLUCOSE TEST STRIP glucose blood 1 BOSULIF TAB 100 MG PA bosutinib 4 BOSULIF TAB 500 MG PA bosutinib 4

bromfed dm syrup 30-2-10 mg/5ml 1 BULLSEYE MINI SAFETY LANCETS MISC lancets 1 BULLSEYE SAFETY LANCETS MISC lancets 1 CAPRELSA TAB 100 MG PA vandetanib 4 CAPRELSA TAB 300 MG PA vandetanib 4

PAGE 241 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

carbinoxamine maleate tab 4 mg 1 AL Up to 64 yrs old

CARDIOCOM LANCING DEVICE MISC lancet devices 1 CAREFINE PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 CAREFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 CAREFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 CAREFINE PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 CAREONE ADVANCED LANCING DEV MISC lancet devices 1 CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 CAREONE BLOOD GLUCOSE TEST STRIP glucose blood 1 CAREONE INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 CAREONE INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 CAREONE INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 CAREONE INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 CAREONE INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 CAREONE INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 CAREONE LANCET THIN 23G MISC lancets 1 CAREONE LANCET ULTRA THIN 28G MISC lancets 1 CAREONE ULTIGUARD INSULIN SYR MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 CAREONE UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1

PAGE 242 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CAREONE UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS PLUS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 CAREONE UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 CARESENS CONTROL A SOLUTION blood glucose calibration 1 CARESENS N GLUCOSE TEST STRIP glucose blood 1

cetirizine hcl childrens alrgy syrup 1 mg/ml 1 QL 50 / 30 days

cetirizine hcl solution 1 mg/ml 1 QL 50 / 30 days

cetirizine hcl syrup 1 mg/ml 1 QL 50 / 30 days

cetirizine hcl syrup 5 mg/5ml 1

cetirizine hcl tab 10 mg 1 QL 50 / 30 days

cetirizine hcl tab 5 mg 1 QL 50 / 30 days

CHEK-STIX CONTROL STRIP acetone (urine) test 1 CHEMET CAP 100 MG succimer 3 CHEMSTRIP K STRIP acetone (urine) test 1 CHERRY CONCENTRATE SYRUP cherry syrup 2 CHERRY SYRUP cherry syrup 2

PAGE 243 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

childrens loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

cimetidine 200 tab 200 mg 1

cimetidine acid reducer tab 200 mg 1

cimetidine hcl solution 300 mg/5ml 1

cimetidine tab 200 mg 1

cimetidine tab 300 mg 1

cimetidine tab 400 mg 1

cimetidine tab 800 mg 1 CLARITIN REDITABS TAB DISP 10 MG QL 50 / 30 days loratadine 1 CLEANLET LANCETS 28G MISC lancets 1

clemastine fumarate syrup 0.67 mg/5ml 1 AL Up to 64 yrs old

CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML AL Up to 64 yrs old clemastine fumarate 1

clemastine fumarate tab 2.68 mg 1 AL Up to 64 yrs old

CLEVER CHEK AUTO-CODE TEST STRIP glucose blood 1 CLEVER CHEK AUTO-CODE VOICE STRIP glucose blood 1 CLEVER CHEK LANCETS MISC lancets 1 CLEVER CHEK SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 CLEVER CHEK TEST STRIP glucose blood 1 CLEVER CHOICE AUTO-CODE TEST STRIP glucose blood 1 CLEVER CHOICE MICRO SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 CLEVER CHOICE MICRO TEST STRIP glucose blood 1 CLICKFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 CLICKFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

PAGE 244 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLICKFINE PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 CLOSERCARE MISC lancet devices 1 COAGUCHEK LANCETS MISC lancets 1 COMETRIQ (100 MG DAILY DOSE) KIT 1 X 80 & 1 X 20 MG PA cabozantinib s-malate 4 COMETRIQ (140 MG DAILY DOSE) KIT 1 X 80 & 3 X 20 MG PA cabozantinib s-malate 4 COMETRIQ (60 MG DAILY DOSE) KIT 20 MG PA cabozantinib s-malate 4 COMFORT ASSIST INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 COMFORT ASSURED LANCETS 28G MISC lancets 1 COMFORT ASSURED LANCETS 33G MISC lancets 1 COMFORT EZ INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1

PAGE 245 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMFORT EZ INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 COMFORT EZ PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 COMFORT EZ PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 COMFORT EZ PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 COMFORT EZ PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 COMFORT LANCETS MISC lancets 1 CONTROL AST STRIP glucose blood 1 CONTROL BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 CONTROL SOLUTION NORMAL blood glucose calibration 1 CONTROL TEST STRIP glucose blood 1 CREON CP DR PART 12000 UNIT pancrelipase (lipase-protease-amylase) 2 CREON CP DR PART 24000 UNIT pancrelipase (lipase-protease-amylase) 2 CREON CP DR PART 3000-9500 UNIT pancrelipase (lipase-protease-amylase) 2 CREON CP DR PART 6000 UNIT pancrelipase (lipase-protease-amylase) 2

cvs acid controller max st tab 20 mg 1 CVS ADVANCED GLUCOSE TEST STRIP glucose blood 1

cvs allergy relief tab 10 mg 1 QL 50 / 30 days

PAGE 246 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CVS BLOOD GLUCOSE METER KIT W/DEVICE blood glucose monitoring supplies 1

cvs heartburn relief tab 200 mg 1 CVS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 CVS INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 CVS INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 CVS LANCETS 21G MISC lancets 1 CVS LANCETS MICRO THIN 33G MISC lancets 1 CVS LANCETS ORIGINAL MISC lancets 1 CVS LANCETS THIN 26G MISC lancets 1 CVS LANCETS THIN MISC lancets 1 CVS LANCETS ULTRA THIN 30G MISC lancets 1 CVS LANCING DEVICE MISC lancet devices 1

cvs loratadine tab 10 mg 1 QL 50 / 30 days

CVS ULTRA THIN LANCETS MISC lancets 1

cyproheptadine hcl syrup 2 mg/5ml 1 AL Up to 64 yrs old

cyproheptadine hcl tab 4 mg 1 AL Up to 64 yrs old

deferoxamine mesylate recon soln 500 mg 1 DEPEN TITRATABS TAB 250 MG penicillamine 4 DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML AL Up to 64 yrs old dexchlorpheniramine maleate 1 DIASTAR EASY TEST II LANCETS MISC lancets 1 DIASTAR EASY TEST LANCETS MISC lancets 1

PAGE 247 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIATRUE CONTROL LEVEL 2 SOLUTION NORMAL blood glucose calibration 1 DIATRUE PLUS TEST STRIP glucose blood 1 DIDGET KIT W/DEVICE blood glucose monitoring supplies 1 DIMENHYDRINATE SOLUTION 50 MG/ML dimenhydrinate 3

diphenhydramine hcl cap 50 mg 1 AL Up to 64 yrs old

diphenhydramine hcl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

diphenhydramine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

DROPLET LANCETS ULTRA THIN 30G MISC lancets 1 DROPLET LANCING DEVICE MISC lancet devices 1 DROXIA CAP 200 MG hydroxyurea (sickle cell anemia) 2 DROXIA CAP 300 MG hydroxyurea (sickle cell anemia) 2 DROXIA CAP 400 MG hydroxyurea (sickle cell anemia) 2 DRUG MART LANCETS THIN 26G MISC lancets 1 DRUG MART LANCING DEVICE MISC lancet devices 1 DRUG MART ON-THE-GO LANCET 30G MISC lancets 1 DRUG MART ULTRA COMFORT SYR MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 DRUG MART UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 DRUG MART UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 DRUG MART UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 DRUG MART UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

PAGE 248 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DRUG MART UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 DRUG MART UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 DRUG MART UNILET LANCETS 28G MISC lancets 1 DRUG MART UNILET LANCETS 30G MISC lancets 1 DUANE READE LANCET ALTERN SITE MISC lancets 1 DUANE READE LANCET SUPER THIN MISC lancets 1 DUANE READE LANCET ULTRA THIN MISC lancets 1 DUANE READE UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 DUANE READE UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 DUANE READE UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 DUO-CARE CONTROL SOLUTION LIQUID blood glucose calibration 1 DUO-CARE TEST STRIP glucose blood 1

duraxin cap 300-200-20 mg 1 E-Z JECT LANCET MICRO-THIN 33G MISC lancets 1 E-Z JECT LANCET SUPER THIN 30G MISC lancets 1 E-Z JECT LANCETS 21G MISC lancets 1 E-Z JECT LANCETS MISC lancets 1 E-Z JECT LANCETS THIN 26G MISC lancets 1 EASIVENT MASK LARGE MISC QL 2 / 365 days spacer/aerosol-holding chambers 2 EASIVENT MASK MEDIUM MISC QL 2 / 365 days spacer/aerosol-holding chambers 2

PAGE 249 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EASIVENT MASK SMALL MISC QL 2 / 365 days spacer/aerosol-holding chambers 2 EASIVENT MISC QL 2 / 365 days spacer/aerosol-holding chambers 2 EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 EASY COMFORT LANCETS MISC lancets 1 EASY COMFORT PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 EASY COMFORT PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 EASY COMFORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 EASY COMFORT PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 EASY MINI LANCING DEVICE MISC lancet devices 1 EASY PLUS BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 EASY PLUS BLOOD GLUCOSE TEST STRIP glucose blood 1 EASY PLUS II GLUCOSE TEST STRIP glucose blood 1 EASY STEP CONTROL SOLUTION NORMAL blood glucose calibration 1 EASY STEP GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 EASY STEP TEST STRIP glucose blood 1

PAGE 250 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EASY TALK BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 EASY TALK BLOOD GLUCOSE TEST STRIP glucose blood 1 EASY TALK CONTROL SOLUTION NORMAL blood glucose calibration 1 EASY TOUCH CONTROL HIGH & LOW SOLUTION blood glucose calibration 1 EASY TOUCH GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 EASY TOUCH HEALTHPRO CONTROL SOLUTION blood glucose calibration 1 EASY TOUCH HEALTHPRO SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 EASY TOUCH HEALTHPRO TEST STRIP glucose blood 1 EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SAFETY SYR MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY TOUCH INSULIN SAFETY SYR MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1

PAGE 251 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EASY TOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 EASY TOUCH LANCETS 21G MISC lancets 1 EASY TOUCH LANCETS 23G MISC lancets 1 EASY TOUCH LANCETS 26G MISC lancets 1 EASY TOUCH LANCETS 28G MISC lancets 1 EASY TOUCH LANCETS 28G/TWIST MISC lancets 1 EASY TOUCH LANCETS 30G MISC lancets 1 EASY TOUCH LANCETS 30G/TWIST MISC lancets 1 EASY TOUCH LANCETS 32G MISC lancets 1 EASY TOUCH LANCETS 32G/TWIST MISC lancets 1 EASY TOUCH LANCETS 33G/TWIST MISC lancets 1 EASY TOUCH LANCING DEVICE MISC lancet devices 1 EASY TOUCH PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 EASY TOUCH PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 EASY TOUCH PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1

PAGE 252 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EASY TOUCH PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 EASY TOUCH PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 EASY TOUCH SAFETY LANCETS 21G MISC lancets 1 EASY TOUCH SAFETY LANCETS 23G MISC lancets 1 EASY TOUCH SAFETY LANCETS 26G MISC lancets 1 EASY TOUCH SAFETY LANCETS 28G MISC lancets 1 EASY TOUCH TEST STRIP glucose blood 1 EASY TRAK BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 EASY TRAK BLOOD GLUCOSE TEST STRIP glucose blood 1 EASY TRAK CONTROL SOLUTION NORMAL blood glucose calibration 1 EASY TWIST & CAP LANCETS MISC lancets 1 EASYGLUCO CONTROL SOLUTION NORMAL blood glucose calibration 1 EASYGLUCO STRIP glucose blood 1 EASYMAX 15 LEVEL 1 CONTROL SOLUTION blood glucose calibration 1 EASYMAX 15 LEVEL 2 CONTROL SOLUTION blood glucose calibration 1 EASYMAX 15 TEST STRIP glucose blood 1 EASYMAX CONTROL SOLUTION NORMAL blood glucose calibration 1 EASYMAX L BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EASYMAX N BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EASYMAX NG BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1

PAGE 253 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EASYMAX TEST STRIP glucose blood 1 EASYMAX V BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EASYMAX V2 BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EASYPLUS BLOOD GLUCOSE TEST STRIP glucose blood 1 EASYPLUS R13N BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EASYPLUS V BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EASYPRO PLUS KIT W/DEVICE blood glucose monitoring supplies 1 EASYPRO PLUS STRIP glucose blood 1

ed-flex cap 300-200-20 mg 1 ELEMENT AUTOCODE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 ELEMENT COMPACT CONTROL 2 SOLUTION blood glucose calibration 1 ELEMENT COMPACT CONTROL 3 SOLUTION blood glucose calibration 1 ELEMENT COMPACT TEST STRIP glucose blood 1 ELEMENT CONTROL LIQUID NORMAL blood glucose calibration 1 ELEMENT TEST STRIP glucose blood 1 ELIGARD KIT 22.5 MG PA leuprolide acetate (3 month) 4 ELIGARD KIT 30 MG PA leuprolide acetate (4 month) 4 ELIGARD KIT 45 MG PA leuprolide acetate (6 month) 4 ELIGARD KIT 7.5 MG PA leuprolide acetate 4 EMBRACE BLOOD GLUCOSE TEST STRIP glucose blood 1

PAGE 254 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EMBRACE EVO BLOOD GLUCOSE TEST STRIP glucose blood 1 EMBRACE EVO CONTROL LEVEL 2 LIQUID NORMAL blood glucose calibration 1 EMBRACE EVO GLUCOSE MONITORING KIT W/DEVICE blood glucose monitoring supplies 1 EMBRACE LANCETS ULTRA THIN 30G MISC lancets 1 EMBRACE PRO GLUCOSE CONTROL LIQUID blood glucose calibration 1 EMBRACE PRO GLUCOSE TEST STRIP glucose blood 1 EMCYT CAP 140 MG estramustine phosphate sodium 3

entre-b suspension 6-10 mg/5ml 1

eq acid reducer max st tab 20 mg 1

eq acid reducer tab 200 mg 1

eq allergy relief childrens elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

eq heartburn relief tab 200 mg 1

eq loratadine tab 10 mg 1 QL 50 / 30 days

eql acid reducer tab 200 mg 1

eql childrens loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

EQL COLOR LANCETS 21G MISC lancets 1 EQL COLOR LANCETS MICRO 33G MISC lancets 1

eql heartburn prevention tab 20 mg 1 EQL INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1

PAGE 255 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EQL INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 EQL INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 EQL SHORT PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 EQL SUPER THIN LANCETS 30G MISC lancets 1 EQL THIN LANCETS 26G MISC lancets 1 EQL TRUE2GO BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 EQL TRUETEST TEST STRIP glucose blood 1 EQL ULTRA SHORT PEN NEEDLE MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 EVENCARE + BLOOD GLUCOSE TEST STRIP glucose blood 1 EVENCARE BLOOD GLUCOSE TEST STRIP glucose blood 1 EVENCARE CONTROL LOW/HIGH LIQUID blood glucose calibration 1 EVENCARE G2 LOW/HIGH CONTROL SOLUTION blood glucose calibration 1 EVENCARE G2 TEST STRIP glucose blood 1 EVENCARE G3 LOW/HIGH CONTROL SOLUTION blood glucose calibration 1 EVENCARE G3 TEST STRIP glucose blood 1 EVOLUTION AUTOCODE STRIP glucose blood 1 EVOLUTION CONTROL SOLUTION NORMAL blood glucose calibration 1 EXACTECH R-S-G TEST STRIP glucose blood 1

PAGE 256 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EXACTECH TEST STRIP glucose blood 1 EXCEL COMFORT POINT PEN NEEDLE MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 EXCEL COMFORT POINT PEN NEEDLE MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 EXCEL COMFORT POINT PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 EXEL COMFORT POINT INSULIN SYR MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 1 ML 1 insulin syringe/needle u-100

exemestane tab 25 mg 1 EZ SMART BLOOD GLUCOSE LANCETS MISC lancets 1 EZ SMART BLOOD GLUCOSE TEST STRIP glucose blood 1 EZ SMART PLUS GLUCOSE TEST STRIP glucose blood 1 EZ-LETS LANCETS 21G MISC lancets 1 EZ-LETS LANCETS 23G MISC lancets 1

PAGE 257 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EZ-LETS LANCETS 26G MISC lancets 1 EZ-LETS LANCETS 28G MISC lancets 1 EZ-LETS LANCETS 30G MISC lancets 1

famotidine recon susp 40 mg/5ml 1

famotidine tab 20 mg 1

famotidine tab 40 mg 1 FARESTON TAB 60 MG PA toremifene citrate 4 FASLODEX SOLUTION 250 MG/5ML PA fulvestrant 4 FERRIPROX TAB 500 MG PA deferiprone 4

fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

fexofenadine hcl tab 60 mg 1 QL 50 / 30 days

FIFTY50 CONTROL 2.0 SOLUTION blood glucose calibration 1 FIFTY50 GLUCOSE METER 2.0 KIT W/DEVICE blood glucose monitoring supplies 1 FIFTY50 GLUCOSE TEST 2.0 STRIP glucose blood 1 FIFTY50 LANCING DEVICE MISC lancet devices 1 FIFTY50 PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 FIFTY50 PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 FIFTY50 SAFETY SEAL LANCETS MISC lancets 1 FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1

PAGE 258 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FINE 30 MISC lancets 1 FINGERSTIX LANCETS MISC lancets 1 FIRMAGON RECON SOLN 120 MG PA degarelix acetate 4 FIRMAGON RECON SOLN 80 MG PA degarelix acetate 4

flucaine solution 0.25-0.5 % 1

fluoridex sensitivity relief paste 1.1-5 % 1

flutamide cap 125 mg 3 FORA CONTROL SOLUTION NORMAL blood glucose calibration 1 FORA D10 BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA D15G BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA D20 BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 FORA G20 BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA G30A BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA GD20 TEST STRIP glucose blood 1 FORA GD50 BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA LANCETS MISC lancets 1 FORA LANCING DEVICE MISC lancet devices 1 FORA V10 BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA V12 BLOOD GLUCOSE TEST STRIP glucose blood 1 FORA V20 BLOOD GLUCOSE TEST STRIP glucose blood 1

PAGE 259 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FORA V30A BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 FORA V30A BLOOD GLUCOSE TEST STRIP glucose blood 1 FORACARE GD40 TEST STRIP glucose blood 1 FORACARE GDH CONTROL SOLUTION NORMAL blood glucose calibration 1 FORACARE PREMIUM V10 TEST STRIP glucose blood 1 FORACARE TEST N GO TEST STRIP glucose blood 1 FORTISCARE CONTROL SOLUTION NORMAL blood glucose calibration 1 FORTISCARE GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 FREDS PHARMACY AUTOLET LANCING MISC lancet devices 1 FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 FREDS PHARMACY UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 FREDS PHARMACY UNILET LANC 28G MISC lancets 1 FREDS PHARMACY UNILET LANC 30G MISC lancets 1 FREESTYLE CONTROL SOLUTION LIQUID blood glucose calibration 1 FREESTYLE FREEDOM KIT blood glucose monitoring supplies 1 FREESTYLE FREEDOM LITE KIT W/DEVICE blood glucose monitoring supplies 1 FREESTYLE INSULINX SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 FREESTYLE INSULINX TEST STRIP glucose blood 1 FREESTYLE LANCETS MISC lancets 1

PAGE 260 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FREESTYLE LITE TEST STRIP glucose blood 1 FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 FREESTYLE SIDEKICK II KIT blood glucose monitoring supplies 1 FREESTYLE TEST STRIP glucose blood 1 FREESTYLE UNISTICK II LANCETS MISC lancets 1 GE100 BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 GE100 BLOOD GLUCOSE TEST STRIP glucose blood 1 GE100 CONTROL SOLUTION NORMAL blood glucose calibration 1 GHT BLOOD GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 GHT TEST STRIP glucose blood 1 GLEEVEC TAB 100 MG PA imatinib mesylate 4 GLEEVEC TAB 400 MG PA imatinib mesylate 4 GLOBAL EASE INJECT PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 GLOBAL EASE INJECT PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 GLOBAL EASE INJECT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 GLOBAL EASE INJECT PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 GLOBAL INJECT EASE INSULIN SYR MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100

PAGE 261 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLOBAL INJECT EASE INSULIN SYR MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 GLOBAL INJECT EASE INSULIN SYR MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 GLOBAL INJECT EASE LANCETS 28G MISC lancets 1 GLOBAL INJECT EASE LANCETS 30G MISC lancets 1 GLOBAL LANCING DEVICE MISC lancet devices 1 GLUCO PERFECT 3 TEST STRIP glucose blood 1

PAGE 262 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLUCOCARD 01 BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCARD 01 CONTROL LIQUID blood glucose calibration 1 GLUCOCARD 01 CONTROL SOLUTION NORMAL blood glucose calibration 1 GLUCOCARD 01 SENSOR PLUS STRIP glucose blood 1 GLUCOCARD 01 SENSOR STRIP glucose blood 1 GLUCOCARD 01-MINI GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCARD EXPRESSION CONTROL SOLUTION blood glucose calibration 1 GLUCOCARD EXPRESSION MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCARD EXPRESSION TEST STRIP glucose blood 1 GLUCOCARD SHINE CONTROL SOLUTION blood glucose calibration 1 GLUCOCARD SHINE KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCARD SHINE TEST STRIP glucose blood 1 GLUCOCARD VITAL MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCARD VITAL TEST STRIP glucose blood 1 GLUCOCARD X-METER KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCARD X-SENSOR CONTROL SOLUTION NORMAL blood glucose calibration 1 GLUCOCARD X-SENSOR STRIP glucose blood 1 GLUCOCOM CONTROL LIQUID NORMAL blood glucose calibration 1 GLUCOCOM LANCETS 28G MISC lancets 1 GLUCOCOM LANCETS 30G MISC lancets 1

PAGE 263 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GLUCOCOM LANCETS 33G MISC lancets 1 GLUCOCOM MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 GLUCOCOM TEST STRIP glucose blood 1 GLUCOLET 2 AUTOMATIC LANCING MISC lancet devices 1 GLUCONAVII BLOOD GLUCOSE SYS KIT W/DEVICE blood glucose monitoring supplies 1 GLUCONAVII BLOOD GLUCOSE TEST STRIP glucose blood 1 GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 GLUCOSE CONTROL SOLUTION blood glucose calibration 1 GLUCOSE CONTROL SOLUTION NORMAL blood glucose calibration 1 GLUCOSOURCE LANCET DEVICE MISC lancet devices 1 GLUCOSOURCE LANCETS MISC lancets 1 GMATE BLOOD GLUCOSE TEST STRIP glucose blood 1

PAGE 264 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GMATE CONTROL LEVEL 2 SOLUTION blood glucose calibration 1 GMATE SMART STARTER KIT W/DEVICE blood glucose monitoring supplies 1

gnp acid reducer max st tab 20 mg 1 GNP CLICKFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 GNP CLICKFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

gnp heartburn relief 200 tab 200 mg 1

gnp heartburn relief tab 200 mg 1 GNP INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 GNP INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 GNP LANCETS 21G MISC lancets 1 GNP LANCETS MICRO THIN 33G MISC lancets 1 GNP LANCETS MISC lancets 1

PAGE 265 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GNP LANCETS SUPER THIN 30G MISC lancets 1 GNP LANCETS THIN 26G MISC lancets 1 GNP LANCETS THIN MISC lancets 1

gnp loratadine childrens syrup 5 mg/5ml 1 QL 50 / 30 days

gnp loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

gnp loratadine tab 10 mg 1 QL 50 / 30 days

GNP MICRO THIN LANCETS 33G MISC lancets 1 GNP SUPER THIN LANCETS 30G MISC lancets 1 GNP ULTRA COM INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 GNP ULTRA COM INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 GNP ULTRA COM INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100

PAGE 266 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 H-E-B INCONTROL ADV LANCING MISC lancet devices 1 H-E-B INCONTROL LANCETS 28G MISC lancets 1 H-E-B INCONTROL LANCETS 30G MISC lancets 1 H-E-B INCONTROL PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 H-E-B INCONTROL PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 H-E-B INCONTROL PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 H-E-B INCONTROL PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 H-E-B INCONTROL PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 HAEMOLANCE PLUS HIGH FLOW MISC lancets 1 HAEMOLANCE PLUS LOW FLOW MISC lancets 1 HAEMOLANCE PLUS MAX FLOW MISC lancets 1 HAEMOLANCE PLUS MISC lancets 1 HAEMOLANCE PLUS PEDIATRIC FLOW MISC lancets 1 HEALTH CARE LANCING DEVICE MISC lancet devices 1 HEALTHWISE LANCETS 30G MISC lancets 1 HEALTHWISE LANCING PEN MISC lancet devices 1 HEALTHWISE MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 HEALTHWISE PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 HEALTHWISE SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

PAGE 267 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEALTHWISE UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 HEALTHY ACCENTS LANCING DEVICE MISC lancet devices 1 HEALTHY ACCENTS UNIFINE PENTIP MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 HEALTHY ACCENTS UNIFINE PENTIP MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 HEALTHY ACCENTS UNILET LANCETS MISC lancets 1

heartburn relief max st tab 20 mg 1

heartburn relief tab 200 mg 1

hm famotidine tab 20 mg 1

hm fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

hm fexofenadine hcl tab 60 mg 1 QL 50 / 30 days

hm loratadine childrens syrup 5 mg/5ml 1 QL 50 / 30 days

hydrocod polst-cpm polst er liquid er 10-8 mg/5ml 1

hydroxyurea cap 500 mg 1

hydroxyzine hcl solution 10 mg/5ml 1 AL Up to 64 yrs old

HYDROXYZINE HCL SOLUTION 25 MG/ML AL Up to 64 yrs old hydroxyzine hcl 1

hydroxyzine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

hydroxyzine hcl syrup 10 mg/5ml 1 AL Up to 64 yrs old

hydroxyzine hcl tab 10 mg 1 AL Up to 64 yrs old

hydroxyzine hcl tab 25 mg 1 AL Up to 64 yrs old

hydroxyzine hcl tab 50 mg 1 AL Up to 64 yrs old

HYDROXYZINE PAMOATE CAP 100 MG AL Up to 64 yrs old hydroxyzine pamoate 1

PAGE 268 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

hydroxyzine pamoate cap 25 mg 1 AL Up to 64 yrs old

hydroxyzine pamoate cap 50 mg 1 AL Up to 64 yrs old

IBG STAR BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 INFINITY BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 INFINITY BLOOD GLUCOSE TEST STRIP glucose blood 1 INFINITY CONTROL SOLUTION NORMAL blood glucose calibration 1 INLYTA TAB 1 MG PA axitinib 4 INLYTA TAB 5 MG PA axitinib 4 INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 INSULIN SYRINGE/NEEDLE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1

PAGE 269 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INSULIN SYRINGE/NEEDLE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 INSUPEN PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 INSUPEN ULTRAFIN MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 INSUPEN ULTRAFIN MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 INSUPEN ULTRAFIN MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 INTRON A RECON SOLN 10000000 UNIT PA interferon alfa-2b 4 INTRON A RECON SOLN 18000000 UNIT PA interferon alfa-2b 4 INTRON A RECON SOLN 50000000 UNIT PA interferon alfa-2b 4 INTRON A SOLUTION 6000000 UNIT/ML PA interferon alfa-2b 4 JAKAFI TAB 10 MG PA ruxolitinib phosphate 4 JAKAFI TAB 15 MG PA ruxolitinib phosphate 4 JAKAFI TAB 20 MG PA ruxolitinib phosphate 4 JAKAFI TAB 25 MG PA ruxolitinib phosphate 4 JAKAFI TAB 5 MG PA ruxolitinib phosphate 4 KETOCARE STRIP acetone (urine) test 1 KETONE TEST STRIP acetone (urine) test 1 KETOSTIX STRIP acetone (urine) test 1 KINNEY LANCETS MISC lancets 1 KINNEY THIN LANCETS MISC lancets 1 KINRAY INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1

PAGE 270 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KINRAY INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 KINRAY INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 KINRAY INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1

kls acid controller max st tab 20 mg 1

kp cetirizine hcl tab 10 mg 1 QL 50 / 30 days

kp cetirizine hcl tab 5 mg 1 QL 50 / 30 days

kp fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

KROGER BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 KROGER BLOOD GLUCOSE TEST STRIP glucose blood 1 KROGER INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 KROGER INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 KROGER LANCETS 21G MISC lancets 1 KROGER LANCETS MICRO THIN 33G MISC lancets 1 KROGER LANCETS MISC lancets 1

PAGE 271 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KROGER LANCETS SUPER THIN MISC lancets 1 KROGER LANCETS THIN 26G MISC lancets 1 KROGER LANCETS THIN MISC lancets 1 KROGER LANCETS ULTRATHIN 30G MISC lancets 1 KROGER LANCING DEVICE MISC lancet devices 1 KROGER PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 KROGER PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 KROGER PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 KROGER PREMIUM BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 KROGER PREMIUM GLUCOSE TEST STRIP glucose blood 1 KROGER TEST STRIP glucose blood 1 KYPROLIS RECON SOLN 60 MG PA carfilzomib 4 LANCET DEVICE MISC lancet devices 1 LANCETS 28G MISC lancets 1 LANCETS 30G MISC lancets 1 LANCETS MICRO THIN 33G MISC lancets 1 LANCETS MISC lancets 1 LANCETS SUPER THIN 28G MISC lancets 1 LANCETS THIN MISC lancets 1 LANCETS ULTRA FINE MISC lancets 1

PAGE 272 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LANCETS ULTRA THIN 30G MISC lancets 1 LANCETS ULTRA THIN MISC lancets 1 LANCING DEVICE MISC lancet devices 1 LASTACAFT SOLUTION 0.25 % PA alcaftadine 3 LEADER ADVANCED LANCING DEVICE MISC lancet devices 1 LEADER INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 LEADER INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 LEADER UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 LEADER UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 LEADER UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 LEADER UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

PAGE 273 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEADER UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1

QL 30 / 30 days

letrozole tab 2.5 mg 1 GL Female

AL At least 18 yrs old

LEUKERAN TAB 2 MG PA chlorambucil 4

leuprolide acetate kit 1 mg/0.2ml 4 PA

LIBERTY GLUCOSE CONTROL LIQUID NORMAL blood glucose calibration 1 LIBERTY GLUCOSE CONTROL MID SOLUTION blood glucose calibration 1 LIBERTY GLUCOSE CONTROL SOLUTION blood glucose calibration 1 LIBERTY GLUCOSE CONTROL SOLUTION NORMAL blood glucose calibration 1 LIBERTY MINI LANCING DEVICE MISC lancet devices 1 LIBERTY NEXT GENERATION TEST STRIP glucose blood 1 LIBERTY TEST STRIP glucose blood 1

lidocaine hcl solution 4 % 1 QL 100 / 23 days

LITE TOUCH LANCETS MISC lancets 1 LITE TOUCH LANCING DEVICE MISC lancet devices 1 LITE TOUCH LANCING PEN MISC lancet devices 1 LITE TOUCH PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 LITETOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1

PAGE 274 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LITETOUCH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 LITETOUCH LANCETS MISC lancets 1 LITETOUCH PEN NEEDLES MISC 29G X 12.7MM QL 200 / 30 days insulin pen needle 1 LITETOUCH PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 LITETOUCH PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 LIVE BETTER ADV LANCING DEVICE MISC lancet devices 1 LIVE BETTER LANCET SUPER THIN MISC lancets 1 LIVE BETTER LANCET ULTRA THIN MISC lancets 1 LIVE BETTER PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 LIVE BETTER PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 LIVE BETTER PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 LONGS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 LONGS LANCETS STANDARD MISC lancets 1

PAGE 275 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LONGS LANCETS THIN MISC lancets 1 LONGS LANCETS ULTRA THIN MISC lancets 1

loratadine allergy relief tab disp 10 mg 1 QL 50 / 30 days

loratadine tab 10 mg 1 QL 50 / 30 days

LUPRON DEPOT KIT 11.25 MG PA leuprolide acetate (3 month) 4 LUPRON DEPOT KIT 22.5 MG PA leuprolide acetate (3 month) 4 LUPRON DEPOT KIT 3.75 MG PA leuprolide acetate 4 LUPRON DEPOT KIT 30 MG PA leuprolide acetate (4 month) 4 LUPRON DEPOT KIT 45 MG PA leuprolide acetate (6 month) 4 LYSODREN TAB 500 MG PA mitotane 2 MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 MATULANE CAP 50 MG PA procarbazine hcl 4 MAXI-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 MAXI-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 MAXIMA BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1

PAGE 276 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MAXIMA BLOOD GLUCOSE TEST STRIP glucose blood 1 MAXIMA CONTROL SOLUTION blood glucose calibration 1 MAXIMA CONTROL SOLUTION NORMAL blood glucose calibration 1 MAXIMA METER KIT W/DEVICE blood glucose monitoring supplies 1 MAXIMA STARTER KIT W/DEVICE blood glucose monitoring supplies 1

meclizine hcl tab 12.5 mg 1

meclizine hcl tab 25 mg 1

medi-phedryl elixir 12.5 mg/5ml 1 AL Up to 64 yrs old

MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 MEDICHOICE SAFETY LANCET EXTRA MISC lancets 1 MEDICHOICE SAFETY LANCET MISC lancets 1 MEDICHOICE SAFETY LANCET NORM MISC lancets 1 MEDICINE SHOPPE PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 MEDICINE SHOPPE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 MEDICINE SHOPPE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 MEDISENSE GLUCOSE KETONE CONTR LIQUID blood glucose calibration 1 MEDISENSE HI/MID/LOW CONTROL LIQUID blood glucose calibration 1 MEDISENSE HIGH/LOW CONTROL LIQUID blood glucose calibration 1 MEDISENSE MID CONTROL LIQUID blood glucose calibration 1 MEDISENSE THIN LANCETS MISC lancets 1

PAGE 277 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MEDLANCE EXTRA 21G MISC lancets 1 MEDLANCE LITE 25G MISC lancets 1 MEDLANCE PLUS EXTRA 21G MISC lancets 1 MEDLANCE PLUS LANCETS MISC lancets 1 MEDLANCE PLUS LITE 25G MISC lancets 1 MEDLANCE PLUS SPECIAL 0.8MM MISC lancets 1 MEDLANCE PLUS SUPERLITE 30G MISC lancets 1 MEDLANCE PLUS UNIVERSAL 21G MISC lancets 1 MEDLANCE UNIVERSAL 21G MISC lancets 1

megestrol acetate suspension 40 mg/ml 1

megestrol acetate suspension 400 mg/10ml 1

megestrol acetate tab 20 mg 1

megestrol acetate tab 40 mg 1 MEIJER BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 MEIJER BLOOD GLUCOSE TEST STRIP glucose blood 1 MEIJER LANCETS MISC lancets 1 MEIJER LANCETS THIN MISC lancets 1 MEIJER LANCETS UNIVERSAL 30G MISC lancets 1 MEIJER LANCETS UNIVERSAL 33G MISC lancets 1 MEIJER PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 MEIJER PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1

PAGE 278 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MEIJER PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 MEIJER PREMIUM BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 MEIJER PREMIUM GLUCOSE TEST STRIP glucose blood 1 MEIJER SUPER THIN LANCETS MISC lancets 1 MEIJER TRUE2GO BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE blood glucose monitoring supplies 1 MEIJER TRUETEST TEST STRIP glucose blood 1 MEIJER TRUETRACK GLUCOSE SYS KIT W/DEVICE blood glucose monitoring supplies 1 MEIJER TRUETRACK TEST STRIP glucose blood 1

mercaptopurine tab 50 mg 1

methotrexate sodium (pf) solution 1 gm/40ml 1

methotrexate sodium (pf) solution 100 mg/4ml 1

methotrexate sodium (pf) solution 25 mg/ml 1

methotrexate sodium (pf) solution 250 mg/10ml 1

methotrexate sodium (pf) solution 50 mg/2ml 1

methotrexate sodium recon soln 1 gm 1

methotrexate tab 2.5 mg 1

methylergonovine maleate tab 0.2 mg 1 MICRODOT BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 MICRODOT CONTROL HIGH/LOW SOLUTION blood glucose calibration 1 MICRODOT TEST STRIP glucose blood 1 MICROLET LANCETS MISC lancets 1 MICROTAINER SAFETY FLOW LANCET MISC lancets 1

PAGE 279 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MINI LANCING DEVICE MISC lancet devices 1 MONOJECT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 MONOJECT INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 MONOJECT ULTRA COMFORT SYRINGE MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 28G X 1/2" 1 ML 1 QL 200 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 1 ML 1 insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100

PAGE 280 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOJECT ULTRA COMFORT SYRINGE MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 MONOLET LANCETS MISC lancets 1 MONOLET OPD LANCETS MISC lancets 1 MONOLETTOR SAFETY LANCETS MISC lancets 1 MOORE MONO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 MOORE MONO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 MS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 MS INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 MS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 MS INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 MULTI-LANCET DEVICE MISC lancet devices 1 MYGLUCOHEALTH BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 MYGLUCOHEALTH CONTROL SOLUTION blood glucose calibration 1 MYGLUCOHEALTH LANCETS 30G MISC lancets 1 MYGLUCOHEALTH TEST STRIP glucose blood 1 MYLERAN TAB 2 MG PA busulfan 4

PAGE 281 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NETGROUP LANCETS MISC lancets 1 NEUTEK 2TEK CONTROL SOLUTION blood glucose calibration 1 NEUTEK 2TEK TEST STRIP glucose blood 1 NEXAVAR TAB 200 MG PA sorafenib tosylate 4

nizatidine cap 150 mg 1

nizatidine cap 300 mg 1

nizatidine solution 15 mg/ml 1 NOVA MAX BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 NOVA MAX GLUCOSE TEST STRIP glucose blood 1 NOVA MAX PLUS GLU/KET CONTROL LIQUID blood glucose calibration 1 NOVA MAX PLUS KETONE TEST STRIP QL 10 / 30 days ketone blood test 1 NOVA SAFETY LANCETS 23G MISC lancets 1 NOVA SAFETY LANCETS 28G MISC lancets 1 NOVA SUREFLEX LANCETS MISC lancets 1 NOVA SUREFLEX LANCING DEVICE MISC lancet devices 1 NOVOFINE PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1

olopatadine hcl solution 0.6 % 3 ST

ON CALL EXPRESS BLOOD GLUCOSE STRIP glucose blood 1 ON CALL EXPRESS GLUCOSE CONTR SOLUTION blood glucose calibration 1 ON CALL EXPRESS MONITORING SYS KIT W/DEVICE blood glucose monitoring supplies 1 ON CALL LANCETS MISC lancets 1

PAGE 282 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ON CALL LANCING DEVICE MISC lancet devices 1 ON CALL PLUS BLOOD GLUCOSE STRIP glucose blood 1 ON CALL PLUS GLUCOSE CONTROL SOLUTION blood glucose calibration 1 ON CALL PLUS LANCETS MISC lancets 1 ON CALL PLUS LANCING DEVICE MISC lancet devices 1 ON CALL PLUS METER KIT W/DEVICE blood glucose monitoring supplies 1 ON CALL PLUS MONITORING SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 ON CALL VIVID BLOOD GLUCOSE STRIP glucose blood 1 ON CALL VIVID GLUCOSE CONTROL SOLUTION blood glucose calibration 1 ON CALL VIVID METER KIT W/DEVICE blood glucose monitoring supplies 1 ON CALL VIVID MONITORING KIT W/DEVICE blood glucose monitoring supplies 1 ON CALL VIVID PAL METER KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH DELICA LANCETS 33G MISC lancets 1 ONETOUCH DELICA LANCETS FINE MISC lancets 1 ONETOUCH DELICA LANCING DEV MISC lancet devices 1 ONETOUCH FINEPOINT LANCETS MISC lancets 1 ONETOUCH LANCETS MISC lancets 1 ONETOUCH ULTRA 2 KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH ULTRA BLUE STRIP glucose blood 1 ONETOUCH ULTRA CONTROL SOLUTION blood glucose calibration 1

PAGE 283 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ONETOUCH ULTRA MINI KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH ULTRA SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH ULTRALINK KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH ULTRASMART KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH ULTRASOFT LANCETS MISC lancets 1 ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH VERIO KIT W/DEVICE blood glucose monitoring supplies 1 ONETOUCH VERIO SOLUTION blood glucose calibration 1 ONETOUCH VERIO STRIP glucose blood 1 ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 OPTIUM BLOOD GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 OPTIUM TEST STRIP glucose blood 1 OPTIUMEZ TEST STRIP glucose blood 1 OPTUMRX BLOOD GLUCOSE METER KIT W/DEVICE blood glucose monitoring supplies 1 OPTUMRX BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 OPTUMRX BLOOD GLUCOSE TEST STRIP glucose blood 1 OPTUMRX GLUCOSE CONTROL SOLUTION blood glucose calibration 1 PARADIGM LINK GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 PATADAY SOLUTION 0.2 % PA olopatadine hcl 3 PATANOL SOLUTION 0.1 % PA olopatadine hcl 3

PAGE 284 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PC LANCETS SUPER THIN 30G MISC lancets 1 PC UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 PC UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 PC UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 PC UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 PEN NEEDLES 1/2" MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 PEN NEEDLES 3/16" MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 PEN NEEDLES 5/16" MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 PENTETATE CALCIUM TRISODIUM SOLUTION 200 MG/ML pentetate calcium trisodium 1 PENTETATE ZINC TRISODIUM SOLUTION 200 MG/ML pentetate zinc trisodium 1 PERFECT LANCETS 28G MISC lancets 1 PERFECT LANCETS 30G MISC lancets 1 PHARMACIST CHOICE AUTOCODE STRIP glucose blood 1 PHARMACIST CHOICE AUTOCODE SYS KIT W/DEVICE blood glucose monitoring supplies 1 PHARMACIST CHOICE LANCETS MISC lancets 1 PHARMACY COUNTER LANCETS MISC lancets 1

phenadoz suppos 12.5 mg 1 AL Up to 64 yrs old

phenadoz suppos 25 mg 1 AL Up to 64 yrs old

PAGE 285 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

phenergan suppos 50 mg 1 AL Up to 64 yrs old

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 1.75-0.75-2.75 MG/ML 1 phenylephrine-chlorphen-dm POCKETCHEM EZ CONTROL SOLUTION blood glucose calibration 1 POCKETCHEM EZ SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 POCKETCHEM EZ TEST STRIP glucose blood 1 POMALYST CAP 1 MG PA pomalidomide 4 POMALYST CAP 2 MG PA pomalidomide 4 POMALYST CAP 3 MG PA pomalidomide 4 POMALYST CAP 4 MG PA pomalidomide 4 PRECISION GLUCOSE KETONE CONTR LIQUID blood glucose calibration 1 PRECISION LINK KIT blood glucose monitoring supplies 1 PRECISION PCX PLUS TEST STRIP glucose blood 1 PRECISION PCX STRIP glucose blood 1 PRECISION POINT OF CARE TEST STRIP glucose blood 1 PRECISION QID TEST STRIP glucose blood 1 PRECISION SURE-DOSE SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 PRECISION SURE-DOSE SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 PRECISION SURE-DOSE SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 PRECISION SUREDOSE PLUS SYR MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 PRECISION SUREDOSE PLUS SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1

PAGE 286 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRECISION XTRA BLOOD GLUCOSE STRIP glucose blood 1 PRECISION XTRA KETONE STRIP QL 10 / 30 days ketone blood test 1 PREFERRED PLUS INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 28G X 1/2" 1 ML 1 QL 200 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 29G X 1/2" 1 ML 1 insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 30G X 5/16" 1 ML 1 insulin syringe/needle u-100 PREFERRED PLUS LANCETS COLORED MISC lancets 1 PREFERRED PLUS LANCETS THIN MISC lancets 1 PREFERRED PLUS UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 PREFERRED PLUS UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1

PAGE 287 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PRODIGY AUTOCODE BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 PRODIGY INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 PRODIGY INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 PRODIGY INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 PRODIGY LANCETS 28G MISC lancets 1 PRODIGY LANCING DEVICE MISC lancet devices 1 PRODIGY NO CODING BLOOD GLUC STRIP glucose blood 1 PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 PRODIGY TWIST TOP LANCETS 28G MISC lancets 1 PRODIGY VOICE BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1

promethazine hcl solution 25 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 50 mg/ml 1 AL Up to 64 yrs old

promethazine hcl solution 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl suppos 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 25 mg 1 AL Up to 64 yrs old

promethazine hcl suppos 50 mg 1 AL Up to 64 yrs old

promethazine hcl syrup 6.25 mg/5ml 1 AL Up to 64 yrs old

promethazine hcl tab 12.5 mg 1 AL Up to 64 yrs old

promethazine hcl tab 25 mg 1 AL Up to 64 yrs old

promethazine hcl tab 50 mg 1 AL Up to 64 yrs old

PROMETHAZINE VC PLAIN SYRUP 6.25-5 MG/5ML promethazine & phenylephrine 1 PROMETHAZINE VC/CODEINE SYRUP 6.25-5-10 MG/5ML phenyleph-promethazine w/ cod 1

PAGE 288 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

promethazine-codeine syrup 6.25-10 mg/5ml 1

promethazine-dm syrup 6.25-15 mg/5ml 1

promethegan suppos 12.5 mg 1 AL Up to 64 yrs old

promethegan suppos 25 mg 1 AL Up to 64 yrs old

promethegan suppos 50 mg 1 AL Up to 64 yrs old

PTS PANELS KETONE TEST STRIP QL 10 / 30 days ketone blood test 1

PULMOZYME SOLUTION 1 MG/ML QL 60 / 30 days 4 dornase alfa PA

px acid reducer max st tab 20 mg 1

px acid reducer tab 200 mg 1 PX ADVANCED LANCING DEVICE MISC lancet devices 1 PX EXTRA SHORT PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 PX INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 PX INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 PX INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 PX INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 PX INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 PX INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 PX LANCET AUTO INJECTOR MISC lancet devices 1 PX LANCETS ULTRA THIN MISC lancets 1 PX MINI PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 PX PEN NEEDLE MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 PX PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

PAGE 289 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PYROGALLIC ACID OINTMENT 25-2 % pyrogallol-chlorobutanol 1

qc acid controller max st tab 20 mg 1 QC ADVANCED LANCING DEVICE MISC lancet devices 1 QC INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 QC LANCETS SUPER THIN 30G MISC lancets 1 QC LANCETS ULTRA THIN MISC lancets 1

qc loratadine allergy relief tab 10 mg 1 QL 50 / 30 days

QC PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 QC PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 QC PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 QC UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1

quenalin syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

QUICKTEK CONTROL SOLUTION LIQUID blood glucose calibration 1 QUICKTEK TEST STRIP glucose blood 1 QUICKTEK/METER KIT blood glucose monitoring supplies 1

ra acid reducer max st tab 20 mg 1

ra acid reducer tab 200 mg 1 RA E-ZJECT COLOR LANCETS 33G MISC lancets 1 RA E-ZJECT LANCETS 28G MISC lancets 1 RA E-ZJECT LANCETS THIN 26G MISC lancets 1 RA E-ZJECT LANCETS THIN 28G MISC lancets 1

PAGE 290 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RA E-ZJECT LANCETS ULTRA THIN MISC lancets 1 RA INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 RA INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 RA INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 RA INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 RA LANCING DEVICE MISC lancet devices 1 RA PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 RA PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 RA TRUE2GO BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 RA TRUERESULT BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 RA TRUETEST TEST STRIP glucose blood 1

ranitidine hcl cap 150 mg 3

ranitidine hcl cap 300 mg 3

ranitidine hcl syrup 15 mg/ml 1

ranitidine hcl syrup 150 mg/10ml 1

ranitidine hcl syrup 75 mg/5ml 1

ranitidine hcl tab 150 mg 1

ranitidine hcl tab 300 mg 1 REFUAH PLUS BLOOD GLUCOSE TEST STRIP glucose blood 1 REFUAH PLUS GLUCOSE CONTROL SOLUTION blood glucose calibration 1 REFUAH PLUS MONITORING SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 RELI-ON INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1

PAGE 291 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RELION BLOOD GLUCOSE TEST STRIP glucose blood 1 RELION CONFIRM GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 RELION CONFIRM/MICRO TEST STRIP glucose blood 1 RELION INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 RELION INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 RELION KETONE STRIP acetone (urine) test 1 RELION LANCETS MICRO-THIN 33G MISC lancets 1 RELION LANCETS STANDARD 21G MISC lancets 1 RELION LANCETS THIN 26G MISC lancets 1 RELION LANCETS ULTRA-THIN 30G MISC lancets 1 RELION LANCING DEVICE MISC lancet devices 1 RELION MICRO KIT W/DEVICE blood glucose monitoring supplies 1 RELION MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1

PAGE 292 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RELION PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 RELION PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 RELION PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 RELION PRIME TEST STRIP glucose blood 1 RELION SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 RELION ULTIMA GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 RELION ULTIMA TEST STRIP glucose blood 1 RELION ULTRA THIN LANCETS 30G MISC lancets 1 RELION ULTRA THIN PLUS LANCETS MISC lancets 1 RESCON-JR TAB ER 12H 3-20 MG dexchlorpheniramine-phenylephrine 1 RESCON-JR TAB ER 12H 4-20 MG chlorpheniramine & phenylephrine 1 REVEAL BLOOD GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 REVEAL BLOOD GLUCOSE TEST STRIP glucose blood 1 REVLIMID CAP 10 MG PA lenalidomide 4 REVLIMID CAP 15 MG PA lenalidomide 4 REVLIMID CAP 2.5 MG PA lenalidomide 4 REVLIMID CAP 25 MG PA lenalidomide 4 REVLIMID CAP 5 MG PA lenalidomide 4 REXALL BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 REXALL BLOOD GLUCOSE TEST STRIP glucose blood 1

PAGE 293 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS REXALL LANCETS ULTRA THIN 30G MISC lancets 1 RIDAURA CAP 3 MG PA auranofin 4 RIGHTEST GC300 CONTROL LIQUID NORMAL blood glucose calibration 1 RIGHTEST GD500 LANCING DEVICE MISC lancet devices 1 RIGHTEST GL300 LANCETS MISC lancets 1 RIGHTEST GM100 BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 RIGHTEST GM300 BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 RIGHTEST GM550 BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 RIGHTEST GS100 BLOOD GLUCOSE STRIP glucose blood 1 RIGHTEST GS300 BLOOD GLUCOSE STRIP glucose blood 1 RIGHTEST GS550 BLOOD GLUCOSE STRIP glucose blood 1 SAFESNAP INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 SAFESNAP INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 SAFESNAP INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 SAFESNAP INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 SAFESNAP INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 SAFETY LANCET 21G/PRESSURE ACT MISC lancets 1 SAFETY LANCET 28G/PRESSURE ACT MISC lancets 1 SAFETY LANCETS 21G MISC lancets 1 SAFETY LANCETS 28G MISC lancets 1

PAGE 294 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SAFETY LANCETS MISC lancets 1 SAFETY LET LANCETS MISC lancets 1 SAFETY SEAL LANCETS MISC lancets 1 SAFETY-GLIDE SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 SANTYL OINTMENT 250 UNIT/GM collagenase 3 SAPSCARE TWIST TOP LANCETS MISC lancets 1

sb acid controller max st tab 20 mg 1 SB INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 SB INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 SB INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 SB INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 SB INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 SB LANCETS THIN MISC lancets 1 SB LANCETS ULTRA THIN MISC lancets 1

sb loratadine tab 10 mg 1 QL 50 / 30 days

SCHNUCKS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 SCHNUCKS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 SHOPKO AUTOLET LANCING DEVICE MISC lancet devices 1 SHOPKO ON-THE-GO LANCETS 30G MISC lancets 1 SHOPKO UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1

PAGE 295 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SHOPKO UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 SHOPKO UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 SHOPKO UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 SHOPKO UNILET LANCETS 28G MISC lancets 1 SHOPKO UNILET LANCETS 30G MISC lancets 1

silphen cough syrup 12.5 mg/5ml 1 AL Up to 64 yrs old

SIMPLE DIAGNOSTICS LANCING DEV MISC lancet devices 1

sm acid reducer max st tab 20 mg 1

sm acid reducer tab 200 mg 1

sm childrens loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

sm fexofenadine hcl tab 180 mg 1 QL 50 / 30 days

sm fexofenadine hcl tab 60 mg 1 QL 50 / 30 days

SM INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 SM INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 SM INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 SM INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 SM LANCETS 33G MISC lancets 1

sm loratadine allergy relief tab disp 10 mg 1 QL 50 / 30 days

sm loratadine syrup 5 mg/5ml 1 QL 50 / 30 days

sm loratadine tab 10 mg 1 QL 50 / 30 days

sm loratadine tab disp 10 mg 1 QL 50 / 30 days

SMART DIABETES VANTAGE LANCETS MISC lancets 1 SMART DIABETES VANTAGE LANCING MISC lancet devices 1

PAGE 296 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SMART DIABETES XPRES SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 SMART DIABETES XPRES TEST STRIP glucose blood 1 SMART SENSE COLOR LANCETS 33G MISC lancets 1 SMART SENSE PREMIUM SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 SMART SENSE PREMIUM TEST STRIP glucose blood 1 SMART SENSE STANDARD LANCETS MISC lancets 1 SMART SENSE SUPER THIN LANCETS MISC lancets 1 SMART SENSE THIN LANCETS 26G MISC lancets 1 SMART SENSE VALUE GLUCOSE SYS KIT W/DEVICE blood glucose monitoring supplies 1 SMART SENSE VALUE TEST STRIP glucose blood 1 SMARTEST BLOOD GLUCOSE TEST STRIP glucose blood 1 SMARTEST CONTROL MEDIUM SOLUTION blood glucose calibration 1 SMARTEST EJECT STARTER KIT W/DEVICE blood glucose monitoring supplies 1 SMARTEST LANCETS 28G MISC lancets 1 SMARTEST PERSONA STARTER KIT W/DEVICE blood glucose monitoring supplies 1 SMARTEST PRONTO STARTER KIT W/DEVICE blood glucose monitoring supplies 1 SMARTEST PROTEGE STARTER KIT W/DEVICE blood glucose monitoring supplies 1 SOLARTEK GLUCOSE CONTROL LIQUID blood glucose calibration 1 SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 SOLUS V2 LANCETS 28G MISC lancets 1

PAGE 297 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SOLUS V2 LANCING DEVICE MISC lancet devices 1 SOLUS V2 TEST STRIP glucose blood 1 SOLUS V2 TWIST LANCETS 30G MISC lancets 1 SPRYCEL TAB 100 MG PA dasatinib 4 SPRYCEL TAB 140 MG PA dasatinib 4 SPRYCEL TAB 20 MG PA dasatinib 4 SPRYCEL TAB 50 MG PA dasatinib 4 SPRYCEL TAB 70 MG PA dasatinib 4 SPRYCEL TAB 80 MG PA dasatinib 4 STERILANCE TL MISC lancets 1 STIVARGA TAB 40 MG PA regorafenib 4 SUPER THIN LANCETS MISC lancets 1 SURE COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 SURE COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100

PAGE 298 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 SURE COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 SURE COMFORT LANCETS 28G MISC lancets 1 SURE COMFORT LANCETS 30G MISC lancets 1 SURE COMFORT LANCING PEN MISC lancet devices 1 SURE COMFORT PEN NEEDLES MISC 29G X 12.7MM QL 200 / 30 days insulin pen needle 1 SURE COMFORT PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 SURE COMFORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 SURE COMFORT PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 SURE EDGE TEST STRIP glucose blood 1 SURE-FINE PEN NEEDLES MISC 29G X 12.7MM QL 200 / 30 days insulin pen needle 1 SURE-FINE PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 SURE-FINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1

PAGE 299 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SURE-JECT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 SURE-LANCE FLAT LANCETS MISC lancets 1 SURE-LANCE LANCETS 26G MISC lancets 1 SURE-LANCE THIN LANCETS 28G MISC lancets 1 SURE-LANCE ULTRA THIN LANCETS MISC lancets 1 SURE-PEN MISC lancet devices 1 SURE-TEST EASYPLUS MINI TEST STRIP glucose blood 1 SURE-TOUCH LANCETS UNIVERSAL MISC lancets 1 SURECHEK BLOOD GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 SURECHEK BLOOD GLUCOSE TEST STRIP glucose blood 1

PAGE 300 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SURELITE LANCETS MISC lancets 1 SURESTEP GLUCOSE CONTROL SOLUTION blood glucose calibration 1 SURESTEP PRO NORMAL GLUCOSE LIQUID blood glucose calibration 1 SURESTEP PRO TEST STRIP glucose blood 1 SUTENT CAP 12.5 MG PA sunitinib malate 4 SUTENT CAP 25 MG PA sunitinib malate 4 SUTENT CAP 50 MG PA sunitinib malate 4 SYLATRON KIT 200 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 300 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 4 X 200 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 4 X 300 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYLATRON KIT 600 MCG PA peginterferon alfa-2b (antineoplastic) 4 SYPRINE CAP 250 MG trientine hcl 4 TABLOID TAB 40 MG PA thioguanine 4 TAI DOC CONTROL SOLUTION NORMAL blood glucose calibration 1

tamoxifen citrate tab 10 mg 1

tamoxifen citrate tab 20 mg 1 TARCEVA TAB 100 MG PA erlotinib hcl 4 TARCEVA TAB 150 MG PA erlotinib hcl 4 TARCEVA TAB 25 MG PA erlotinib hcl 4 TARGRETIN CAP 75 MG PA bexarotene 4

PAGE 301 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TASIGNA CAP 150 MG PA nilotinib hcl 4 TASIGNA CAP 200 MG PA nilotinib hcl 4 TECHLITE AST LANCETS MISC lancets 1 TECHLITE LANCETS 30G MISC lancets 1 TELCARE BLOOD GLUCOSE SYSTEM KIT W/DEVICE blood glucose monitoring supplies 1 TELCARE BLOOD GLUCOSE TEST STRIP glucose blood 1 TELCARE GLUCOSE CONTROL SOLUTION blood glucose calibration 1 TERUMO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 TERUMO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 TERUMO INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 TERUMO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 TERUMO INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 TERUMO SURGUARD INSULIN SYR MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 TERUMO SURGUARD INSULIN SYR MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 TGQ 15DM/5PEH/2CPM SYRUP 15-5-2 MG/5ML phenylephrine-chlorphen-dm 1

tgt acid reducer tab 200 mg 1 TGT ADVANCED LANCING DEVICE MISC lancet devices 1

PAGE 302 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TGT BLOOD GLUCOSE MONITORING KIT W/DEVICE blood glucose monitoring supplies 1 TGT BLOOD GLUCOSE TEST STRIP glucose blood 1 TGT LANCET ALTERNATE SITE MISC lancets 1 TGT LANCET MICRO THIN 33G MISC lancets 1 TGT LANCET SUPER THIN 30G MISC lancets 1 TGT LANCET THIN 23G MISC lancets 1 TGT LANCET THIN 26G MISC lancets 1 TGT LANCET ULTRA THIN 28G MISC lancets 1 TGT LANCET ULTRA THIN 30G MISC lancets 1 TGT LANCING DEVICE MISC lancet devices 1

tgt loratadine childrens syrup 5 mg/5ml 1 QL 50 / 30 days

THINPRO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 THINPRO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 THINPRO INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 THINPRO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 THINPRO INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 THYROGEN RECON SOLN 1.1 MG PA thyrotropin alfa 4 TODAYS HEALTH LANCING DEVICE MISC lancet devices 1 TODAYS HEALTH MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 TODAYS HEALTH PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1

PAGE 303 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TODAYS HEALTH SHORT PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 TODAYS HEALTH THIN LANCETS 28G MISC lancets 1 TODAYS HEALTH THIN LANCETS 30G MISC lancets 1 TOLBUTAMIDE TAB 500 MG tolbutamide 1 TOPCARE CLICKFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 TOPCARE CLICKFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 1 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 30G X 5/16" 1 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 31G X 5/16" 1 ML 1 insulin syringe/needle u-100 TRELSTAR DEPOT MIXJECT RECON SUSP 3.75 MG PA triptorelin pamoate 4

PAGE 304 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRELSTAR LA MIXJECT RECON SUSP 11.25 MG PA triptorelin pamoate 4 TRELSTAR MIXJECT RECON SUSP 22.5 MG PA triptorelin pamoate 4 TRELSTAR RECON SUSP 11.25 MG PA triptorelin pamoate 4 TRELSTAR RECON SUSP 3.75 MG PA triptorelin pamoate 4

tretinoin cap 10 mg 4 PA

TREXALL TAB 10 MG PA methotrexate sodium 3 TREXALL TAB 15 MG PA methotrexate sodium 3 TREXALL TAB 5 MG PA methotrexate sodium 3 TREXALL TAB 7.5 MG PA methotrexate sodium 3 TRUE METRIX BLOOD GLUCOSE TEST STRIP glucose blood 1 TRUE METRIX LEVEL 2 SOLUTION NORMAL blood glucose calibration 1 TRUE METRIX METER KIT W/DEVICE blood glucose monitoring supplies 1 TRUE2GO BLOOD GLUCOSE MONITOR KIT W/DEVICE blood glucose monitoring supplies 1 TRUECONTROL GLUCOSE CONT LEV 0 LIQUID blood glucose calibration 1 TRUECONTROL GLUCOSE CONT LEV 1 LIQUID blood glucose calibration 1 TRUEDRAW LANCING DEVICE MISC lancet devices 1 TRUEPLUS INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1

PAGE 305 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRUEPLUS INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 TRUEPLUS INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 TRUEPLUS LANCETS 26G MISC lancets 1 TRUEPLUS LANCETS 28G MISC lancets 1 TRUEPLUS LANCETS 30G MISC lancets 1 TRUEPLUS LANCETS 33G MISC lancets 1 TRUEPLUS SAFETY LANCETS 28G MISC lancets 1 TRUERESULT BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 TRUETEST CONTROL LEVEL 1 LIQUID blood glucose calibration 1 TRUETEST CONTROL LEVEL 2 LIQUID blood glucose calibration 1 TRUETEST CONTROL LEVEL 3 LIQUID blood glucose calibration 1 TRUETEST TEST STRIP glucose blood 1 TRUETRACK BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 TRUETRACK SMART SYSTEM KIT blood glucose monitoring supplies 1 TRUETRACK TEST STRIP glucose blood 1

PAGE 306 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TYKERB TAB 250 MG PA lapatinib ditosylate 4 ULTI-LANCE AUTOMATIC MISC lancet devices 1 ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML insulin syringe/needle u-100 1 ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 ULTICARE MICRO PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 ULTICARE MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1

PAGE 307 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ULTICARE PEN NEEDLES MISC 29G X 12.7MM QL 200 / 30 days insulin pen needle 1 ULTICARE PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 ULTICARE SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 ULTICARE THIN LANCETS 30G MISC lancets 1 ULTILET CLASSIC LANCETS MISC lancets 1 ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 1 ML insulin syringe/needle u-100 1 ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1 ULTILET LANCETS MISC lancets 1 ULTILET PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 ULTILET SAFETY LANCETS 23G MISC lancets 1 ULTIMA TEST STRIP glucose blood 1 ULTRA COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 ULTRA COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTRA COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100

PAGE 308 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ULTRA THIN LANCETS 28G MISC lancets 1 ULTRA THIN LANCETS 30G MISC lancets 1 ULTRA TRAK PRO BLOOD GLUCOSE KIT W/DEVICE blood glucose monitoring supplies 1 ULTRA-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML 1 QL 200 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML 1 QL 200 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML 1 insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML 1 insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML 1 insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML 1 insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 1 ML 1 insulin syringe/needle u-100 ULTRA-THIN II AUTO LANCET MISC lancets 1 ULTRA-THIN II INS SYR SHORT MISC 31G X 5/16" 1 ML insulin syringe/needle u-100 1

PAGE 309 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ULTRA-THIN II INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 ULTRA-THIN II PEN NEEDLES MISC 29G X 12.7MM QL 200 / 30 days insulin pen needle 1 ULTRATRAK PRO CONTROL SOLUTION blood glucose calibration 1 ULTRATRAK PRO CONTROL SOLUTION NORMAL blood glucose calibration 1 ULTRATRAK PRO TEST STRIP glucose blood 1 ULTRATRAK ULTIMATE CONTROL SOLUTION blood glucose calibration 1 ULTRATRAK ULTIMATE TEST STRIP glucose blood 1 UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS PLUS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 UNILET COMFORTOUCH LANCET MISC lancets 1 UNILET EXCELITE II MISC lancets 1 UNILET EXCELITE MISC lancets 1

PAGE 310 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS UNILET G.P. LANCET MISC lancets 1 UNILET G.P. SUPERLITE LANCET MISC lancets 1 UNILET GP 28 ULTRA THIN MISC lancets 1 UNILET LANCET MISC lancets 1 UNILET SUPERLITE LANCET MISC lancets 1 UNISTIK 3 GENTLE MISC lancets 1 UNISTRIP1 GENERIC STRIP glucose blood 1 UNIVERSAL 1 LANCETS THIN 26G MISC lancets 1 UNIVERSAL 1 LANCETS ULTRA THIN MISC lancets 1 V-R MONO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 V-R MONO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 1 V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 VALSTAR SOLUTION 40 MG/ML PA valrubicin 4 VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML insulin syringe/needle u-100 1 VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 VALUE PLUS LANCET STANDARD 21G MISC lancets 1 VALUE PLUS LANCETS SUPER THIN MISC lancets 1 VALUE PLUS LANCETS THIN 26G MISC lancets 1

PAGE 311 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VALUE PLUS LANCING DEVICE MISC lancet devices 1 VALUMARK LANCET SUPER THIN 30G MISC lancets 1 VALUMARK LANCET ULTRA THIN 28G MISC lancets 1 VALUMARK PEN NEEDLES MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 VALUMARK PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 VALUMARK PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 VANISHPOINT INSULIN SYRINGE MISC 29G X 1/2" 1 ML insulin syringe/needle u-100 1 VANISHPOINT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 1 VANTAS KIT 50 MG PA histrelin acetate 4 VICTORY AGM-4000 TEST STRIP glucose blood 1 VICTORY CONTROL LEVEL 1/2 SOLUTION blood glucose calibration 1 VIDA MIA AUTOLET LANCING DEV MISC lancet devices 1 VIDA MIA UNIFINE PENTIPS MISC 29G X 12MM QL 200 / 30 days insulin pen needle 1 VIDA MIA UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 VIDA MIA UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 VIDA MIA UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 VIDA MIA UNILET LANCETS 28G MISC lancets 1 VIDA MIA UNILET LANCETS 30G MISC lancets 1 VOCAL POINT BLOOD GLUCOSE TEST STRIP glucose blood 1 VOTRIENT TAB 200 MG PA pazopanib hcl 4

PAGE 312 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1

wal-itin tab 10 mg 1 WALGREENS ADV TRAVEL LANCETS MISC lancets 1 WALGREENS LANCETS MICRO THIN MISC lancets 1 WALGREENS LANCETS MISC lancets 1 WALGREENS LANCETS SUPER THIN MISC lancets 1 WALGREENS THIN LANCETS MISC lancets 1 WALGREENS ULTRA THIN LANCETS MISC lancets 1 WAVESENSE AMP KIT W/DEVICE blood glucose monitoring supplies 1 WAVESENSE KEYNOTE KIT W/DEVICE blood glucose monitoring supplies 1 WAVESENSE PRESTO STRIP glucose blood 1 WD MEDIC INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 1 WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1 WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1 WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1 WEGMANS UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1 XALKORI CAP 200 MG PA crizotinib 4 XALKORI CAP 250 MG PA crizotinib 4 XELODA TAB 150 MG PA capecitabine 4 XELODA TAB 500 MG PA capecitabine 4

PAGE 313 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XPRES CONTROL SOLUTION NORMAL blood glucose calibration 1 ZENPEP CP DR PART 25000 UNIT pancrelipase (lipase-protease-amylase) 2 ZOLADEX IMPLANT 10.8 MG PA goserelin acetate 3 ZOLADEX IMPLANT 3.6 MG PA goserelin acetate 3 ZYTIGA TAB 250 MG PA abiraterone acetate 4 Vitamins

AMINOBENZOATE POTASSIUM PACKET 2 GM potassium aminobenzoate 1

aqueous vitamin d liquid 400 unit/ml 5

ascorbic acid solution 500 mg/ml 1 AVORIA CAL+D PACKET 500-40-60-400 calcium-magnesium-vitamin c-vitamin d 5 AVORIA GC+ PACKET glucosamine-chondroitin-calcium-magnesium-vit c-vit d 5 B-6 FOLIC ACID CAP 400-1000-50 MCG-MCG-MG cobalamine combinations 1 B-NATAL LOZ HANDLE 25 MG pyridoxine hcl 5 B-NATAL LOZENGE 25 MG pyridoxine hcl 5 BIOGAIA PROTECTIS/VITAMIN D LIQUID lactobacillus reuteri-vitamin d 5 BP FOLINATAL PLUS B TAB 1 MG prenatal w/ calcium carbonate-vit b6-vit b12-folic acid 1

bprotected pedia d-vite liquid 400 unit/ml 5

calcitriol cap 0.25 mcg 1

calcitriol cap 0.5 mcg 1

calcitriol solution 1 mcg/ml 3

calcitriol solution 1 mcg/ml 3

cvs folic acid tab 800 mcg 5 QL 30 / 30 days

cvs vit d 5000 high-potency cap 5000 unit 5 QL 60 / 30 days

PAGE 314 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cvs vitamin d cap 2000 unit 5 QL 60 / 30 days

cvs vitamin d infants liquid 400 unit/ml 5

cvs vitamin d3 cap 1000 unit 5 QL 60 / 30 days

cvs vitamin d3 cap 400 unit 5 QL 60 / 30 days

cyanocobalamin solution 1000 mcg/ml 1

d 1000 cap 1000 unit 5 QL 60 / 30 days

d 1000 chew tab 1000 unit 5

d 1000 tab 1000 unit 5

d 400 chew tab 400 unit 5

d 400 tab 400 unit 5

d 5000 cap 5000 unit 5 QL 60 / 30 days

d 5000 tab 5000 unit 5

d-1000 extra strength tab 1000 unit 5

d-1000 tab 1000 unit 5

d-3-5 cap 5000 unit 5 QL 60 / 30 days

d-400 tab 400 unit 5

d-5000 maximum strength cap 5000 unit 5 QL 60 / 30 days

d-5000 tab 5000 unit 5

d-vita liquid 400 unit/ml 5

d2000 ultra strength cap 2000 unit 5 QL 60 / 30 days

d3 adult chew tab 1000 unit 5

d3 high potency cap 1000 unit 5 QL 60 / 30 days

d3 maximum strength cap 5000 unit 5 QL 60 / 30 days

d3 maximum strength liquid 5000 unit/ml 5

d3 super strength cap 2000 unit 5 QL 60 / 30 days

d3-1000 cap 1000 unit 5 QL 60 / 30 days

d3-1000 tab 1000 unit 5

d3-50 cap 50000 unit 5 QL 60 / 30 days

delta d3 tab 400 unit 5

PAGE 315 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIALYVITE VITAMIN D3 MAX TAB 50000 UNIT cholecalciferol 5

eql folic acid tab 400 mcg 5 QL 30 / 30 days

eql vitamin d-3 tab 400 unit 5

eql vitamin d3 tab 1000 unit 5

ergocalciferol cap 50000 unit 1

fa-vitamin b-6-vitamin b-12 tab 2.2-25-0.5 mg 1

ferotrinsic cap 1 FERRAPLUS 90 TAB 90-1 MG iron-folic acid-vitamin b12-vitamin c-docusate sodium 1

ferrogels forte cap 460-60-0.01-1 mg 1 FOLIC ACID SOLUTION 5 MG/ML folic acid 1

folic acid tab 1 mg 5 QL 30 / 30 days

folic acid tab 400 mcg 5 QL 30 / 30 days

folic acid tab 800 mcg 5 QL 30 / 30 days

folplex 2.2 tab 2.2-25-0.5 mg 1 FOSAMAX PLUS D TAB 70-2800 MG-UNIT PA alendronate sodium-cholecalciferol 3 FOSAMAX PLUS D TAB 70-5600 MG-UNIT PA alendronate sodium-cholecalciferol 3

gnp b-12 sl tab 2500 mcg 5

gnp folic acid tab 400 mcg 5 QL 30 / 30 days

gnp vitamin d chew tab 400 unit 5

gnp vitamin d super strength tab 5000 unit 5

gnp vitamin d tab 1000 unit 5

gnp vitamin d3 extra strength tab 1000 unit 5 HECTOROL CAP 0.5 MCG PA doxercalciferol 3 HECTOROL CAP 1 MCG PA doxercalciferol 3 HECTOROL CAP 2.5 MCG PA doxercalciferol 3

hematinic/folic acid tab 324-1 mg 1

PAGE 316 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEMATOGEN FA CAP 200-250-0.01-1 MG fe fumarate-vitamin c-vitamin b12-folic acid 1

hematogen forte cap 460-60-0.01-1 mg 1

hemocyte-f tab 324-1 mg 1

hm folic acid tab 400 mcg 5 QL 30 / 30 days

hm vitamin d tab 1000 unit 5

hm vitamin d tab 400 unit 5

hm vitamin d3 cap 2000 unit 5 QL 60 / 30 days

HYDROXOCOBALAMIN SOLUTION 1000 MCG/ML hydroxocobalamin 1

iferex 150 forte cap 150-25-1 mg-mcg-mg 1

just d liquid 400 unit/ml 5

kp folic acid tab 800 mcg 5 QL 30 / 30 days

kp vitamin d cap 1000 unit 5 QL 60 / 30 days

kp vitamin d cap 2000 unit 5 QL 60 / 30 days

kp vitamin d chew tab 400 unit 5 LEUCOVORIN CALCIUM TAB 10 MG PA leucovorin calcium 4 LEUCOVORIN CALCIUM TAB 15 MG PA leucovorin calcium 4

leucovorin calcium tab 25 mg 4 PA

leucovorin calcium tab 5 mg 4 PA

maximum d3 cap 10000 unit 5 QL 60 / 30 days

mega-c/a plus solution 500 mg/ml 1 MEPHYTON TAB 5 MG PA phytonadione 2 MULTI PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5

multi-vit/fluoride solution 0.25 mg/ml 1

multi-vitamin/fluoride solution 0.25 mg/ml 1

nat-rul vitamin d tab 1000 unit 5

nat-rul vitamin d tab 5000 unit 5

PAGE 317 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NIACIN ER TAB ER 1000 MG niacin 1

niacin tab 500 mg 1 NIACOR TAB 500 MG niacin (antihyperlipidemic) 1

nufol tab 2.5-25-1 mg 1

one daily mens tab 1

one daily womens tab 1

pa vitamin d-3 cap 2000 unit 5 QL 60 / 30 days

pa vitamin d-3 cap 5000 unit 5 QL 60 / 30 days

pa vitamin d-3 tab 1000 unit 5 PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1

poly-iron 150 forte cap 150-25-1 mg-mcg-mg 1 POTABA CAP 500 MG potassium aminobenzoate 3 POTABA TAB 500 MG potassium aminobenzoate 3 PRENATAL 19 TAB prenatal vit w/ docusate-fe fumarate-folic acid 1 PRENATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1 PRENATAL LOW IRON TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 PRENATAL ONE DAILY TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5

pronutrients vitamin d3 cap 1000 unit 5 QL 60 / 30 days

px folic acid tab 400 mcg 5 QL 30 / 30 days

PYRIDOXINE HCL SOLUTION 100 MG/ML pyridoxine hcl 3

ra folic acid tab 400 mcg 5 QL 30 / 30 days

ra folic acid tab 800 mcg 5 QL 30 / 30 days

ra niacin tab 500 mg 1

PAGE 318 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ra no flush niacin tab 500 mg 1

ra vitamin d-3 cap 2000 unit 5 QL 60 / 30 days

ra vitamin d-3 cap 5000 unit 5 QL 60 / 30 days

ra vitamin d-3 tab 1000 unit 5 REPLESTA CHILDRENS WAFER 14000 UNIT cholecalciferol 5 REPLESTA NX WAFER 14000 UNIT cholecalciferol 5 REPLESTA WAFER 50000 UNIT cholecalciferol 5 RIGHT STEP PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid 5 RX SUPPORT HB/REFLUX/ALOE TAB folic acid-cyanocobalamin-vit b6-vit d-calcium-aloe 5 SE-NATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid 1

sm folic acid tab 400 mcg 5 QL 30 / 30 days

sm vitamin d tab 400 unit 5

sm vitamin d3 cap 2000 unit 5 QL 60 / 30 days

sm vitamin d3 tab 1000 unit 5

sodium ascorbate solution 250 mg/ml 1 TANDEM F CAP 162-115.2-1 MG ferrous fumarate-iron polysaccharide complex-folic acid 1 TARON-PREX CAP 30-1.2-265 MG prenatal w/o vit a w/ fe fumarate-dss-fa-dha 1

th folic acid tab 400 mcg 5 QL 30 / 30 days

th vitamin d3 cap 1000 unit 5 QL 60 / 30 days

th vitamin d3 cap 2000 unit 5 QL 60 / 30 days

thera-d 2000 tab 2000 unit 5 THERA-D 4000 TAB 4000 UNIT cholecalciferol 5

tl gard rx tab 2.2-25-1 mg 1

tri-vit/fluoride solution 0.25 mg/ml 1

tri-vit/fluoride solution 0.5 mg/ml 1

PAGE 319 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tri-vitamin/fluoride solution 0.25 mg/ml 1

tri-vitamin/fluoride solution 0.5 mg/ml 1

triple-vitamin/fluoride solution 0.25 mg/ml 1

vitamin d (cholecalciferol) chew tab 400 unit 5

vitamin d (cholecalciferol) tab 1000 unit 5

vitamin d (ergocalciferol) cap 50000 unit 1

vitamin d cap 1000 unit 5 QL 60 / 30 days

vitamin d cap 2000 unit 5 QL 60 / 30 days

vitamin d cap 400 unit 5 QL 60 / 30 days

vitamin d liquid 400 unit/ml 5

vitamin d tab 1000 unit 5

vitamin d tab 2000 unit 5

vitamin d tab 400 unit 5

vitamin d-1000 max st tab 1000 unit 5

vitamin d-3 cap 1000 unit 5 QL 60 / 30 days

vitamin d-3 tab 5000 unit 5

vitamin d-400 tab 400 unit 5

vitamin d3 adult gummies chew tab 1000 unit 5

vitamin d3 cap 1000 unit 5 QL 60 / 30 days

vitamin d3 cap 10000 unit 5 QL 60 / 30 days

vitamin d3 cap 2000 unit 5 QL 60 / 30 days

vitamin d3 cap 400 unit 5 QL 60 / 30 days

vitamin d3 cap 5000 unit 5 QL 60 / 30 days

vitamin d3 chew tab 1000 unit 5

vitamin d3 high potency cap 1000 unit 5 QL 60 / 30 days

vitamin d3 liquid 400 unit/ml 5

vitamin d3 liquid 5000 unit/ml 5

vitamin d3 maximum strength cap 5000 unit 5 QL 60 / 30 days

vitamin d3 tab 1000 unit 5

PAGE 320 LAST UPDATED 07/2015 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMIN D3 TAB 3000 UNIT cholecalciferol 5

vitamin d3 tab 400 unit 5

vitamin d3 tab 5000 unit 5

vitamins acd-fluoride solution 0.25 mg/ml 1 ZEMPLAR CAP 1 MCG PA paricalcitol 3 ZEMPLAR CAP 2 MCG PA paricalcitol 3 ZEMPLAR CAP 4 MCG PA paricalcitol 3

PAGE 321 LAST UPDATED 07/2015 Index of covered drugs Accu-Chek Voicemate 234 1 Accutrend Glucose 234 1st Choice Lancets Super Thin 232 Accutrend Glucose Control 234 1st Choice Lancets Thin 232 Acebutolol HCl 34,55,60,63 1st Choice Lancets Ultra Thin 232 Acetaminophen 82,106 1st Choice Pen Needles 232 Acetaminophen w/ Codeine 82,83 1st Tier Unifine Pentips 232 Acetaminophen-Salicylamide- 1st Tier Unifine Pentips Plus 232,233 Phenyltoloxamine 86,249,254 1st Tier Unilet ComforTouch 233 Acetazolamide 63,64,100,138,150 AcetaZOLAMIDE 63,100,138,150 A Acetic Acid 142 A-Hydrocort 174 Acetic Acid (Otic) 151 Abacavir Sulfate 22,28 Acetone (Urine) Test 243,270,292 Abacavir Sulfate-Lamivudine 23 Acetylcysteine 191,209,210 Abacavir Sulfate-Lamivudine-Zidovudine 27 Acetylcysteine (Antidote) 191 Abilify 120,121,127 Acetylcysteine (Nutrient) 143 Abilify Discmelt 120,127 Acitretin 228 Abilify Maintena 120,127 Aclidinium Bromide 30 Abiraterone Acetate 314 Actemra 192 AbobotulinumtoxinA 34,194 Acti-Lance 28G 234 Acarbose 162 Acti-Lance Lite Lancets 28G 234 Accu-Chek Active 233 Acti-Lance Special Lancets 17G 234 Accu-Chek Active Glucose Cont 233 Acti-Lance Universal 23G 234 Accu-Chek Aviva 233 Actimmune 192 Accu-Chek Aviva Plus 233 Actonel 192 Accu-Chek Comfort Curve 233 Acura Blood Glucose Meter 234 Accu-Chek Comfort Curve Linear 233 Acura Blood Glucose Starter 234 Accu-Chek Compact Blue Control 233 Acura Blood Glucose Test 234 Accu-Chek Compact Plus 233 Acura Control 235 Accu-Chek Compact Plus Control 233 Acura Plus Blood Glucose Sys 235 Accu-Chek Compact Test Drum 233 Acuvail 148 Accu-Chek FastClix Lancets 233 Acyclovir 22 Accu-Chek Instant Control 233 Acyclovir Topical 212,218 Accu-Chek Multiclix Lancets 233 Adalimumab 158,197 Accu-Chek Nano SmartView 234 Adapalene-Benzoyl Peroxide 214,222 Accu-Chek Safe-T Pro Lancets 234 Adcirca 78 Accu-Chek SmartView 234 Adefovir Dipivoxil 23 Accu-Chek SmartView Control 234 Adjustable Lancing Device 235 Accu-Chek Soft Touch Lancets 234 Adrenaclick 37,207 Accu-Chek Softclix Lancet Dev 234 Advair Diskus 37,174 Accu-Chek Softclix Lancets 234 Advair HFA 37,174 Advance Intuition Control 235 Alphagan P 150 Advance Intuition Monitor 235 Alprazolam 115,116 Advance Intuition Test 235 Alprostadil 78 Advocate Blood Glucose System 235 Alprostadil (Vasodilator) 78,79,80 Advocate Insulin Pen Needles 235 Altabax 212 Advocate Insulin Syringe 235 Alternate Site Lancing Device 237 Advocate Lancets 235 Aluminum Chloride 224 Advocate Lancing Device 235 Amantadine HCl 22,112 Advocate Redi-Code 236 Ambrisentan 210 Advocate Redi-Code+ Talking 236 Amcinonide 218 Advocate Safety Lancets 236 Amiloride & Hydrochlorothiazide 138 Advocate Test 236 Amiloride HCl 64,138 Afinitor 236 Aminobenzoate Potassium 314 Afluria 211 Aminocaproic Acid 40 Afluria Preservative Free 211 Aminophylline 231 AgaMatrix AMP Test 236 Amiodarone HCl 55,58 AgaMatrix Control 236 Amitiza 154 AgaMatrix Jazz 236 Amitriptyline HCl 127 AgaMatrix Jazz Test 236 Amlodipine Besylate 52,64,78 AgaMatrix KeyNote Test 236 Amlodipine Besylate-Benazepril HCl 52,73 AgaMatrix Presto 236 Amlodipine Besylate-Olmesartan Medoxomil 52,73,74 AgaMatrix Presto Test 236 Amlodipine Besylate-Valsartan 52,73 AgaMatrix Ultra-Thin Lancets 236 Amoxapine 127 Aggrenox 41,83 Amoxicillin 11,12,154,155 Albendazole 11 Amoxicillin & Pot Clavulanate 12 Albenza 11 Amphetamine-Dextroamphetamine 96 Albuterol Sulfate 37,38,39,40,207,208,209 Ampicillin 12 Alcaftadine 152,273 Ampyra 192 Alclometasone Dipropionate 218 Anagrelide HCl 41 Alendronate Sodium 192 Anakinra 197 Alendronate Sodium-Cholecalciferol 196,316 Analpram-HC 218 Alfuzosin HCl 34 Anastrozole 237 Alinia 19,20 Androderm 174 Aliskiren Fumarate 77 AndroGel 175 Aliskiren-Hydrochlorothiazide 77,141 AndroGel Pump 175 Allegra Allergy Childrens 205,236 Androxy 175 Allopurinol 192 Anthralin 222 Almotriptan Malate 107 Anti-Stick Insulin Syringe 237 Alocril 151,203 Antipyrine-Benzocaine 148,151 Alomide 151,236 Anzemet 153 Alpha-Lipoic Acid (Thioctic Acid) 192 Apidra 162 Apidra SoloStar 162 Assure Lance Lancets 238 Apraclonidine HCl 151,152 Assure Lancets 238 Apriso 155 Assure Platinum 238 Aptivus 22 Assure Prism Control Level 1&2 238 Aqua Lance Adjustable Lancing 237 Assure Prism multi Test 238 Aranesp (Albumin Free) 46 Assure Pro Control Level 1 & 2 238 Arcalyst 192 Assure Pro Test 238 Arcapta Neohaler 38,208 Astepro 151,205 Arformoterol Tartrate 38 Atazanavir Sulfate 26 Aripiprazole 120,121,127 Atelvia 192 Armodafinil 100 Atenolol 34,55,56,60,64 Artificial Tear Insert 152 Atenolol & Chlorthalidone 60,138 Artificial Tear Solution 151 Atomoxetine HCl 125,126 Asacol HD 155 Atorvastatin Calcium 49 Ascensia Autodisc Control 237 Atovaquone 20 Ascensia Autodisc Controls 237 Atovaquone-Proguanil HCl 20 Ascorbic Acid 314,317 Atralin 218 Asenapine Maleate 125,136 Atripla 22 Asmanex 120 Metered Doses 175 Atropine Sulfate 151 Asmanex 14 Metered Doses 175 Atropine Sulfate (Ophthalmic) 151,152 Asmanex 30 Metered Doses 175 Atrovent HFA 28,208 Asmanex 60 Metered Doses 175 Augmentin 12 Asmanex 7 Metered Doses 175 Auranofin 201,294 Aspirin 41,42,43,44,45,83,84,85,86,87,88,94,95,106,10 Aurora Lancet Super Thin 30G 238 7,108,109,110,111,112 Aurora Lancet Thin 23G 238 Aspirin-Dipyridamole 41,83 Aurora Pen Needles 238 Assure 3 Control 237 Aurora Unifine Pentips 238 Assure 3 Test 237 Auto-Lancet 238 Assure 4 Control Level 1 & 2 237 Auto-Lancet Mini 238 Assure 4 Test 237 Autolet Impression 238 Assure Comfort Lancets 28G 237 Autolet Lancing Device 239 Assure Comfort Lancets 30G 237 Autolet Mini 239 Assure Dose Control 237 Auvi-Q 38,208 Assure Dose Norm/High Control 237 Avandia 162 Assure Haemolance Plus High 237 Avelox 12,18 Assure Haemolance Plus Low 237 Avelox ABC Pack 12,18 Assure Haemolance Plus Micro 237 Avidoxy DK 12,219 Assure Haemolance Plus Normal 237 Avodart 192 Assure Haemolance Plus Ped 237 Avonex 192 Assure ID Insulin Safety Syr 238 Avonex Pen 192 Assure II Check 238 Avonex Prefilled 192 Avoria Cal+D 142,314 Bayer Contour USB 239 Avoria GC+ 142,193,314 Bayer Microlet 2 Lancing Devic 239 Axert 107 Bayer Microlet Lancets 239 Axiron 175 BD AutoShield 239 Axitinib 269 BD Insulin Syr Ultrafine II 239 Azasan 193 BD Insulin Syringe 240 AzaSite 146 BD Insulin Syringe Half-Unit 240 Azathioprine 193 BD Insulin Syringe MicroFine 240 Azelastine HCl 151,152,205 BD Insulin Syringe Ultrafine 240 Azelastine HCl (Ophth) 152,205 BD Integra Insulin Syringe 240 Azilect 112,128 BD Lancet Device 240 Azilsartan Medoxomil 66,67,75 BD Lancet Ultrafine 30G 240 Azithromycin 12,13,17 BD Lancet Ultrafine 33G 241 Azithromycin (Ophth) 146 BD Microtainer Lancets 241 Azor 52,73,74 BD Pen Needle Mini U/F 241 BD Pen Needle Nano U/F 241 B BD Pen Needle Short U/F 241 B-6 Folic Acid 314 BD Pen Needle Ultrafine 241 B-natal 314 BD Safety-Lok Insulin Syringe 241 Bacitracin 146 BD SafetyGlide Insulin Syringe 241 Bacitracin (Ophthalmic) 146 Beclomethasone Diprop Monohyd 148,203 Bacitracin-Poly-Neomycin-HC 146,148,149 Beclomethasone Dipropionate 185,204 Bacitracin-Polymyxin B (Ophth) 146,147 Beclomethasone Dipropionate (Nasal) 150,204 Bacitracin-Polymyxin-Neomycin HC 214,221 Beconase AQ 148,203 Baclofen 33 Belladonna Alkaloids & Opium 28,84 Bactroban Nasal 213 Belladonna Alkaloids-Opium 28,84 Balsalazide Disodium 155 Belladonna-Opium 28,84 Banzel 100 Benazepril & Hydrochlorothiazide 74,138 Baraclude 22 Benazepril HCl 64,74 Bayer Breeze 2 Control 239 Benicar 64,74 Bayer Breeze 2 System 239 Benicar HCT 74,138 Bayer Contour 239 Benzonatate 210 Bayer Contour Link Monitor 239 Benzoyl Peroxide 213,215,216 Bayer Contour Monitor 239 Benzoyl Peroxide-Erythromycin 213 Bayer Contour Next Control 239 Benztropine Mesylate 29,113 Bayer Contour Next EZ 239 Benzyl Alcohol 219 Bayer Contour next Link 239 Bepotastine Besilate 152 Bayer Contour Next Monitor 239 Bepreve 152 Bayer Contour Next Test 239 Berinert 193 Bayer Contour Next USB Monitor 239 Besifloxacin HCl 146 Bayer Contour Test 239 Besivance 146 Betaine 193 Brimonidine Tartrate 150 Betamethasone Dipropionate (Topical) 219 Brimonidine Tartrate-Timolol Maleate 150 Betamethasone Dipropionate Augmented 219 Bromfenac Sodium (Ophth) 148 Betamethasone Sod Phosphate & Acetate 175 Bromocriptine Mesylate 113 Betamethasone Valerate 219 Bromocriptine Mesylate (Diabetes) 162 Betaseron 193 Brompheniramine & Phenyleph 38,255 Betaxolol HCl 34,56,60,61,64 Brovana 38 Betaxolol HCl (Ophth) 150 Budesonide 175 Bethanechol Chloride 31 Budesonide (Inhalation) 175,176,185,203,204 Betoptic-S 150 Budesonide (Nasal) 150,204 Bexarotene 301 Budesonide-Formoterol Fumarate BG Star Test 241 Dihydrate 40,185,186 Bicalutamide 241 Bullseye Mini Safety Lancets 241 Bicillin L-A 13 Bullseye Safety Lancets 241 Bimatoprost 151 Bumetanide 64,139 BioGaia 155 Buprenorphine 85 BioGaia Probiotic 155 Buprenorphine HCl 84 BioGaia ProTectis/Vitamin D 155,314 Buprenorphine HCl-Naloxone HCl Bisoprolol & Hydrochlorothiazide 61,138 Dihydrate 84,94,95,121,126 Bisoprolol Fumarate 34,56,61,64 Bupropion HCl 128 Blephamide S.O.P. 146,148 Bupropion HCl (Smoking Deterrent) 128 Blood Glucose Buspirone HCl 116 Calibration 233,234,235,236,237,238,239,243,246,248, Busulfan 281 249,250,251,253,254,255,256,258,259,260,261,263,26 Butalbital-Acetaminophen 84,89,116,118 4,265,269,274,277,279,281,282,283,284,286,290,291, Butalbital-Acetaminophen- 294,297,301,302,305,306,310,312,314 Caffeine 85,89,96,97,98,116,118 Blood Glucose Monitor System 241 Butalbital-Acetaminophen-Caffeine w/ Blood Glucose Monitoring Codeine 85,96,116 Supplies233,234,235,236,239,241,242,244,246,247,24 Butalbital-Aspirin-Caffeine 85,97,116 8,250,251,253,254,255,256,258,259,260,261,263,264, Butalbital-Aspirin-Caffeine w/Cod 83,85,96,97,116 265,269,271,272,276,277,278,279,281,282,283,284,28 Butenafine HCl 215 5,286,288,290,291,292,293,294,297,300,302,303,305, Butoconazole Nitrate (One Dose) 215 306,309,313 Butorphanol Tartrate 85,107 Blood Glucose System Pak 241 Butrans 85 Blood Glucose Test 241 Bydureon 162 Boceprevir 28 Byetta 10 MCG Pen 162 Bosulif 241 Byetta 5 MCG Pen 162 Bosutinib 241 Bystolic 34,35,61 BP FoliNatal Plus B 142,314 BPO Creamy Wash 213 C Brilinta 42 C1 Esterase Inhibitor (Human) 193 Cabergoline 113 CareSens N Glucose Test 243 Cabozantinib S-Malate 245 Carfilzomib 272 Cafergot 35,97,107 Carteolol HCl (Ophth) 150 Caffeine & Sodium Benzoate 97,107 Carvedilol 35,56,61,65 Caffeine Citrate 97,107 Carvedilol Phosphate 35,56,61,65 Caffeine-Sodium Benzoate 97,107 Caverject 78 Calcipotriene 219 Caverject Impulse 78 Calcipotriene-Betamethasone Dipropionate 228 Cefaclor 13 Calcitonin (Salmon) 176,182,193,198 Cefaclor ER 13 Calcitriol 219,314 Cefaclor Monohydrate 13 Calcitriol (Topical) 219 Cefadroxil 13 Calcium Acetate (Phosphate Binder) 142,144,145 Cefdinir 13 Calcium-Magnesium-Vitamin C-Vitamin D 142,314 Cefixime 17 Canasa 155 Cefpodoxime Proxetil 13 Candesartan Cilexetil-Hydrochlorothiazide 74,139 Cefprozil 13,14 Capecitabine 313 Ceftriaxone Sodium 14 Capex 219 Cefuroxime Axetil 14 Caprelsa 241 Celecoxib 85 Capsaicin 219,220,221,223,226,227,229 CellCept 193 Captopril 64,74 Celontin 101 Captopril & Hydrochlorothiazide 74,75,139 CEM-Urea 220 Captopril-Hydrochlorothiazide 74,75,139 Cephalexin 14,16 Carafate 155 Ceprotin 42 Carbachol (Ophth) 150 Cesamet 153 Carbamazepine 100,101,102,105,121,122,126 Cetirizine HCl 205,206,243,271 Carbidopa 113 Chantix 31 Carbidopa-Levodopa 113 Chantix Continuing Month Pak 31 Carbinoxamine Maleate 205,237,242 Chantix Starting Month Pak 31 CardioCom Lancing Device 242 Chek-Stix Control 243 Cardura XL 35,61,65 Chemet 193,243 CareFine Pen Needles 242 Chemstrip K 243 CareOne Advanced Lancing Dev 242 Cherry 243 CareOne Blood Glucose System 242 Cherry Concentrate 243 CareOne Blood Glucose Test 242 Cherry Syrup 243 CareOne Insulin Syringe 242 Chlorambucil 274 CareOne Lancet Thin 23G 242 Chlordiazepoxide HCl 116 CareOne Lancet Ultra Thin 28G 242 Chlordiazepoxide HCl-Clidinium Bromide 29,116 CareOne UltiGuard Insulin Syr 242 Chlordiazepoxide-Amitriptyline 116,128 CareOne Unifine Pentips 242,243 Chlorhexidine Gluconate 213 CareOne Unifine Pentips Plus 243 Chlorhexidine Gluconate (Mouth- CareSens Control A 243 Throat) 146,147,213,216 Chloroquine Phosphate 20 Clever Choice Auto-Code Test 244 Chlorothiazide 65,139 Clever Choice Micro System 244 Chlorpheniramine & Phenylephrine 40,293 Clever Choice Micro Test 244 Chlorpromazine HCl 128 Clickfine Pen Needles 244,245 Chlorpropamide 162 Clindamycin HCl 15 ChlorproPAMIDE 162 Clindamycin Palmitate Hydrochloride 15 Chlorthalidone 65,139 Clindamycin Phosphate (Topical) 213,214 Chlorzoxazone 33,34 Clindamycin Phosphate Vaginal 213 Cholecalciferol 314,315,316,317,318,319,320,321 Clindamycin Phosphate-Benzoyl Peroxide 213 Cholestyramine Light 49,51 Clindamycin Phosphate-Tretinoin 217,230 Choline & Mag Salicylate 85 Clobetasol Propionate 220,221 Choline Fenofibrate 51 Clobetasol Propionate Emulsion 220 Chorionic Gonadotropin 176 Clocortolone Pivalate 220 Cialis 78 Cloderm 220 Cilostazol 42,79 Cloderm Pump 220 Ciloxan 146 Clomipramine HCl 128 Cimetidine 154,155,156,157,160,161,234,244,247,255, Clonazepam 101,116,117 265,268,289,290,296,302 Clonidine HCl 38,65 Cimetidine HCl 155,244 Clopidogrel Bisulfate 42 Cinacalcet HCl 201 Clorazepate Dipotassium 101,117 Cipro 14,18 Closercare 245 Cipro HC 146,148 Clotrimazole 214 Ciprodex 146,148 Clotrimazole (Topical) 214,215,216,217 Ciprofloxacin 14,18 Clotrimazole Vaginal 214,216,217 Ciprofloxacin HCl 14,18,19,146 Clotrimazole w/ Betamethasone 214,220 Ciprofloxacin HCl (Ophth) 146 Clozapine 128,129 Ciprofloxacin HCl (Otic) 146 CloZAPine 129 Ciprofloxacin-Ciprofloxacin HCl 14,19 CoaguChek Lancets 245 Ciprofloxacin-Dexamethasone 146,148 Coal Tar 220 Ciprofloxacin-Hydrocortisone 146,148 Coal Tar (Crude) 220 Citalopram Hydrobromide 128 Coal Tar Extract 220 Clarithromycin 14,19,156 Cobalamine Combinations 314 Claritin Reditabs 205,244 Codeine Sulfate 85,210 Cleanlet Lancets 28G 244 Coenzyme Q10 193 Clemastine Fumarate 205,244 Coenzyme Q10 (Ubidecarenone) 193 Cleocin 213 Colchicine 193 Clever Chek Auto-Code Test 244 Colchicine w/ Probenecid 142,193 Clever Chek Auto-Code Voice 244 Colesevelam HCl 52,166 Clever Chek Lancets 244 Colestipol HCl 49,50,51 Clever Chek System 244 Collagenase 227,295 Clever Chek Test 244 Coly-Mycin S 146,148 Colyte with Flavor Packs 156 CVS Blood Glucose Meter 247 Combigan 150 CVS Insulin Syringe 247 CombiPatch 167,176 CVS Lancets 21G 247 Combivent Respimat 29,38,208 CVS Lancets Micro Thin 33G 247 Cometriq (100 mg Daily Dose) 245 CVS Lancets Original 247 Cometriq (140 mg Daily Dose) 245 CVS Lancets Thin 247 Cometriq (60 mg Daily Dose) 245 CVS Lancets Thin 26G 247 Comfort Assist Insulin Syringe 245 CVS Lancets Ultra Thin 30G 247 Comfort Assured Lancets 28G 245 CVS Lancing Device 247 Comfort Assured Lancets 33G 245 CVS Ultra Thin Lancets 247 Comfort EZ Insulin Syringe 245,246 Cyanocobalamin 47,315,316 Comfort EZ Pen Needles 246 Cyclobenzaprine HCl 34 Comfort Lancets 246 Cyclopentolate HCl 152 Complera 22 Cycloset 162 Condylox 220 Cyclosporine 193,201 Conjugated Estrogens-Medroxyprogesterone CycloSPORINE Modified 193 Acetate 173,185 Cyclosporine Modified (For Microemulsion) 193,196 Control 246 Cymbalta 121,129 Control AST 246 Cyproheptadine HCl 205,247 Control Blood Glucose System 246 Cystadane 193 Control Test 246 Cystaran 152 Copaxone 193 Cysteamine HCl 152 Cordran 220,221 Cytra-3 143 Coreg CR 35,56,61,65 CortAlo 221 D Cortifoam 221 Dabigatran Etexilate Mesylate 45 Cortisone Acetate 176 Dalfampridine 192 Cortisporin 214,221 Dalteparin Sodium 43,44 Cortisporin-TC 146,148 Dapsone 19,20 Cottonseed Oil 221 Daraprim 20 Cottonseed Oil (Bulk) 221 Darbepoetin Alfa-Polysorbate 80 46 Cranberry (Vaccinium macrocarpon) 193 Darifenacin Hydrobromide 231 Creon 156,246 Darunavir Ethanolate 25 Crestor 50 Dasatinib 298 Crinone 176 Daytrana 97 Crixivan 22 Deferiprone 258 Crizotinib 313 Deferoxamine Mesylate 194,247 Cromolyn Sodium (Mastocytosis) 152,203 Degarelix Acetate 259 Cromolyn Sodium (Ophth) 152,203 Delavirdine Mesylate 25,26 Crotamiton 214 Delzicol 156 CVS Advanced Glucose Test 246 Demeclocycline HCl 15 Denavir 214 Diazepam 101,117 Denosumab 200 Dibenzyline 35,65 Depen Titratabs 194,247 Diclofenac Potassium 86 Depo-Medrol 177 Diclofenac Sodium 86 Depo-Provera 177 Diclofenac Sodium (Ophth) 148 Depo-SubQ Provera 104 177 Diclofenac Sodium (Topical) 230 Desipramine HCl 129 Diclofenac w/ Misoprostol 86,156 Desmopressin Acetate 40,177,185 Dicloxacillin Sodium 15 Desmopressin Acetate Refrigerated 40,177 Dicyclomine HCl 29 Desmopressin Acetate Spray 40,177 Didanosine 22,28 Desmopressin Acetate Spray Refrigerated 40,177 Didget 248 Desogestrel & Ethinyl Diethylpropion HCl 97,98 Estradiol 167,168,173,175,178,185 Dificid 15 Desogestrel-Ethinyl Estradiol Diflorasone Diacetate 222 (Triphasic) 167,174,176,186 Diflunisal 86 Desonide 221,225 Difluprednate 148 Desoximetasone 222 Digoxin 56,57 Desvenlafaxine 129 Dihydroergotamine Mesylate 35,108 Desvenlafaxine ER 129 Dilantin 56,101 Desvenlafaxine Fumarate 129 Dilatrate-SR 79 Desvenlafaxine Fumarate ER 129 Diltiazem HCl 53,56,57,66,79 Desvenlafaxine Succinate 135 Diltiazem HCl Coated Beads 53,56,57,65,66,78,79 Detrol LA 231 Diltiazem HCl Extended Release Dexamethasone 175,177,178 Beads 53,55,57,59,60,66,71,79,82 Dexamethasone Intensol 177 Dimenhydrinate 153,248 Dexamethasone Sod Phosphate PF 177 DimenhyDRINATE 153,248 Dexamethasone Sodium Phosphate 177 Dipentum 156 Dexamethasone Sodium Phosphate (Ophth) 148 Diphenhydramine Dexchlorpheniramine Maleate 247 HCl28,29,30,112,113,114,115,116,117,118,120,205,20 Dexchlorpheniramine-Phenylephrine 39,293 6,207,210,211,237,248,255,277,290,296 Dexmethylphenidate HCl 97,98 Diphenhydramine-Zinc Acetate 230 DexPak 10 Day 178 Diphenoxylate w/ Atropine 29,30,156,158 DexPak 13 Day 178 Diphenoxylate-Atropine 29,156 DexPak 6 Day 178 Dipyridamole 42,79 Dextroamphetamine Sulfate 97 Disopyramide Phosphate 57,58 Dextromethorphan HBr-Quinidine Sulfate 123 Disulfiram 194 Dialyvite Vitamin D3 Max 316 Divalproex Sodium 101,102,108,121,122 Diastar Easy Test II Lancets 247 Dolasetron Mesylate 153 Diastar Easy Test Lancets 247 Donepezil Hydrochloride 31 DiaTrue Control Level 2 248 Dornase Alfa 211,289 DiaTrue Plus Test 248 Dorzolamide HCl 150 Dorzolamide HCl-Timolol Maleate 150 E-Z Ject Lancet Super Thin 30G 249 Doxapram HCl 98 E-Z Ject Lancets 249 Doxazosin Mesylate 35,61,66 E-Z Ject Lancets 21G 249 Doxazosin Mesylate (BPH) 35,61,65 E-Z Ject Lancets Thin 26G 249 Doxepin HCl 129,130 E.E.S. 400 15 Doxepin HCl (Antipruritic) 226 EasiVent 250 Doxercalciferol 316 EasiVent Mask Large 249 Doxycycline (Monohydrate) 12,15,20 EasiVent Mask Medium 249 Doxycycline Hyclate 15,16,20,21 EasiVent Mask Small 250 Doxycycline w/ Suncreen & Salicylic Acid 12,219 Easy Comfort Insulin Syringe 250 Dritho-Creme HP 222 Easy Comfort Lancets 250 Dronabinol 153 Easy Comfort Pen Needles 250 Dronedarone HCl 58 Easy Mini Lancing Device 250 Droperidol 117 Easy Plus Blood Glucose System 250 Droplet Lancets Ultra Thin 30G 248 Easy Plus Blood Glucose Test 250 Droplet Lancing Device 248 Easy Plus II Glucose Test 250 Droxia 248 Easy Step Control 250 Drug Mart Lancets Thin 26G 248 Easy Step Glucose Monitor 250 Drug Mart Lancing Device 248 Easy Step Test 250 Drug Mart On-The-Go Lancet 30G 248 Easy Talk Blood Glucose System 251 Drug Mart Ultra Comfort Syr 248 Easy Talk Blood Glucose Test 251 Drug Mart Unifine Pentips 248,249 Easy Talk Control 251 Drug Mart Unifine Pentips Plus 249 Easy Touch Control High & Low 251 Drug Mart Unilet Lancets 28G 249 Easy Touch Glucose System 251 Drug Mart Unilet Lancets 30G 249 Easy Touch HealthPro Control 251 Duane Reade Lancet Altern Site 249 Easy Touch HealthPro System 251 Duane Reade Lancet Super Thin 249 Easy Touch HealthPro Test 251 Duane Reade Lancet Ultra Thin 249 Easy Touch Insulin Safety Syr 251 Duane Reade Unifine Pentips 249 Easy Touch Insulin Syringe 251,252 Dulera 38,178 Easy Touch Lancets 21G 252 Duloxetine HCl 121,122,129,130 Easy Touch Lancets 23G 252 Duo-Care Control Solution 249 Easy Touch Lancets 26G 252 Duo-Care Test 249 Easy Touch Lancets 28G 252 Durezol 148 Easy Touch Lancets 28G/Twist 252 Dutasteride 192 Easy Touch Lancets 30G 252 Dyphylline-Guaifenesin 210,231 Easy Touch Lancets 30G/Twist 252 Dyrenium 66,139 Easy Touch Lancets 32G 252 Dysport 34,194 Easy Touch Lancets 32G/Twist 252 Easy Touch Lancets 33G/Twist 252 E Easy Touch Lancing Device 252 E-Z Ject Lancet Micro-Thin 33G 249 Easy Touch Pen Needles 252,253 Easy Touch Safety Lancets 21G 253 Element Test 254 Easy Touch Safety Lancets 23G 253 Eletriptan Hydrobromide 110 Easy Touch Safety Lancets 26G 253 Elidel 194,222 Easy Touch Safety Lancets 28G 253 Eligard 178,254 Easy Touch Test 253 Elixophyllin 67,98,139,208,232 Easy Trak Blood Glucose System 253 Ella 178 Easy Trak Blood Glucose Test 253 Elmiron 194 Easy Trak Control 253 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir 27,201 Easy Twist & Cap Lancets 253 Embrace Blood Glucose Test 254 EasyGluco 253 Embrace Evo Blood Glucose Test 255 EasyGluco Control 253 Embrace Evo Control Level 2 255 EasyMax 15 Level 1 Control 253 Embrace Evo Glucose Monitoring 255 EasyMax 15 Level 2 Control 253 Embrace Lancets Ultra Thin 30G 255 EasyMax 15 Test 253 Embrace Pro Glucose Control 255 EasyMax Control 253 Embrace Pro Glucose Test 255 EasyMax L Blood Glucose 253 Emcyt 255 EasyMax N Blood Glucose 253 Emsam 113,130 EasyMax NG Blood Glucose 253 Emtricitabine 22 EasyMax Test 254 Emtricitabine-Rilpivirine-Tenofovir Disoproxil EasyMax V Blood Glucose 254 Fumarate 22 EasyMax V2 Blood Glucose 254 Emtricitabine-Tenofovir Disoproxil Fumarate 27 EasyPlus Blood Glucose Test 254 Emtriva 22 EasyPlus R13N Blood Glucose 254 Enablex 231 EasyPlus V Blood Glucose 254 Enalapril Maleate 67,75 EasyPRO Plus 254 Enalapril Maleate & Hydrochlorothiazide 75,139 Ecallantide 197 Enbrel 194 Echothiophate Iodide 151 Endometrin 178 Econazole Nitrate 214 Enjuvia 168,194 Edarbi 66,67,75 Enoxaparin Sodium 43 Edecrin 67,139 Entacapone 113 Edex 79,80 Entecavir 22 Edurant 22 Epiduo 214,222 Efavirenz 27 Epinastine HCl (Ophth) 152 Efavirenz-Emtricitabine-Tenofovir Disoproxil Epinephrine 37,38,39,207,208 Fumarate 22 EPINEPHrine 38,208 Effer-K 143 Epinephrine HCl 38,208 Element Autocode System 254 EpiPen 2-Pak 38,208 Element Compact Control 2 254 EpiPen Jr 2-Pak 39,208 Element Compact Control 3 254 Epivir 23 Element Compact Test 254 Epivir HBV 23 Element Control 254 Eplerenone 67,75,139 Epoetin Alfa 47,49 Estropipate 169,195 Epogen 47 Eszopiclone 118 Eprosartan Mesylate 67,75 Etanercept 194 Epzicom 23 Ethacrynic Acid 67,139 EQL Color Lancets 21G 255 Ethambutol HCl 19 EQL Color Lancets Micro 33G 255 Ethosuximide 102 EQL Insulin Syringe 255,256 Ethotoin 104 EQL Short Pen Needle 256 Ethyl Chloride 222 EQL Super Thin Lancets 30G 256 Ethynodiol Diacet & Eth Estrad 170,174,180,186 EQL Thin Lancets 26G 256 Etidronate Disodium 195 EQL TRUE2go Blood Glucose 256 Etodolac 87 EQL TRUEtest Test 256 Etonogestrel-Ethinyl Estradiol 172,184 EQL Ultra Short Pen Needle 256 Etravirine 23 Ergocalciferol 316,320 Eurax 214 Ergoloid Mesylates 35 Evamist 169,196 Ergotamine w/ Caffeine 35,97,107 EvenCare + Blood Glucose Test 256 Erlotinib HCl 301 EvenCare Blood Glucose Test 256 Ertaczo 214 EvenCare Control Low/High 256 Ery-Tab 15 EvenCare G2 Low/High Control 256 Erythrocin Stearate 15 EvenCare G2 Test 256 Erythromycin (Acne Aid) 214 EvenCare G3 Low/High Control 256 Erythromycin (Ophth) 146,147 EvenCare G3 Test 256 Erythromycin Base 15,16 Everolimus 236 Erythromycin Ethylsuccinate 15,16 Everolimus (Immunosuppressant) 203 Erythromycin Stearate 15 Evista 169,196 Escitalopram Oxalate 130 Evolution Autocode 256 Esomeprazole Magnesium 159 Evolution Control 256 Estazolam 117 ExacTech R-S-G Test 256 Esterified Estrogens 171,198 ExacTech Test 257 Esterified Estrogens & Methyltestosterone 167,176 Excel Comfort Point Pen Needle 257 Estrace 168,194 Exel Comfort Point Insulin Syr 257 Estradiol 168,169,194,195,196 Exelon 32 Estradiol & Norethindrone Exemestane 257 Acetate 167,169,171,176,179,182 Exenatide 162 Estradiol Vaginal 168,169,174,194,195,203 Extavia 196 Estradiol Valerate 169,195 Ez Smart Blood Glucose Lancets 257 Estramustine Phosphate Sodium 255 Ez Smart Blood Glucose Test 257 Estring 169,195 Ez Smart Plus Glucose Test 257 Estrogel 169,195 EZ-Lets Lancets 21G 257 Estrogens, Conjugated 172,200 EZ-Lets Lancets 23G 257 Estrogens, Conjugated Synthetic B 168,194 EZ-Lets Lancets 26G 258 EZ-Lets Lancets 28G 258 Finasteride 196 EZ-Lets Lancets 30G 258 Finasteride (Alopecia) 196,222 Ezetimibe 52 Fine 30 259 Ezetimibe-Simvastatin 51,52 Fingerstix Lancets 259 Ezogabine 105 Fingolimod HCl 196 Firazyr 196 F Firmagon 259 Factive 16 First-Lansoprazole 157 Famciclovir 23 Flagyl ER 20,157 Famotidine154,156,157,158,160,161,234,246,255,258, Flarex 148 265,268,271,289,290,295,296 Flavoxate HCl 231 Fanapt 130 Flecainide Acetate 57 Fareston 170,258 Flovent Diskus 179,204 Faslodex 258 Fluarix 212 Fe Fumarate-Vitamin C-Vitamin B12-Folic Fluarix Quadrivalent 212 Acid 47,316,317 Flucelvax 212 Felbamate 102 Fluconazole 18 Felodipine 53,67 Fludrocortisone Acetate 179 Fenofibrate 50,51 Flulaval 212 Fenofibrate Micronized 50 Flulaval Quadrivalent 212 Fenofibric Acid 50 Flunisolide 149,179,204 Fentanyl 87 Flunisolide (Nasal) 149,179,204 FerraPlus 90 47,157,316 Fluocinolone Acetonide 219,222,228 Ferriprox 258 Fluocinolone Acetonide (Otic) 149 Ferrous Fumarate w/ B12-Vit C-FA-IFC 47,316 Fluocinonide 223 Ferrous Fumarate-Folic Acid 47,48,316,317 Fluorescein w/ Proparacaine 259 Ferrous Fumarate-Iron Polysaccharide Complex-Folic Fluorometholone (Ophth) 149 Acid 49,319 Fluorometholone Acetate 148 Ferrous Gluconate 47,48 Fluorouracil (Topical) 223 Ferrous Sulfate 47,48,49 Fluoxetine HCl 130,131 Fesoterodine Fumarate 231 Fluoxetine HCl (PMDD) 130 Fexofenadine HCl 205,206,207,236,258,268,271,296 Fluoxymesterone 175 Fidaxomicin 15 Fluphenazine Decanoate 131 Fifty50 Control 2.0 258 Fluphenazine HCl 131 Fifty50 Glucose Meter 2.0 258 FluPHENAZine HCl 131 Fifty50 Glucose Test 2.0 258 Flurandrenolide 220,221 Fifty50 Lancing Device 258 Flurazepam HCl 117 Fifty50 Pen Needles 258 Flurbiprofen 87 Fifty50 Safety Seal Lancets 258 Flurbiprofen Sodium 149 Fifty50 Superior Comfort Syr 258 Flutamide 259 Filgrastim 48 Fluticasone Furoate 150,186,204 Fluticasone Propionate 223 Forteo 179 Fluticasone Propionate (Inhalation) 179,204 FortisCare Control 260 Fluticasone Propionate (Nasal) 149,179,204 FortisCare Glucose System 260 Fluticasone-Salmeterol 37,174 Fosamax Plus D 196,316 Fluvastatin Sodium 50 Fosamprenavir Calcium 24 Fluvirin 212 Fosfomycin Tromethamine 11 Fluvirin Preservative Free 212 Fosinopril Sodium 67,75 Fluvoxamine Maleate 131 Fosinopril Sodium & Hydrochlorothiazide 75,139 Fluzone 212 Fosrenol 145,196 Fluzone Preservative Free 212 Fragmin 43,44 Fluzone Quadrivalent 212 Freds Pharmacy Autolet Lancing 260 FML 149 Freds Pharmacy Unifine Pentip+ 260 Focalin XR 98 Freds Pharmacy Unifine Pentips 260 Folic Acid 314,316,317,318,319 Freds Pharmacy Unilet Lanc 28G 260 Folic Acid-Cyanocobalamin-Vit B6-Vit D-Calcium- Freds Pharmacy Unilet Lanc 30G 260 Aloe 144,201,319 FreeStyle Control Solution 260 Folic Acid-Vitamin B6-Vitamin B12 316,318,319 FreeStyle Freedom 260 Fomepizole 196 FreeStyle Freedom Lite 260 Fondaparinux Sodium 43 FreeStyle InsuLinx System 260 FORA Control 259 FreeStyle InsuLinx Test 260 FORA D10 Blood Glucose Test 259 FreeStyle Lancets 260 FORA D15g Blood Glucose Test 259 FreeStyle Lite Test 261 FORA D20 Blood Glucose Test 259 FreeStyle Precision Ins Syr 261 FORA G20 Blood Glucose System 259 FreeStyle Sidekick II 261 FORA G20 Blood Glucose Test 259 FreeStyle Test 261 FORA G30a Blood Glucose Test 259 FreeStyle Unistick II Lancets 261 Fora GD20 Test 259 Frova 108 FORA GD50 Blood Glucose Test 259 Frovatriptan Succinate 108 FORA Lancets 259 Fulvestrant 258 FORA Lancing Device 259 Furosemide 67,140 FORA V10 Blood Glucose Test 259 FORA V12 Blood Glucose Test 259 G FORA V20 Blood Glucose Test 259 Gabapentin 87,102 FORA V30a Blood Glucose System 260 Gabitril 102 FORA V30a Blood Glucose Test 260 Galantamine Hydrobromide 32 ForaCare GD40 Test 260 Ganciclovir Ophthalmic 148 ForaCare GDH Control 260 Ganirelix Acetate 196 ForaCare premium V10 Test 260 Gatifloxacin (Ophth) 148 ForaCare Test N Go Test 260 GE100 Blood Glucose System 261 Foradil Aerolizer 39,208 GE100 Blood Glucose Test 261 Formoterol Fumarate 39,208,209 GE100 Control 261 Gelnique 231 Glucocard X-Meter 263 Gemfibrozil 50 Glucocard X-Sensor 263 Gemifloxacin Mesylate 16 Glucocard X-Sensor Control 263 Genotropin 179,188 GlucoCom Control 263 Genotropin MiniQuick 179,187,188 GlucoCom Lancets 28G 263 Gentamicin Sulfate 215 GlucoCom Lancets 30G 263 Gentamicin Sulfate (Ophth) 146 GlucoCom Lancets 33G 264 Gentamicin Sulfate (Topical) 215 GlucoCom Monitor 264 GHT Blood Glucose Monitor 261 GlucoCom Test 264 GHT Test 261 Glucolet 2 Automatic Lancing 264 Gilenya 196 GlucoNavii Blood Glucose Sys 264 Glatiramer Acetate 193 GlucoNavii Blood Glucose Test 264 Gleevec 261 GlucoPro Insulin Syringe 264 Glimepiride 162,163 Glucosamine HCl 197 Glipizide 163 Glucosamine Hydrochloride 197 Glipizide-Metformin HCl 163 Glucosamine-Chondroitin-Calcium-Magnesium-Vit C- Global Ease Inject Pen Needles 261 Vit D 142,193,314 Global Inject Ease Insulin Syr 261,262 Glucose Global Inject Ease Lancets 28G 262 Blood 233,234,235,236,237,238,239,241,242,243,244, Global Inject Ease Lancets 30G 262 246,248,249,250,251,253,254,255,256,257,258,259,26 Global Lancing Device 262 0,261,262,263,264,269,271,272,274,277,278,279,281, GlucaGen Diagnostic 166,196 282,283,284,285,286,287,288,290,291,292,293,294,29 GlucaGen HypoKit 167,196 7,298,299,300,301,302,303,305,306,308,310,311,312, Glucagon (rDNA) 167,196 313 Glucagon Emergency 167,196 Glucose Control 264 Glucagon HCl (rDNA) 167,196 Glucosource Lancet Device 264 Glucagon HCl rDNA (Diagnostic) 166,196 Glucosource Lancets 264 Gluco Perfect 3 Test 262 Glumetza 163 Glucocard 01 Blood Glucose 263 Glyburide 163 Glucocard 01 Control 263 GlyBURIDE 163 Glucocard 01 Sensor 263 Glyburide Micronized 163 Glucocard 01 Sensor Plus 263 Glyburide-Metformin 163 Glucocard 01-mini Glucose 263 Glycine (GU Irrigant) 142,143 Glucocard Expression Control 263 Glycopyrrolate 29 Glucocard Expression Monitor 263 Glyset 163 Glucocard Expression Test 263 Gmate Blood Glucose Test 264 Glucocard Shine 263 Gmate Control Level 2 265 Glucocard Shine Control 263 Gmate Smart Starter 265 Glucocard Shine Test 263 GNP Clickfine Pen Needles 265 Glucocard Vital Monitor 263 GNP Insulin Syringe 265 Glucocard Vital Test 263 GNP Lancets 265 GNP Lancets 21G 265 Healthy Accents Unifine Pentip 268 GNP Lancets Micro Thin 33G 265 Healthy Accents Unilet Lancets 268 GNP Lancets Super Thin 30G 266 Hectorol 316 GNP Lancets Thin 266 Hematogen FA 47,317 GNP Lancets Thin 26G 266 Heparin Lock Flush 44 GNP Micro Thin Lancets 33G 266 Heparin Sodium (Porcine) 44 GNP Super Thin Lancets 30G 266 Heparin Sodium (Porcine) Lock Flush 44,45 GNP Ultra Com Insulin Syringe 266,267 Hepsera 23 Goserelin Acetate 186,314 Histrelin Acetate 312 Granisetron HCl 153 Homatropine HBr 152 Griseofulvin Microsize 18 HumaLOG 164 Griseofulvin Ultramicrosize 18 HumaLOG Mix 50/50 164 Guanfacine HCl 67,122 HumaLOG Mix 50/50 KwikPen 163 Gynazole-1 215 HumaLOG Mix 75/25 164 HumaLOG Mix 75/25 KwikPen 164 H Humira 158,197 H-E-B inControl Adv Lancing 267 Humira Pediatric Crohns Start 158,197 H-E-B inControl Lancets 28G 267 Humira Pen-Crohns Starter 158,197 H-E-B inControl Lancets 30G 267 HumuLIN N 164 H-E-B inControl Pen Needles 267 HumuLIN R 164 Haemolance Plus 267 HumuLIN R U-500 (CONCENTRATED) 164 Haemolance Plus High Flow 267 Hyaluronate Sodium (Emollient) 224,228 Haemolance Plus Low Flow 267 Hydralazine HCl 67 Haemolance Plus Max Flow 267 Hydrochlorothiazide 68,140 Haemolance Plus Pediatric Flow 267 Hydrocodone Polistirex-Chlorpheniramine Halac 223 Polistirex 210,268 Halcinonide 223 Hydrocodone w/ Homatropine 29,30,210,211 Halobetasol Propionate 223 Hydrocodone-Acetaminophen 88,89,92,96 Halobetasol Propionate & Ammonium Lactate 223 Hydrocodone-Ibuprofen 88,89,94 Halog 223 Hydrocortisone 180 Haloperidol 131 Hydrocortisone (Intrarectal) 220,224 Haloperidol Decanoate 131 Hydrocortisone (Rectal) 226 Haloperidol Lactate 131 Hydrocortisone Health Care Lancing Device 267 (Topical)218,219,221,222,223,224,225,226,227,228,22 HealthWise Lancets 30G 267 9 HealthWise Lancing Pen 267 Hydrocortisone Acetate (Intrarectal) 221 HealthWise Mini Pen Needles 267 Hydrocortisone Acetate (Rectal) 218,224 HealthWise Pen Needles 267 Hydrocortisone Acetate w/ Pramoxine 218,223,224,226 HealthWise Short Pen Needles 267 Hydrocortisone Acetate-Aloe Vera 221 HealthWise Unifine Pentips 268 Hydrocortisone Butyrate 224 Healthy Accents Lancing Device 268 Hydrocortisone Butyrate Hydrophilic Lipo Base 224 Hydrocortisone Sod Succinate 174 Infinity Blood Glucose Test 269 Hydrocortisone Valerate 224 Infinity Control 269 Hydrocortisone w/Acetic Acid 148,149,151,152 Influenza Virus Vaccine Split 211,212 Hydromorphone HCl 88 Influenza Virus Vaccine Split Preservative Free211,212 HYDROmorphone HCl 88 Influenza Virus Vaccine Split Quadrivalent 212 Hydroquinone 218 Influenza Virus Vaccine Tissue-Cultured Subunit 212 Hydroquinone Microspheres 218 Influenza Virus Vaccine Types A & B Preservative Hydroquinone w/ Sunscreens 218 Free 212 Hydroxocobalamin 48,317 Influenza Virus Vaccine Types A & B Surface Hydroxychloroquine Sulfate 20,197 Antigen 212 Hydroxyprogesterone Caproate 180 Inlyta 269 Hydroxyprogesterone Caproate (Bulk) 180 Insulin Aspart 165 Hydroxyurea 268 Insulin Aspart Protamine & Aspart (Human) 165 Hydroxyurea (Sickle Cell Anemia) 248 Insulin Detemir 165 Hydroxyzine HCl 117,118,268 Insulin Glargine 164,165 HydrOXYzine HCl 117,268 Insulin Glulisine 162 Hydroxyzine Pamoate 118,268,269 Insulin Isophane & Reg (Human) 165 HydrOXYzine Pamoate 118,268 Insulin Isophane (Human) 164,165 Hyoscyamine Sulfate 29,30 Insulin Lispro (Human) 164 Insulin Lispro Protamine & Lispro (Human) 163,164 I Insulin Pen Ibandronate Sodium 197 Needle 232,233,235,238,239,241,242,243,244,245,246 IBG STAR Blood Glucose System 269 ,248,249,250,252,253,256,257,258,260,261,265,267,2 Ibuprofen 85,86,87,88,89,94,95,96,107,108,109,110,11 68,270,272,273,274,275,277,278,279,282,285,287,289 2 ,290,291,292,293,295,296,299,303,304,307,308,310,3 Icatibant Acetate 196 12,313 Iloperidone 130 Insulin Regular (Human) 164,165 Iloprost 211 Insulin Syringe 269 Imatinib Mesylate 261 Insulin Syringe/Needle 269,270 Imipramine HCl 131 Insulin Syringe/Needle U- Imipramine Pamoate 131,132 100 235,237,238,239,240,241,242,245,246,247,248,25 Imiquimod 224 0,251,252,255,256,257,258,261,262,264,265,266,267, Incivek 23 269,270,271,273,274,275,276,277,280,281,286,287,28 Increlex 188 8,289,290,291,292,294,295,296,298,299,300,302,303, Indacaterol Maleate 38,208 304,305,306,307,308,309,310,311,312,313 Indapamide 68,140 Insupen Pen Needles 270 Indinavir Sulfate 22 Insupen Ultrafin 270 Indomethacin 89,197 Intelence 23 Infed 48 Interferon Alfa-2B 23,197,270 Infergen 23 Interferon alfacon-1 23 Infinity Blood Glucose System 269 Interferon Beta-1a 192,200 Interferon Beta-1b 193,196 Jentadueto 164 Interferon Gamma-1B 192 Intron A 23,197,270 K Invega 132 Kalbitor 197 Invega Sustenna 132 Kaletra 24 Invirase 23 Kalydeco 209 Iodine (Topical) 215 Keflex 16 Iodine Strong 210 Kenalog 224 Iodine Strong (Lugol's) 210 Ketek 16 Iodine Strong (Lugol's) (Bulk) 210 KetoCare 270 Iodine Tincture 215 Ketoconazole 18 Iopidine 152 Ketoconazole (Topical) 215 Ipratropium Bromide 30,208 Ketone Blood Test 282,287,289 Ipratropium Bromide (Nasal) 30,208 Ketone Test 270 Ipratropium Bromide HFA 28,208 Ketoprofen 89,109 Ipratropium-Albuterol 29,30,38,39,208 Ketoprofen ER 89,109 Irbesartan 68,75 Ketorolac Tromethamine (Ophth) 148,149 Irbesartan-Hydrochlorothiazide 75,140 Ketostix 270 Iron Dextran 47,48 Kineret 197 Iron Polysaccharide Complex-Vit B12-Folic Kinney Lancets 270 Acid 48,317,318 Kinney Thin Lancets 270 Iron-Folic Acid-Vitamin B12-Vitamin C-Docusate Kinray Insulin Syringe 270,271 Sodium 47,157,316 Klor-Con M15 143 Isentress 24 Kristalose 143 Isocarboxazid 133 Kroger Blood Glucose 271 Isometheptene-Caffeine-Acetaminophen 89,98,109 Kroger Blood Glucose Test 271 Isoniazid 19 Kroger Insulin Syringe 271 Isoniazid & Rifampin 19 Kroger Lancets 271 Isoniazid-Rifampin w/ Pyrazinamide 19 Kroger Lancets 21G 271 Isopto Carbachol 150 Kroger Lancets Micro Thin 33G 271 Isosorbide Dinitrate 79,80 Kroger Lancets Super Thin 272 Isosorbide Mononitrate 80 Kroger Lancets Thin 272 Isoxsuprine HCl 80 Kroger Lancets Thin 26G 272 Isradipine 54,68 Kroger Lancets UltraThin 30G 272 Ivacaftor 209 Kroger Lancing Device 272 Ivermectin (Pediculicide) 217 Kroger Pen Needles 272 Kroger Premium Blood Glucose 272 J Kroger Premium Glucose Test 272 Jakafi 270 Kroger Test 272 Janumet XR 164 Kyprolis 272 Januvia 164 Lantus 165 L Lantus SoloStar 164 Labetalol HCl 35,57,61,62,68 Lapatinib Ditosylate 307 Lacrisert 152 Lastacaft 152,273 Lactic Acid (Ammonium Lactate) 218,223,225 Latanoprost 150 Lactic Acid w/ Vitamin E 225 Latuda 132 Lactobacillus Reuteri 155 Lavoclen-4 Creamy Wash 215 Lactobacillus Reuteri-Vitamin D 155,314 Lavoclen-8 Creamy Wash 215 Lactulose 142,143 Leader Advanced Lancing Device 273 Lactulose (Encephalopathy) 143 Leader Insulin Syringe 273 LaMICtal ODT 102,122 Leader Unifine Pentips 273 Lamivudine 23,24 Leader Unifine Pentips Plus 273,274 Lamivudine (HBV) 23 Leflunomide 197 Lamivudine-Zidovudine 24 Lenalidomide 201,293 Lamotrigine 102,103,122 Letairis 210 Lancet Device 272 Letrozole 274 Lancet Leucovorin Calcium 197,198,317 Devices 234,235,237,238,239,240,242,245,247,248,25 Leukeran 274 0,252,258,259,260,262,264,267,268,272,273,274,275, Leukine 48 280,281,282,283,288,289,290,291,292,294,295,296,29 Leuprolide Acetate 178,181,254,274,276 8,299,300,302,303,305,307,312 Leuprolide Acetate (3 Month) 178,181,254,276 Lancets 232,233,234,235,236,237,238,239,240,241,24 Leuprolide Acetate (4 Month) 178,181,254,276 2,244,245,246,247,248,249,250,252,253,255,256,257, Leuprolide Acetate (6 Month) 178,181,254,276 258,259,260,261,262,263,264,265,266,267,268,270,27 Levalbuterol HCl 39,208 1,272,273,274,275,276,277,278,279,281,282,283,284, Levalbuterol Tartrate 40,209 285,287,288,289,290,291,292,293,294,295,296,297,29 Levatol 62 8,299,300,301,302,303,304,306,308,309,310,311,312, Levemir 165 313 Levemir FlexTouch 165 Lancets 28G 272 Levetiracetam 103 Lancets 30G 272 Levobunolol HCl 151 Lancets Micro Thin 33G 272 Levocarnitine (Metabolic Modifiers) 198 Lancets Super Thin 28G 272 Levofloxacin 16,19 Lancets Thin 272 Levofloxacin (Ophth) 146 Lancets Ultra Fine 272 Levonorgestrel 181 Lancets Ultra Thin 273 Levonorgestrel & Eth Lancets Ultra Thin 30G 273 Estradiol167,170,171,172,173,174,175,176,179,180,18 Lancing Device 273 1,184,185 Lanoxin 57 Levonorgestrel (Emergency OC) 181 Lanreotide Acetate 187 Levonorgestrel-Eth Estradiol Lansoprazole 156,157,158,160,161 (Triphasic) 168,170,171,174,178,181,182,186 Lanthanum Carbonate 145,196 Levonorgestrel-Ethinyl Estradiol (91-Day) 170,171,181 Levorphanol Tartrate 89 Live Better Pen Needles 275 Levothyroxine Sodium 188,189,190,191 Lodosyn 113 Lexiva 24 Lodoxamide Tromethamine 151,236 Liberty Glucose Control 274 Longs Insulin Syringe 275 Liberty Glucose Control Mid 274 Longs Lancets Standard 275 Liberty Mini Lancing Device 274 Longs Lancets Thin 276 Liberty Next Generation Test 274 Longs Lancets Ultra Thin 276 Liberty Test 274 Loperamide HCl 155,156,157,158,160,161,162 Lidocaine 225 Lopinavir-Ritonavir 24 Lidocaine HCl 223,225,227 Loratadine 205,206,207,244,246,247,255,266,268,276, Lidocaine HCl (Local Anesth.) 274 290,295,296,303,313 Lidocaine HCl (Mouth-Throat) 152 Lorazepam 103,118 Lidocaine-Hydrocortisone Ace 225 LORazepam Intensol 103,118 Lidocaine-Hydrocortisone Acetate (Rectal) 225 Lorzone 34 Lidocaine-Prilocaine 225 Losartan Potassium 68,76 Lidoderm 225 Losartan Potassium & Hydrochlorothiazide 76,140 Linaclotide 158 Lotemax 149 Linagliptin 166 Loteprednol Etabonate 149 Linagliptin-Metformin HCl 164 Lovastatin 51 Lindane 215 Lovaza 51 Linezolid 17,18 Loxapine Succinate 132 Linzess 158 Lozi-Flur 198 Liothyronine Sodium 189 Lubiprostone 154 Liotrix (T3-T4) 190 Lubricants 225 Lipofen 50 Lugols 215 Liraglutide 166 Lumigan 151 Lisinopril 68,75 Lunesta 118 Lisinopril & Hydrochlorothiazide 75,76,140 Lupron Depot 181,276 Lite Touch Lancets 274 Lurasidone HCl 132 Lite Touch Lancing Device 274 Lyrica 103,104,123 Lite Touch Lancing Pen 274 Lysodren 276 Lite Touch Pen Needles 274 Litetouch Insulin Syringe 274,275 M Litetouch Lancets 275 Mafenide Acetate 215 Litetouch Pen Needles 275 Magellan Insulin Safety Syr 276 Lithium 123 Malathion 215 Lithium Carbonate 122,123 Maprotiline HCl 132 Livalo 50,51 Maraviroc 26 Live Better Adv Lancing Device 275 Marplan 133 Live Better Lancet Super Thin 275 Matulane 276 Live Better Lancet Ultra Thin 275 Maxi-Comfort Insulin Syringe 276 Maxima Blood Glucose System 276 Meijer Premium Glucose Test 279 Maxima Blood Glucose Test 277 Meijer Super Thin Lancets 279 Maxima Control 277 Meijer TRUE2go Blood Glucose 279 Maxima Meter 277 Meijer TRUEresult Glucose Sys 279 Maxima Starter 277 Meijer TRUEtest Test 279 Mebendazole 11 Meijer TRUEtrack Glucose Sys 279 Mecasermin 188 Meijer TRUEtrack Test 279 Meclizine HCl 153,277 Meloxicam 89 Meclofenamate Sodium 89 Melquin 3 218 Medic Insulin Syringe 277 Memantine HCl 123 MediChoice Safety Lancet 277 Menest 171,198 MediChoice Safety Lancet Extra 277 Mentax 215 MediChoice Safety Lancet Norm 277 Menthol (Topical Analgesic) 224 Medicine Shoppe Pen Needles 277 Meperidine HCl 89,90 MediSense Glucose Ketone Contr 277 Mephyton 198,317 Medisense Hi/Mid/Low Control 277 Meprobamate 118 Medisense High/Low Control 277 Mepron 20 Medisense Mid Control 277 Mercaptopurine 198,279 MediSense Thin Lancets 277 Mesalamine 155,156,158,160 Medlance Extra 21G 278 Mesna 198 Medlance Lite 25G 278 Mesnex 198 Medlance Plus Extra 21G 278 Mestinon 32 Medlance Plus Lancets 278 Metaproterenol Sulfate 39,208,209 Medlance Plus Lite 25G 278 Metaxalone 34 Medlance Plus Special 0.8mm 278 Metformin HCl 163,165 Medlance Plus SuperLite 30G 278 Methadone HCl 90 Medlance Plus Universal 21G 278 Methadose 90 Medlance Universal 21G 278 Methamphetamine HCl 98 Medroxyprogesterone Acetate 182 Methenamine Hippurate 11 Medroxyprogesterone Acetate (Antineoplastic) 177 Methenamine Mandelate 11 Medroxyprogesterone Acetate (Contraceptive) 177,181 Methenamine-Hyosc-Methylene Blue-Benzoic Acid- Mefloquine HCl 20 Phenyl Sal 11,29,89 Megestrol Acetate 182,278 Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Meijer Blood Glucose 278 Sal 11,30,31,94,95,199,203 Meijer Blood Glucose Test 278 Methimazole 189 Meijer Lancets 278 Methitest 182 Meijer Lancets Thin 278 Methocarbamol 34 Meijer Lancets Universal 30G 278 Methotrexate Sodium 198,202,279,305 Meijer Lancets Universal 33G 278 Methoxsalen (Topical) 218 Meijer Pen Needles 278,279 Methoxsalen Rapid 218 Meijer Premium Blood Glucose 279 Methscopolamine Bromide 30 Methsuximide 101 Mitotane 276 Methyclothiazide 68,140 Modafinil 100 Methyldopa 39,68 Moderiba 800 Dose Pack 24 Methylergonovine Maleate 279 Moexipril HCl 69,76 Methylphenidate 97 Moexipril-Hydrochlorothiazide 76,141 Methylphenidate HCl 98,99 Mometasone Furoate 226 Methylphenidate HCl ER 99 Mometasone Furoate (Inhalation) 175 Methylprednisolone 182 Mometasone Furoate (Nasal) 149,182,204 Methylprednisolone Acetate 177 Mometasone Furoate-Formoterol Fumarate Methyltestosterone 182 Dihydrate 38,178 Metipranolol 151 Monoject Insulin Syringe 280 Metoclopramide HCl 158 Monoject Ultra Comfort Syringe 280,281 Metolazone 68,140 Monolet Lancets 281 Metoprolol & Hydrochlorothiazide 62,140 Monolet OPD Lancets 281 Metoprolol Succinate 35,36,58,62,68,69 Monolettor Safety Lancets 281 Metoprolol Tartrate 36,58,62,69 Montelukast Sodium 204 Metronidazole 20,21,157,159 Monurol 11 Metronidazole (Topical) 215,216 Moore Mono Insulin Syringe 281 Metronidazole Vaginal 20,22,215,217 Morphine Sulfate 84,86,90,91,92 Mexiletine HCl 58 Morphine Sulfate (PF) 90,91 Miacalcin 182,198 Moxeza 146 Micardis 69,76 Moxifloxacin HCl 12,18 Micardis HCT 76,140,141 Moxifloxacin HCl (Ophth) 146,148 Miconazole Nitrate (Topical) 212,213,215,216,217 MS Insulin Syringe 281 Miconazole Nitrate Vaginal 214,215,216,217 Multaq 58 Microdot Blood Glucose System 279 Multi Prenatal 48,317 Microdot Control High/Low 279 Multi-Lancet Device 281 Microdot Test 279 Multiple Vitamins w/ Minerals 144,318 Microlet Lancets 279 Mupirocin 216 Microtainer Safety Flow Lancet 279 Mupirocin Calcium 213 Midodrine HCl 39 Mupirocin Calcium (Topical) 216 Miglitol 163 Muse 80 Millipred 182 Mycobutin 16,19 Milnacipran HCl 125,136 Mycophenolate Mofetil 193,198,199 Mini Lancing Device 280 Mycophenolate Sodium 199 Minocycline HCl 16,21,225,226 Myfortic 199 Minoxidil 69 MyGlucoHealth Blood Glucose 281 Mirapex ER 113,114 MyGlucoHealth Control 281 Mirtazapine 133 MyGlucoHealth Lancets 30G 281 Misc Natural Products 202 MyGlucoHealth Test 281 Misoprostol 159 Myleran 281 Neutek 2Tek Control 282 N Neutek 2Tek Test 282 Nabilone 153 Nevanac 149 Nabumetone 92 Nevirapine 24,28 Nadolol 36,62,69 NexAVAR 282 Nadolol & Bendroflumethiazide 62,141 Nexium 24HR 159 Nalbuphine HCl 92 Niacin 318,319 Naltrexone 126,203 Niacin (Antihyperlipidemic) 51,318 Naltrexone HCl 123,199 Niacin ER 318 Namenda 123 Niacor 318 Namenda Titration Pak 123 Niaspan 51 Naphazoline HCl 152 Nicardipine HCl 54,69,80 Naproxen 92,109,199 Nicotine 31,32,33 Naproxen Sodium 92,109,199 Nicotine Polacrilex 32,33 Naratriptan HCl 109 Nicotrol 33 Nasacort Allergy 24HR 149,204 Nicotrol NS 33 Nasonex 149,182,204 Nifedipine 52,54,64,69,70,78,80,81 Natacyn 146 Nilotinib HCl 302 Natamycin 146 Nimodipine 54,70,81 Nateglinide 165 Nisoldipine 54,70 Natroba 216 Nisoldipine ER 54,70 Nature-Throid 189,190 Nitazoxanide 19,20 Nebivolol HCl 34,35,61 Nitisinone 199 Nedocromil Sodium (Ophth) 151,203 Nitro-Bid 81 Nefazodone HCl 133 Nitro-Dur 81 Nelfinavir Mesylate 28 Nitrofurantoin 11 Neomycin Sulfate 16 Nitrofurantoin Macrocrystal 11 Neomycin-Bacitracin Zn-Polymyxin 147 Nitroglycerin 80,81,82 Neomycin-Bacitracin-Polymyxin 217 Nitroglycerin (Intra-Anal) 227 Neomycin-Colistin-HC-Thonzonium 146,148 Nitrolingual 81 Neomycin-Polymy-Dexameth 147,149 Nitrostat 81,82 Neomycin-Polymyxin-Gramicidin 147 Nizatidine 159,282 Neomycin-Polymyxin-HC 147,149,214,221 Norco 92 Neomycin-Polymyxin-HC (Ophth) 147,149 Norditropin FlexPro 183,188 Neomycin-Polymyxin-HC (Otic) 147,149 Norditropin NordiFlex Pen 183,188 Neomycin/Polymyxin B GU 216 Norelgestromin-Ethinyl Estradiol 172,174,184,186 Nepafenac 149 Norethin Acet & Estrad- NetGroup Lancets 282 Fe 170,171,172,173,180,182,183,186 Neumega 48 Norethindrone & Eth Neupogen 48 Estradiol 167,168,171,172,174,176,182,183,186 Neupro 114 Norethindrone (Contraceptive) 176,178,180,183 Norethindrone Acet & Eth Estra 170,180 Nystatin (Mouth-Throat) 18 Norethindrone Acetate 183 Nystatin (Topical) 216 Norethindrone Acetate-Ethinyl Estradiol 170,180 Nystatin-Triamcinolone 216,226 Norethindrone-Eth Estradiol (Triphasic) 167,168,172,174,176,177,183 O Norgestimate-Ethinyl Octreotide Acetate 159,161,187 Estradiol 168,171,172,173,178,182,183,185 Ofloxacin 16 Norgestimate-Ethinyl Estradiol Ofloxacin (Ophth) 147 (Triphasic) 172,173,183,186 Ofloxacin (Otic) 147 Norgestrel & Ethinyl Estradiol167,168,171,176,178,181 Olanzapine 123,124,133,134 Norpace CR 58 Olanzapine-Fluoxetine HCl 134 Nortriptyline HCl 133 Olmesartan Medoxomil 64,74 Norvir 24 Olmesartan Medoxomil-Hydrochlorothiazide 74,138 Nova Max Blood Glucose System 282 Olopatadine HCl 152,153,284 Nova Max Glucose Test 282 Olopatadine HCl (Nasal) 152,282 Nova Max Plus Glu/Ket Control 282 Olsalazine Sodium 156 Nova Max Plus Ketone Test 282 Omalizumab 211 Nova Safety Lancets 23G 282 Omega 3 Fatty Acids-Omega 6 Fatty Acids-Omega 9 Nova Safety Lancets 28G 282 Fatty Acids 199 Nova Sureflex Lancets 282 Omega-3-6-9 199 Nova Sureflex Lancing Device 282 Omega-3-acid Ethyl Esters 51 NovoFine Plus 282 Omeprazole 159 NovoLIN 70/30 165 Omeprazole-Sodium Bicarbonate 159,160 NovoLIN 70/30 ReliOn 165 Omontys 48 NovoLIN N 165 On Call Express Blood Glucose 282 NovoLIN N ReliOn 165 On Call Express Glucose Contr 282 NovoLIN R 165 On Call Express Monitoring Sys 282 NovoLIN R ReliOn 165 On Call Lancets 282 NovoLOG 165 On Call Lancing Device 283 NovoLOG Mix 70/30 165 On Call Plus Blood Glucose 283 NovoLOG Mix 70/30 FlexPen 165 On Call Plus Glucose Control 283 NovoLOG PenFill 165 On Call Plus Lancets 283 Nucynta ER 92 On Call Plus Lancing Device 283 Nuedexta 123 On Call Plus Meter 283 Nutropin AQ NuSpin 10 183,188 On Call Plus Monitoring System 283 Nutropin AQ NuSpin 20 183,188 On Call Vivid Blood Glucose 283 Nutropin AQ NuSpin 5 184,188 On Call Vivid Glucose Control 283 Nutropin AQ Pen 184,188 On Call Vivid Meter 283 NuvaRing 172,184 On Call Vivid Monitoring 283 Nuvigil 100 On Call Vivid Pal Meter 283 Nystatin 18 Ondansetron 153 Ondansetron HCl 153 Oxsoralen 218 OneTouch Delica Lancets 33G 283 Oxsoralen Ultra 218 OneTouch Delica Lancets Fine 283 Oxybutynin 231 OneTouch Delica Lancing Dev 283 Oxybutynin Chloride 231 OneTouch FinePoint Lancets 283 Oxycodone HCl 93 OneTouch Lancets 283 OxyCODONE HCl 93 OneTouch Ultra 2 283 Oxycodone w/ Acetaminophen 86,93,94 OneTouch Ultra Blue 283 Oxycodone-Aspirin 86,93 OneTouch Ultra Control 283 Oxycodone-Ibuprofen 93 OneTouch Ultra Mini 284 Oxymorphone HCl 92,93,94 OneTouch Ultra System 284 Oxytrol 231 OneTouch UltraLink 284 OneTouch UltraSmart 284 P OneTouch UltraSoft Lancets 284 Paliperidone 132 OneTouch Verio 284 Paliperidone Palmitate 132 OneTouch Verio IQ System 284 Palivizumab 27 OneTouch Verio Sync System 284 Pancrelipase (Lipase-Protease- Onglyza 165,166 Amylase) 156,162,246,314 Opana ER 92,93 Pantoprazole Sodium 159 Ophthalmic Irrigation Solution 152 Papaverine HCl 82 Ophthalmic Irrigation Solution - Intraocular 152 Paradigm Link Glucose Monitor 284 Oprelvekin 48 Paricalcitol 321 Optium Blood Glucose Monitor 284 Paroxetine HCl 134 Optium Test 284 Pataday 152,284 OptiumEZ Test 284 Patanol 153,284 OptumRx Blood Glucose Meter 284 Paxil 134 OptumRx Blood Glucose System 284 Pazopanib HCl 312 OptumRx Blood Glucose Test 284 PC Lancets Super Thin 30G 285 OptumRx Glucose Control 284 PC Unifine Pentips 285 Orap 134 Pediatric Multivitamins w/Fl 198,317 Orfadin 199 Pediatric Vitamins ACD w/ Orphenadrine Citrate 34,114 Fluoride 202,203,319,320,321 Orphenadrine w/ Aspirin & Caff 34,93,100 PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Ortho Evra 172,184 Sulfate 156,157,159 Oseltamivir Phosphate 27 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod OsmoPrep 159 Chloride 157,159,162 Oxaprozin 93 Peg-Intron 24 Oxazepam 118 Peg-Intron Redipen 25 Oxcarbazepine 104 Peg-Intron Redipen Pak 4 25 Oxiconazole Nitrate 216 Peganone 104 Oxistat 216 Pegasys 25 Pegasys ProClick 25 Phenyleph-Promethazine w/ Cod 39,211,288 Peginesatide Acetate 48 Phenylephrine-Chlorphen-DM 39,40,210,211,286,302 Peginterferon alfa-2a 25 Phenylephrine-Guaifenesin 39,211 Peginterferon alfa-2b 24,25 Phenytoin 58,104,105 Peginterferon alfa-2b (Antineoplastic) 27,202,301 Phenytoin Sodium 58,105 Pegvisomant 188 Phenytoin Sodium Extended 56,58,101,104 Pen Needles 285 Phoslyra 144,145 Pen Needles 1/2" 285 Phospholine Iodide 151 Pen Needles 3/16" 285 Physostigmine Salicylate 33,199 Pen Needles 5/16" 285 Phytonadione 198,317 Penbutolol Sulfate 62 Pilocarpine HCl 151 Penciclovir 214 Pilocarpine HCl (Oral) 33 Penicillamine 194,247 Pimecrolimus 194,222 Penicillin G Benzathine 13 Pimozide 134 Penicillin V Potassium 17 Pindolol 36,58,62,70 Pentasa 160 Pioglitazone HCl 166 Pentazocine w/ Naloxone 94,124 Pioglitazone HCl-Glimepiride 166 Pentetate Calcium Trisodium 285 Pioglitazone HCl-Metformin HCl 166 Pentetate Zinc Trisodium 285 Piroxicam 94 Pentosan Polysulfate Sodium 194 Pitavastatin Calcium 50,51 Pentoxifylline 48 PNV Fe Fum/Docusate/Folic Acid 48,160,318 Perfect Lancets 28G 285 PocketChem EZ Control 286 Perfect Lancets 30G 285 PocketChem EZ System 286 Perforomist 39,209 PocketChem EZ Test 286 Perindopril Erbumine 70,76 Podocon 226 Permethrin 212,216 Podofilox 220,226 Perphenazine 134 Podophyllum Resin 226 Perphenazine-Amitriptyline 134,135 Polyethylene Glycol 3350 160 Petroleum Jelly 226 Polyethylene Glycol 3350 (Bulk) 160 Pharmacist Choice Autocode 285 Polymyxin B-Trimethoprim 147 Pharmacist Choice Autocode Sys 285 Pomalidomide 199,200,286 Pharmacist Choice Lancets 285 Pomalyst 199,200,286 Pharmacy Counter Lancets 285 Pot & Sod Citrates w/Citric Ac 143 Phenazopyridine HCl 226 Pot Phosphate Monobasic w/ Sod Phosphate Dibasic Phendimetrazine Tartrate 100 & Monobasic 144 Phendimetrazine Tartrate ER 100 Potaba 318 Phenelzine Sulfate 135 Potassium Aminobenzoate 314,318 Phenobarbital 104,119 Potassium Bicarb & Chloride 143,144 PHENobarbital 104,119 Potassium Bicarbonate 143,144 Phenoxybenzamine HCl 35,65 Potassium Bicarbonate-Citric Acid 143 Phentermine HCl 100 Potassium Chloride 143,144 Potassium Chloride ER 144 Premarin 172,200 Potassium Chloride Microencapsulated Crystals Premphase 173,185 CR 143,144 Prempro 173,185 Potassium Citrate (Alkalinizer) 144,145 Prenatal 49,144,318 Potassium Citrate-Citric Acid 144 Prenatal 19 48,160,318 Potiga 105 Prenatal Low Iron 48,318 Pradaxa 45 Prenatal One Daily 48,318 Pramipexole Dihydrochloride 113,114 Prenatal Vit w/ Docusate-Fe Fumarate-Folic Pramlintide Acetate 166 Acid 48,49,160,161,318,319 Pramoxine HCl 226 Prenatal Vit w/ Ferrous Fumarate-Folic Pramoxine-Camphor-Zinc Acetate 219 Acid 48,49,144,317,318,319 Pramoxine-HC 223 Prenatal w/ Calcium Carbonate-Vit B6-Vit B12-Folic Prandin 166 Acid 142,314 Pravastatin Sodium 51 Prenatal w/o Vit A w/ Fe Fumarate-DSS-FA- Prazosin HCl 36,62,70 DHA 49,161,202,319 Precision Glucose Ketone Contr 286 Prepopik 160 Precision Link 286 Prezista 25 Precision PCx 286 Primaquine Phosphate 21 Precision PCX Plus Test 286 Primidone 105 Precision Point of Care Test 286 Pristiq 135 Precision QID Test 286 ProAir HFA 39,209 Precision Sure-Dose Syringe 286 Probenecid 144,200 Precision SureDose Plus Syr 286 Procarbazine HCl 276 Precision Xtra Blood Glucose 287 Prochlorperazine 129,135,153,154 Precision Xtra Ketone 287 Prochlorperazine Edisylate 135,154 Pred Mild 149 Prochlorperazine Maleate 135,154 Prednicarbate 226 Procrit 49 Prednisolone 182,184 Proctofoam HC 226 Prednisolone Acetate (Ophth) 149 Prodigy AutoCode Blood Glucose 288 PrednisoLONE Sodium Phosphate 149,184 Prodigy Insulin Syringe 288 Prednisolone Sodium Phosphate 184 Prodigy Lancets 28G 288 Prednisolone Sodium Phosphate (Ophth) 149 Prodigy Lancing Device 288 Prednisone 184,185 Prodigy No Coding Blood Gluc 288 PredniSONE 184,185 Prodigy Pocket Blood Glucose 288 PredniSONE (Pak) 184 Prodigy Twist Top Lancets 28G 288 PredniSONE Intensol 184 Prodigy Voice Blood Glucose 288 Preferred Plus Insulin Syringe 287 Progesterone (Vaginal) 176,178 Preferred Plus Lancets Colored 287 Prolia 200 Preferred Plus Lancets Thin 287 Promethazine & Phenylephrine 39,288 Preferred Plus Unifine Pentips 287 Promethazine Pregabalin 103,104,123 HCl 119,120,153,154,206,207,285,286,288,289 Promethazine VC Plain 39,288 Qnasl 150,204 Promethazine VC/Codeine 39,211,288 Qualaquin 21 Promethazine w/Codeine 211,289 Quetiapine Fumarate 124,125,135,136 Promethazine-DM 211,289 QuickTek Control Solution 290 Propafenone HCl 58 QuickTek Test 290 Propantheline Bromide 30 QuickTek/Meter 290 Proparacaine HCl 152,153 Quinapril HCl 71,76 Propranolol & Hydrochlorothiazide 63,141 Quinapril-Hydrochlorothiazide 76,77,141 Propranolol HCl 36,59,62,63,70,71,110 Quinidine Gluconate 21,59 Propranolol-HCTZ 63,141 Quinidine Sulfate 21,59 Propylthiouracil 190 QuiNIDine Sulfate 21,59 Protein C Concentrate (Human) 42 QuiNIDine Sulfate ER 21,59 Proventil HFA 39,209 Quinine Sulfate 21 Prudoxin 226 Qvar 185,204 Pseudoephed-Bromphen-DM 38,210,241 Pseudoephedrine w/ DM-GG 40,211 R PTS Panels Ketone Test 289 RA E-Zject Color Lancets 33G 290 Pulmicort 185,204 RA E-Zject Lancets 28G 290 Pulmicort Flexhaler 185,204 RA E-Zject Lancets Thin 26G 290 Pulmozyme 211,289 RA E-Zject Lancets Thin 28G 290 PX Advanced Lancing Device 289 RA E-Zject Lancets Ultra Thin 291 PX Extra Short Pen Needles 289 RA Insulin Syringe 291 PX Insulin Syringe 289 RA Lancing Device 291 PX Lancet Auto Injector 289 RA Pen Needles 291 PX Lancets Ultra Thin 289 RA TRUE2go Blood Glucose 291 PX Mini Pen Needles 289 RA TRUEresult Blood Glucose 291 PX Pen Needle 289 RA TRUEtest Test 291 Pyrazinamide 19 Raloxifene HCl 169,196 Pyridostigmine Bromide 32,33 Raltegravir Potassium 24 Pyridoxine HCl 314,318 Ramelteon 120 Pyrimethamine 20 Ramipril 71,77 Pyrogallic Acid 227,290 Ranexa 59 Pyrogallol-Chlorobutanol 227,290 Ranitidine HCl 160,161,291 Ranolazine 59 Q Rapaflo 36 QC Advanced Lancing Device 290 Rapamune 200 QC Insulin Syringe 290 Rasagiline Mesylate 112,128 QC Lancets Super Thin 30G 290 Rebetol 25 QC Lancets Ultra Thin 290 Rebif 200 QC Pen Needles 290 Rebif Rebidose 200 QC Unifine Pentips 290 Rebif Rebidose Titration Pack 200 Rebif Titration Pack 200 Rexall Blood Glucose System 293 Rectiv 227 Rexall Blood Glucose Test 293 RefuAH Plus Blood Glucose Test 291 Rexall Lancets Ultra Thin 30G 294 RefuAH Plus Glucose Control 291 Reyataz 26 RefuAH Plus Monitoring System 291 Rhinocort Aqua 150,204 Regorafenib 298 Ribasphere 26 Relenza Diskhaler 25 Ribasphere RibaPak 26 Reli-On Insulin Syringe 291 RibaTab 26 ReliOn Blood Glucose Test 292 Ribavirin (Hepatitis C) 24,25,26 ReliOn Confirm Glucose Monitor 292 Ridaura 201,294 ReliOn Confirm/micro Test 292 Rifabutin 16,19 ReliOn Insulin Syringe 292 Rifamate 19 ReliOn Ketone 292 Rifampin 17,19 ReliOn Lancets Micro-Thin 33G 292 Rifater 19 ReliOn Lancets Standard 21G 292 Right Step Prenatal 49,319 ReliOn Lancets Thin 26G 292 Rightest GC300 Control 294 ReliOn Lancets Ultra-Thin 30G 292 Rightest GD500 Lancing Device 294 ReliOn Lancing Device 292 Rightest GL300 Lancets 294 ReliOn Micro 292 Rightest GM100 Blood Glucose 294 ReliOn Mini Pen Needles 292 Rightest GM300 Blood Glucose 294 ReliOn Pen Needles 293 Rightest GM550 Blood Glucose 294 ReliOn Prime Test 293 Rightest GS100 Blood Glucose 294 ReliOn Short Pen Needles 293 Rightest GS300 Blood Glucose 294 ReliOn Ultima Glucose System 293 Rightest GS550 Blood Glucose 294 ReliOn Ultima Test 293 Rilonacept 192 ReliOn Ultra Thin Lancets 30G 293 Rilpivirine HCl 22 ReliOn Ultra Thin Plus Lancets 293 Rilutek 124 Relpax 110 Riluzole 124 Renagel 145,200 Rimantadine Hydrochloride 26 Renvela 145,200,201 Rimexolone 150 Repaglinide 166 Risedronate Sodium 192 Replesta 319 Risperidone 124,125,135,136 Replesta Childrens 319 Ritonavir 24 Replesta NX 319 Rivaroxaban 46 Rescon-Jr 39,40,293 Rivastigmine 32 Rescriptor 25,26 Rivastigmine Tartrate 33 Reserpine 71 Rizatriptan Benzoate 110 Retapamulin 212 Ropinirole Hydrochloride 114,115 Reveal Blood Glucose Monitor 293 Rosiglitazone Maleate 162 Reveal Blood Glucose Test 293 Rosuvastatin Calcium 50 Revlimid 201,293 Rotigotine 114 Rozerem 120 Sensipar 201 Rufinamide 100 Serevent Diskus 40,209 Ruxolitinib Phosphate 270 SEROquel XR 125,136 Rx Support HB/Reflux/Aloe 144,201,319 Sertaconazole Nitrate 214 Sertraline HCl 136 S Sevelamer Carbonate 145,200,201 Sabril 105 Sevelamer HCl 145,200 SafeSnap Insulin Syringe 294 Shopko Autolet Lancing Device 295 Safety Lancet 21G/Pressure Act 294 Shopko On-the-Go Lancets 30G 295 Safety Lancet 28G/Pressure Act 294 Shopko Unifine Pentips 295,296 Safety Lancets 295 Shopko Unilet Lancets 28G 296 Safety Lancets 21G 294 Shopko Unilet Lancets 30G 296 Safety Lancets 28G 294 Sildenafil Citrate (Pulmonary Hypertension) 82,211,232 Safety Let Lancets 295 Silodosin 36 Safety Seal Lancets 295 Silver Nitrate 147 Safety-Glide Syringe 295 Simple Diagnostics Lancing Dev 296 Salicylic Acid 227 Simvastatin 51 Salmeterol Xinafoate 40,209 Sinecatechins 230 Salsalate 94 Sirolimus 200 Salvax 227 Sitagliptin Phosphate 164 Samsca 141 Sitagliptin-Metformin HCl 164 SandIMMUNE 201 Sklice 217 SandoSTATIN LAR Depot 161,187 SM Insulin Syringe 296 Santyl 227,295 SM Lancets 33G 296 Saphris 125,136 Smart Diabetes Vantage Lancets 296 SAPScare Twist Top Lancets 295 Smart Diabetes Vantage Lancing 296 Saquinavir Mesylate 23 Smart Diabetes Xpres System 297 Sargramostim 48 Smart Diabetes Xpres Test 297 Savella 125,136 Smart Sense Color Lancets 33G 297 Saxagliptin HCl 165,166 Smart Sense Premium System 297 SB Insulin Syringe 295 Smart Sense Premium Test 297 SB Lancets Thin 295 Smart Sense Standard Lancets 297 SB Lancets Ultra Thin 295 Smart Sense Super Thin Lancets 297 Schnucks Insulin Syringe 295 Smart Sense Thin Lancets 26G 297 Se-Natal 19 49,161,319 Smart Sense Value Glucose Sys 297 Selegiline 113,130 Smart Sense Value Test 297 Selegiline HCl 115,136 Smartest Blood Glucose Test 297 Selenium Sulfide 217 Smartest Control Medium 297 Selenium Sulfide-Pyrithione Zinc in Urea Smartest Eject Starter 297 Vehicle 217,228 Smartest Lancets 28G 297 Selzentry 26 Smartest Persona Starter 297 Smartest Pronto Starter 297 Spironolactone & Hydrochlorothiazide 77,141 Smartest Protege Starter 297 Sprycel 298 Sodium Ascorbate 319 Stannous Fluoride 199,201 Sodium Chloride 144 Stavudine 26,27 Sodium Chloride (GU Irrigant) 142,144 Stavzor 105,111,125 Sodium Chloride (Inhalant) 211 Stelara 228 Sodium Chloride Flush 144 SteriLance TL 298 Sodium Citrate & Citric Acid 142 Stimate 40,185 Sodium Fluoride 196,198,201 Stivarga 298 Sodium Fluoride (Dental) 193,194,199,201 Strattera 125,126 Sodium Fluoride-Potassium Nitrate 196,259 Stribild 27,201 Sodium Oxybate 126 Suboxone 94,95,126 Sodium Phosphate Monobasic-Sodium Phosphate Succimer 193,243 Dibasic 159 Sucralfate 155,161 Sodium Picosulfate-Magnesium Oxide-Anhydrous Sulfacetamide Sod-Prednisolone 146,147,148,150 Citric Acid 160 Sulfacetamide Sodium 216,217 Sodium Polystyrene Sulfonate 145,197,201 Sulfacetamide Sodium (Acne) 217 Sodium Sulfacetamide Wash 201,217 Sulfacetamide Sodium (Ophth) 147 Sodium Sulfate-Potassium Sulfate-Magnesium Sulfacetamide Sodium in Bakuchiol Vehicle 201,217 Sulfate 161 Sulfacetamide Sodium w/ Sulfur 217,228 Sodium Thiosulfate-Salicylic Acid 214,217,222,230 Sulfadiazine 17 Solartek Glucose Control 297 SulfADIAZINE 17 Solifenacin Succinate 231 Sulfamethoxazole-Trimethoprim 11,17,21 Solus V2 Blood Glucose System 297 Sulfasalazine 17,161,202 Solus V2 Lancets 28G 297 Sulindac 95 Solus V2 Lancing Device 298 Sumatriptan 111 Solus V2 Test 298 SUMAtriptan 111 Solus V2 Twist Lancets 30G 298 Sumatriptan Succinate 111 Somatropin 179,183,184,186,187,188 SUMAtriptan Succinate 111 Somatuline Depot 187 Sunitinib Malate 301 Somavert 188 Super Thin Lancets 298 Sorafenib Tosylate 282 Suprax 17 Sorbitol 144,145 Suprep Bowel Prep 161 Sorbitol Irrigation 144,145 Sure Comfort Insulin Syringe 298,299 Sorbitol-Mannitol 145 Sure Comfort Lancets 28G 299 Soriatane 228 Sure Comfort Lancets 30G 299 Sotalol HCl 36,37,59,63,71 Sure Comfort Lancing Pen 299 Spacer/Aerosol-Holding Chambers 249,250 Sure Comfort Pen Needles 299 Spinosad 216 Sure Edge Test 299 Spiriva HandiHaler 30,209 Sure-Fine Pen Needles 299 Spironolactone 71,77,141 Sure-Ject Insulin Syringe 300 Sure-Lance Flat Lancets 300 Tasigna 302 Sure-Lance Lancets 26G 300 Tasmar 115 Sure-Lance Thin Lancets 28G 300 Tazarotene 228 Sure-Lance Ultra Thin Lancets 300 Tazorac 228 Sure-Pen 300 TechLite AST Lancets 302 Sure-Test EasyPlus Mini Test 300 TechLite Lancets 30G 302 Sure-Touch Lancets Universal 300 TEGretol-XR 105,126 SureChek Blood Glucose Monitor 300 Tekturna 77 SureChek Blood Glucose Test 300 Tekturna HCT 77,141 Surelite Lancets 301 Telaprevir 23 SureStep Glucose Control 301 Telbivudine 27 SureStep Pro Normal Glucose 301 Telcare Blood Glucose System 302 SureStep Pro Test 301 Telcare Blood Glucose Test 302 Sustiva 27 Telcare Glucose Control 302 Sutent 301 Telithromycin 16 Sylatron 27,202,301 Telmisartan 69,76 Symbicort 40,185,186 Telmisartan-Hydrochlorothiazide 76,140,141 SymlinPen 120 166 Temazepam 120 SymlinPen 60 166 Tenofovir Disoproxil Fumarate 28 Synagis 27 Terazosin HCl 37,63,72 Synalar 228 Terbinafine HCl 18 Synthroid 190 Terbutaline Sulfate 40,209 Syprine 301 Terconazole Vaginal 217 Teriparatide (Recombinant) 179 T Terumo Insulin Syringe 302 Tabloid 301 Terumo SurGuard Insulin Syr 302 Taclonex 228 Testosterone 174,175,186 Tacrolimus 197,202 Tetrabenazine 126 Tadalafil 78 Tetracaine HCl (Ophth) 151,153 Tadalafil (Pulmonary Hypertension) 78 Tetracycline HCl 17,21,161 Tafluprost 151 Tetrahydrozoline HCl (Ophth) 153 Tai Doc Control 301 Tev-Tropin 186,188 Tamiflu 27 TGQ 15DM/5PEH/2CPM 40,211,302 Tamoxifen Citrate 173,301 TGQ 30PSE/150GFN/15DM 40,211 Tamsulosin HCl 37 TGT Advanced Lancing Device 302 Tandem F 49,319 TGT Blood Glucose Monitoring 303 Tapentadol HCl 92 TGT Blood Glucose Test 303 Tarceva 301 TGT Lancet Alternate Site 303 Targretin 301 TGT Lancet Micro Thin 33G 303 Tarka 54,55,77 TGT Lancet Super Thin 30G 303 Taron-Prex 49,161,202,319 TGT Lancet Thin 23G 303 TGT Lancet Thin 26G 303 TOLAZamide 166 TGT Lancet Ultra Thin 28G 303 Tolbutamide 166,304 TGT Lancet Ultra Thin 30G 303 TOLBUTamide 166,304 TGT Lancing Device 303 Tolcapone 115 Thalidomide 202 Tolmetin Sodium 95 Thalomid 202 Tolterodine Tartrate 231 Theophylline 67,72,98,100,139,141,142,208,209,232 Tolvaptan 141 Thera-D 4000 319 TopCare Clickfine Pen Needles 304 Thinpro Insulin Syringe 303 TopCare Ultra Comfort Ins Syr 304 Thioguanine 301 Topiramate 105,112 Thiothixene 136 Toremifene Citrate 170,258 Thyrogen 303 Torsemide 72,142 Thyroid 189,190,191 Toviaz 231 Thyrolar-1 190 Tradjenta 166 Thyrolar-1/2 190 Tramadol HCl 95 Thyrolar-1/4 190 TraMADol HCl ER 95 Thyrolar-2 190 Tramadol-Acetaminophen 95 Thyrolar-3 190 Trandolapril 72,77 Thyrotropin Alfa 303 Trandolapril-Verapamil HCl 54,55,77 Tiagabine HCl 102,105 Tranylcypromine Sulfate 137 Ticagrelor 42 Travatan Z 151 Ticlopidine HCl 45 Travoprost 151 Timolol Maleate 37,60,63,72,112 Trazodone HCl 137 Timolol Maleate (Ophth) 151 Trelstar 305 Tinidazole 21 Trelstar Depot Mixject 304 Tiotropium Bromide Monohydrate 30,209 Trelstar LA Mixject 305 Tipranavir 22 Trelstar Mixject 305 Tizanidine HCl 34 Treprostinil 211 TobraDex 147,150 Tretinoin 218,219,229 TobraDex ST 147,150 Tretinoin (Chemotherapy) 305 Tobramycin (Ophth) 147,148 Tretinoin Microsphere 229 Tobramycin-Dexamethasone 147,150 Trexall 202,305 Tobrex 148 Triamcinolone Acetonide 229 Tocilizumab 192 Triamcinolone Acetonide (Mouth) 226,229 Todays Health Lancing Device 303 Triamcinolone Acetonide (Nasal) 149,204 Todays Health Mini Pen Needles 303 Triamcinolone Acetonide (Topical) 224,229 Todays Health Pen Needles 303 Triamterene 66,139 Todays Health Short Pen Needle 304 Triamterene & Hydrochlorothiazide 142 Todays Health Thin Lancets 28G 304 Trianex 229 Todays Health Thin Lancets 30G 304 Triazolam 120 Tolazamide 166 Trientine HCl 301 Trifluoperazine HCl 137 Trifluridine 148 U Triglide 51 Ulipristal Acetate 178 Trilipix 51 Ulti-Lance Automatic 307 Trimethobenzamide HCl 154 UltiCare Insulin Safety Syr 307 Trimethoprim 11 UltiCare Insulin Syringe 307 Trimipramine Maleate 137 UltiCare Micro Pen Needles 307 Triptorelin Pamoate 304,305 UltiCare Mini Pen Needles 307 Trizivir 27 UltiCare Pen Needles 308 Trolamine Salicylate 83 UltiCare Short Pen Needles 308 Tropicamide 152,153 UltiCare Thin Lancets 30G 308 Trospium Chloride 231 Ultilet Classic Lancets 308 True Metrix Blood Glucose Test 305 Ultilet Insulin Syringe Short 308 True Metrix Level 2 305 Ultilet Lancets 308 True Metrix Meter 305 Ultilet Pen Needle 308 TRUE2go Blood Glucose Monitor 305 Ultilet Safety Lancets 23G 308 TrueControl Glucose Cont Lev 0 305 Ultima Test 308 TrueControl Glucose Cont Lev 1 305 Ultra Comfort Insulin Syringe 308 TRUEdraw Lancing Device 305 Ultra Thin Lancets 28G 309 TRUEplus Insulin Syringe 305,306 Ultra Thin Lancets 30G 309 TRUEplus Lancets 26G 306 Ultra Trak Pro Blood Glucose 309 TRUEplus Lancets 28G 306 Ultra-Comfort Insulin Syringe 309 TRUEplus Lancets 30G 306 Ultra-Thin II Auto Lancet 309 TRUEplus Lancets 33G 306 Ultra-Thin II Ins Syr Short 309 TRUEplus Safety Lancets 28G 306 Ultra-Thin II Insulin Syringe 310 TRUEresult Blood Glucose 306 Ultra-Thin II Pen Needles 310 TRUEtest Control Level 1 306 UltraTRAK PRO Control 310 TRUEtest Control Level 2 306 UltraTRAK PRO Test 310 TRUEtest Control Level 3 306 UltraTRAK Ultimate Control 310 TRUEtest Test 306 UltraTRAK Ultimate Test 310 TrueTrack Blood Glucose 306 Unifine Pentips 310 TrueTrack Smart System 306 Unifine Pentips Plus 310 TrueTrack Test 306 Unilet ComforTouch Lancet 310 Truvada 27 Unilet ExceLite 310 Trypsin w/ Castor Oil & Peruvian Balsam 227,230 Unilet ExceLite II 310 Tudorza Pressair 30 Unilet G.P. Lancet 311 Tykerb 307 Unilet G.P. Superlite Lancet 311 Tyvaso 211 Unilet GP 28 Ultra Thin 311 Tyvaso Refill 211 Unilet Lancet 311 Tyvaso Starter 211 Unilet Superlite Lancet 311 Tyzeka 27 Unistik 3 Gentle 311 Unistrip1 Generic 311 Varenicline Tartrate 31 Universal 1 Lancets Thin 26G 311 Veltin 217,230 Universal 1 Lancets Ultra Thin 311 Venlafaxine HCl 137 Uramaxin 230 Venlafaxine HCl ER 137 Urea 220,227,230 Ventavis 211 Urea & Hyaluronate Sodium 230 Ventolin HFA 40,209 Urea in Ammonium Lactate Vehicle 230 Veramyst 150,186,204 Urea in Lactic Acid-Salicylic Acid Vehicle 225 Verapamil HCl 55,60,73,82 Urea in Zinc Undecylenate-Lactic Acid Vehicle 217,230 Veregen 230 Urea Nail 230 VESIcare 231 Uretron D/S 11,31,95,203 Vexol 150 Urocit-K 10 145 Victory AGM-4000 Test 312 Urocit-K 15 145 Victory Control Level 1/2 312 Urocit-K 5 145 Victoza 166 Ursodiol 162 Victrelis 28 Ustekinumab 228 Vida Mia Autolet Lancing Dev 312 Vida Mia Unifine Pentips 312 V Vida Mia Unilet Lancets 28G 312 V-R Mono Insulin Syringe 311 Vida Mia Unilet Lancets 30G 312 Vagifem 174,203 Videx 28 Valacyclovir HCl 27 Vigabatrin 105 Valcyte 28 Vigamox 148 Valganciclovir HCl 28 Viibryd 137,138 Valproate Sodium 105,112,126 Vilazodone HCl 137,138 Valproic Acid 105,111,112,125,126 Viracept 28 Valrubicin 311 Viramune 28 Valsartan 72,77,78 Viramune XR 28 Valsartan-Hydrochlorothiazide 78,142 Viread 28 Valstar 311 Vitamin D3 321 Value Health Insulin Syringe 311 Vivitrol 126,203 Value Plus Lancet Standard 21G 311 Vocal Point Blood Glucose Test 312 Value Plus Lancets Super Thin 311 Voltaren 230 Value Plus Lancets Thin 26G 311 Votrient 312 Value Plus Lancing Device 312 VP Insulin Syringe 313 ValuMark Lancet Super Thin 30G 312 Vytorin 51,52 ValuMark Lancet Ultra Thin 28G 312 ValuMark Pen Needles 312 W Vancomycin HCl 17 Walgreens Adv Travel Lancets 313 Vandetanib 241 Walgreens Lancets 313 VanishPoint Insulin Syringe 312 Walgreens Lancets Micro Thin 313 Vantas 312 Walgreens Lancets Super Thin 313 Walgreens Thin Lancets 313 Zonisamide 105,106 Walgreens Ultra Thin Lancets 313 Zortress 203 Warfarin Sodium 44,45,46 Zostavax 212 WaveSense AMP 313 Zoster Vaccine Live 212 WaveSense KeyNote 313 Zovirax 218 WaveSense Presto 313 Zyflo 204 WD Medic Insulin Syringe 313 Zymaxid 148 Wegmans Unifine Pentips Plus 313 Zytiga 314 Welchol 52,166 Zyvox 17,18 Westhroid 191 White Petrolatum 226 Witch Hazel-Glycerin 224

X Xalkori 313 Xarelto 46 Xeloda 313 Xenazine 126 Xolair 211 Xopenex HFA 40,209 Xpres Control 314 Xyrem 126

Z Zafirlukast 204 Zaleplon 120 Zanamivir 25 Zemplar 321 Zenpep 162,314 Zetia 52 Ziagen 28 Ziana 217,230 Zidovudine 28 Zileuton 204 Zinc Sulfate 145 Zioptan 151 Ziprasidone HCl 126,138 Zirgan 148 Zithromax 17 Zoladex 186,314 Zolpidem Tartrate 120