ERITAGE ~ nebraska HEALTH , - total care_

Welcome to Nebraska Total Care

What is the Nebraska Total Care Value-Add Drug List? Nebraska Medicaid covered drugs on the State Preferred Drug List can be found: https://nebraska.fhsc.com/PDL/PDLlistings.asp. Nebraska Total Care also covers additional drugs. A team of doctors and pharmacists meets regularly to choose which drugs should be on the Nebraska Total Care drug list. The team reviews new and existing drugs and chooses drugs that work best and are safe.

How do I use the Nebraska Total Care Value-Add Drug List? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

The table below tells you what the abbreviations on the Drug List mean. Abbreviation Term What it means AL Age Limit Some drugs are only covered for certain ages. F Formulary These drugs are covered on the Drug List. PA Prior Authorization Some drugs need approval from Nebraska Total Care before they will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. RX/OTC Prescription and These drugs are made in both prescription OTC form and Over-the-counter (OTC) form. SP Specialty Drug Specialty drugs are high-cost drugs used to treat complex or rare conditions and may be limited to a specific pharmacy. MT Maintenance Nebraska Total Care allows 90-day supply of Therapy medications used to treat chronic conditions. What if my drug is not on the Nebraska Total Care Value-Add Drug List? If your drug is not on the Nebraska Total Care drug list, or the State Preferred Drug List, call Member Services at 1-844-385-2192 and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. If your doctor feels you need to have the drug that is not covered, your doctor can ask us to make an exception. Can I go to any pharmacy? Members must use pharmacies that are in the network. These pharmacies have a contract with Nebraska Total Care. To find a pharmacy, call Member Services at 1-844-385-2192. Are there any limits on my drug coverage? Some drugs have limits on coverage. If a drug has limits, it will be noted in the requirements/limits column on the Drug List. How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug cover. • Your doctor can ask us to cover your drug even if it is not on the drug list • Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more.

To request an exception, your doctor can fax a prior authorization form to us at 1-866-399-0929. Once we receive your doctor’s request, we will make our decision within one business day

What if I am a new member? If you are a new member in our plan, you may be taking drugs that are not on our drug list. This drug may also not be on the State Preferred Drug List. You may also be taking a drug that is on our drug list, but the drug may have some limits. In these cases, you should talk to your doctor to see if you should change to drugs that we cover. Your doctor may request an exception so that we could cover the drug you have been taking. See the section, “How do I get an exception to the rules for the drug coverage?” for more information.

What are over-the-counter drugs? Over-the-counter (OTC) drugs are drugs you can buy without a prescription. The Nebraska Total Care Value-Add Drug List covers OTC drugs that are not covered by the State Preferred Drug List. However, if you want Nebraska Total Care to cover an OTC drug on the drug list, your doctor must write a prescription for that drug.

Are brand name drugs covered? Your pharmacy benefit does not cover brand name drugs when generic drugs are available. Brand name drugs may be covered when generic drugs are not available. Brand name drugs could be covered if your doctor states the brand name drug is medically necessary. If a brand name drug is covered, a $3.00 copay may apply. What is a generic drug? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs must be safe and effective. Will the pharmacist give me a generic drug if one is available? Yes. Pharmacies may give you a generic drug, unless your doctor says that you must take the brand name drug or preferred by the state.

Are there any excluded drugs? Excluded drugs The Nebraska Total Care Value-Add Drug List does not include certain drugs. The following types of drugs are not included on the drug list because they are excluded from coverage:  Drugs that do not have FDA approval  Drugs that are being tested but not approved yet  Drugs to help you get pregnant  Drugs used for weight loss  Cosmetic or hair-growth drugs  Drugs used to treat sexual problems  Drugs not on the OTC Drug List Need more information? For more information about your pharmacy benefits, please review your Member Handbook or call Member Services at 1-844-385-2192. Nebraska Total Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Nebraska Total Care does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Nebraska Total Care: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).

• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Nebraska Total Care Contact Center at

1-844-385-2192, TTY: 1-844-307-0342, Relay 711.

If you believe that Nebraska Total Care has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Nebraska Total Care Member Service Center is available to help you. You can also use the member portal on our website at: www.NebraskaTotalCare.com Give it to us in person or by mail: Nebraska Total Care ATTN: Grievances: 2525 North 117th Ave Omaha NE, 68164 When filing for a grievance be sure to include: • Your first and last name • Your Nebraska Medicaid ID number • Your address and telephone number • What you are unhappy with • What you would like to have happen Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- butalbital-acetaminophen- 1 OBESITY/ANOREXIANTS - Drugs to Treat caffeine tabs ADHD, Sleep and Eating Disorders butalbital-aspirin-caffeine 1 caps Analeptics BUTALBITAL/ASPIRIN/CA 1 QL(4 ea daily) caffeine citrate soln 1 FFEINE TABS CVS TENSION 1 caffeine tabs 1 HEADACHE TABS ALTERNATIVE MEDICINES HISTAFLEX TABS 1 Alternative Medicine - M's Analgesics Other acetaminophen caps or 1 1 melatonin tabs 500 mg Alternative Medicine Combinations acetaminophen chew or 80 1 mg glucosamine-chondroitin-vit 1 MP c-manganese caps acetaminophen liqd or 1000 mg/30ml, 160 1 AMINOGLYCOSIDES - Drugs to Treat Bacterial mg/5ml, 500 mg/15ml Infections acetaminophen soln or 160 Aminoglycosides mg/5ml, 325 mg/10.15ml, 1 650 mg/20.3ml tobramycin sulfate soln 1 acetaminophen supp re 1 QL(0.4 ea tobramycin sulfate solr 1 650 mg, 120 mg daily) acetaminophen susp or ANALGESICS - ANTI-INFLAMMATORY - Drugs 160 mg/5ml, 650 1 to Treat Pain, Swelling, Muscle and Joint mg/20.3ml, 80 mg/2.5ml Conditions acetaminophen tabs or 325 1 Pyrimidine Synthesis Inhibitors mg, 500 mg MP acetaminophen tbcr or 650 1 leflunomide tabs 1 mg ANALGESICS - NonNarcotic - Drugs to Treat acetaminophen tbdp or 160 1 Pain, Muscle and Joint Conditions mg, 80 mg FEVERALL INFANTS 1 Analgesic Combinations SUPP acetaminophen-caffeine 1 FEVERALL JUNIOR 1 QL(0.4 ea tabs STRENGTH SUPP daily) acetaminophen- 1 pamabrom-pyrilamine tabs Salicylates aspirin buffered (cal carb- aspirin-acetaminophen- 1 1 caffeine tabs mag carb-mag oxide) tabs aspirin-caffeine tabs 1 aspirin chew or 81 mg 1 butalbital-acetaminophen 1 aspirin effervescent tbef 1 tabs ASPIRIN SUPP RE 300 1 QL(0.4 ea butalbital-acetaminophen- 1 MG daily) caffeine caps

Nebraska Total Care Formulary September 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASPIRIN SUPP RE 600 1 calcium carbonate- 1 MG simethicone chew aspirin tabs or 325 mg 1 GAVISCON CHEW 14.2 1 MG-80 MG aspirin tbec or 325 mg, 81 1 mg MAG-AL LIQD 1 ANORECTAL AND RELATED PRODUCTS - Antacids - Aluminum Salts Rectal Drugs to Treat Pain, Swelling and Itching ALUMINUM HYDROXIDE 1 Intrarectal Steroids SUSP hydrocortisone (intrarectal) 1 Antacids - Bicarbonate enem sodium bicarbonate 1 Rectal Combinations (antacid) tabs phenylephrine in hard fat 1 Antacids - Calcium Salts supp ANTACID CHEW 1 phenylephrine-cocoa butter 1 supp ANTACID SOFT CHEWS 1 CHEW phenylephrine-mineral oil- 1 petrolatum oint calcium carbonate (antacid) 1 phenylephrine-shark liver chew oil-mineral oil-petrolatum 1 calcium carbonate (antacid) 1 oint susp phenylephrine-witch hazel 1 CALCIUM CARBONATE 1 gel TABS 648 MG pramoxine-phenylephrine- 1 CVS ANTACID SOFT glycerin-petrolatum crea CHEWS ULTRA 1 Rectal Local Anesthetics STRENGTH CHEW TUMS CHEWY DELIGHTS 1 lidocaine (anorectal) crea 1 CHEW pramoxine hcl (rectal) foam 1 Antacids - Magnesium Salts magnesium oxide tabs 400 1 ANTACIDS mg, 420 mg, 250 mg ANTI-INFECTIVE AGENTS - MISC. - Drugs to Antacid Combinations Treat Bacterial Infections alum & mag hydrox- 1 simethicone chew Anti-infective Misc. - Combinations sulfamethoxazole- alum & mag hydrox- 1 1 simethicone liqd trimethoprim susp sulfamethoxazole- alum & mag hydrox- 1 1 simethicone susp trimethoprim tabs Glycopeptides aluminum hydroxide-mag 1 carb chew vancomycin hcl solr 1 gm, 1 QL(2 ea daily) 1000 mg aluminum hydroxide-mag 1 carb susp vancomycin hcl solr 500 1 QL(4 ea daily) mg calcium carbonate-mag 1 hydrox chew Lincosamides Nebraska Total Care Formulary September 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINDAMYCIN/SODIUM 1 flecainide acetate tabs 1 MP CHLORIDE SOLN Urinary Anti-infectives propafenone hcl tabs 1 MP methenamine hippurate 1 tabs Antiarrhythmics Type III MP methenamine mandelate 1 amiodarone hcl tabs 1 tabs MP ANTIANGINAL AGENTS - Drugs to Treat Chest dofetilide caps 1 Pain ANTIASTHMATIC AND BRONCHODILATOR Antianginals-Other AGENTS - Drugs to Treat Lung Conditions ranolazine tb12 1 QL(2 ea daily) Anti-Inflammatory Agents Nitrates cromolyn sodium nebu 1 isosorbide dinitrate tbcr 1 MP Xanthines THEO-24 CP24 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety MP Antianxiety Agents - Misc. theophylline soln 1 hydroxyzine hcl soln 1 theophylline tb12 1 MP hydroxyzine hcl syrp 1 theophylline tb24 1 MP hydroxyzine hcl tabs 1 ANTICOAGULANTS - Blood Thinners hydroxyzine pamoate caps 1 Heparins And Heparinoid-Like Agents heparin sodium (porcine) 1 Benzodiazepines soln lorazepam soln 1 ANTICONVULSANTS - Drugs to Treat Seizures ANTIARRHYTHMICS - Drugs to treat abnormal AMPA Glutamate Receptor Antagonists heart rhythms FYCOMPA SUSP 1 MP Antiarrhythmics Type I-A MP disopyramide phosphate 1 MP FYCOMPA TABS 1 caps Anticonvulsants - Benzodiazepines NORPACE CR CP12 1 clobazam susp 1 MP quinidine gluconate tbcr 1 MP clobazam tabs 1 MP quinidine sulfate tabs 1 MP clonazepam tabs 1 Antiarrhythmics Type I-B mexiletine hcl caps 1 MP clonazepam tbdp 1 diazepam (anticonvulsant) 1 Antiarrhythmics Type I-C gel

Nebraska Total Care Formulary September 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anticonvulsants - Misc. lamotrigine kit 1 MP APTIOM TABS 1 AL(At least 4 lamotrigine kit 25 mg 1 yrs old) BRIVIACT SOLN IV 50 1 SP MG/5ML QL(4 ea daily); lamotrigine tabs 100 mg, 1 AL(At least 4 BRIVIACT SOLN OR 10 MP 150 mg, 200 mg, 25 mg 1 yrs old); MP MG/ML lamotrigine tb24 100 mg, BRIVIACT TABS OR 10 MP 200 mg, 250 mg, 300 mg, 1 MG, 100 MG, 25 MG, 50 1 25 mg, 50 mg MG, 75 MG AL(At least 4 lamotrigine tbdp 100 mg, 1 AL(At least 4 carbamazepine chew 1 200 mg, 25 mg, 50 mg yrs old) yrs old); MP levetiracetam in sodium 1 AL(At least 4 carbamazepine cp12 yrs old); MP chloride soln 500 mg/100ml-820 mg/100ml, 1 AL(At least 4 carbamazepine susp 1 540 mg/100ml-1500 yrs old); MP mg/100ml AL(At least 4 carbamazepine tabs 1 levetiracetam in sodium PA yrs old); MP chloride soln 750 1 AL(At least 4 mg/100ml-1000 mg/100ml carbamazepine tb12 1 yrs old); MP levetiracetam soln iv 500 1 mg/5ml DIACOMIT CAPS 1 AL(At least 2 yrs old) levetiracetam soln or 100 1 MP AL(At least 2 mg/ml, 500 mg/5ml DIACOMIT PACK 1 yrs old) levetiracetam tabs or 250 MP EPIDIOLEX SOLN 1 SP mg, 1000 mg, 750 mg, 500 1 mg QL(36 ea gabapentin caps 100 mg 1 levetiracetam tb24 or 500 1 MP daily); MP mg, 750 mg QL(12 ea AL(At least 4 gabapentin caps 300 mg 1 oxcarbazepine susp 1 daily); MP yrs old); MP QL(9 ea daily); AL(At least 4 gabapentin caps 400 mg 1 oxcarbazepine tabs 1 MP yrs old); MP gabapentin soln 250 QL(72 ml 1 OXTELLAR XR TB24 1 AL(At least 4 mg/5ml, 300 mg/6ml daily); MP yrs old) QL(6 ea daily); gabapentin tabs 600 mg 1 pregabalin caps 100 mg, QL(3 ea daily) MP 150 mg, 200 mg, 25 mg, 50 1 QL(4.5 ea mg, 75 mg gabapentin tabs 800 mg 1 daily); MP pregabalin caps 225 mg, 1 QL(2 ea daily) 300 mg LAMICTAL ODT KIT 1 pregabalin soln 20 mg/ml 1 QL(30 ml daily) LAMICTAL XR KIT 1 primidone tabs 1 MP QL(4 ea daily); lamotrigine chew 25 mg, 5 1 AL(Up to 11 yrs AL(Up to 11 yrs mg rufinamide susp 40 mg/ml 1 old ); MP old ); SP

Nebraska Total Care Formulary September 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea daily); phenytoin sodium extended 1 MP rufinamide tabs 200 mg 1 AL(Up to 11 yrs caps old ); SP phenytoin sodium soln 1 QL(8 ea daily); 1 rufinamide tabs 400 mg AL(Up to 11 yrs phenytoin susp 1 MP old ); SP SPRITAM TB3D 1 MP Succinimides CELONTIN CAPS 1 MP topiramate cpsp 15 mg, 25 1 AL(Up to 11 yrs mg old ); MP MP topiramate cs24 100 mg, MP ethosuximide caps 1 150 mg, 200 mg, 25 mg, 50 1 MP mg ethosuximide soln 1 topiramate tabs 100 mg, 1 MP Valproic Acid 200 mg, 25 mg, 50 mg AL(At least 4 divalproex sodium csdr 1 VIMPAT SOLN IV 200 1 yrs old); MP MG/20ML AL(At least 4 divalproex sodium tb24 1 VIMPAT SOLN OR 10 1 yrs old); MP MG/ML AL(At least 4 divalproex sodium tbec 1 VIMPAT TABS OR 100 1 QL(2 ea daily) yrs old); MP MG, 150 MG, 200 MG valproate sodium soln iv 1 VIMPAT TABS OR 50 MG 1 QL(3 ea daily) 100 mg/ml, 500 mg/5ml valproate sodium soln or 1 MP zonisamide caps 1 MP 250 mg/5ml MP Carbamates valproic acid caps 1 felbamate susp 1 MP ANTIDEPRESSANTS - Drugs to Treat Depression 1 MP felbamate tabs Alpha-2 Receptor Antagonists (Tetracyclics) AL(At least 4 GABA Modulators mirtazapine tabs 1 MP yrs old); MP tiagabine hcl tabs 1 AL(At least 4 mirtazapine tbdp 1 yrs old); MP vigabatrin pack 1 SP Antidepressants - Misc. QL(6 ea daily); vigabatrin tabs 1 PA; QL(1 ea SP APLENZIN TB24 1 daily); AL(At Hydantoins least 4 yrs old) DILANTIN CAPS 30 MG 1 MP bupropion hcl tabs 100 mg, 1 AL(At least 4 75 mg yrs old); MP fosphenytoin sodium soln 1 bupropion hcl tb12 100 mg, 1 AL(At least 4 150 mg, 200 mg yrs old); MP PEGANONE TABS 1 MP QL(1 ea daily); bupropion hcl tb24 450 mg, 1 AL(At least 4 150 mg, 300 mg phenytoin chew 1 MP yrs old); MP

Nebraska Total Care Formulary September 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 AL(At least 4 QL(1 ea daily); maprotiline hcl tabs yrs old); MP paroxetine hcl tabs 20 mg, 1 AL(At least 13 30 mg, 40 mg yrs old); MP Monoamine Oxidase Inhibitors (MAOIs) AL(At least 13 QL(1 ea daily); paroxetine hcl tb24 12.5 1 mg yrs old); MP EMSAM PT24 1 AL(At least 18 yrs old) paroxetine hcl tb24 37.5 1 MP mg, 25 mg AL(At least 4 MARPLAN TABS 1 yrs old) PAXIL SUSP 10 MG/5ML 1 MP AL(At least 4 phenelzine sulfate tabs 1 yrs old); MP PEXEVA TABS 1 AL(At least 13 yrs old) tranylcypromine sulfate 1 AL(At least 4 tabs yrs old); MP sertraline hcl conc 20 1 MP mg/ml N-Methyl-D-aspartic acid (NMDA) Receptor QL(2 ea daily); SPRAVATO 56MG DOSE 1 PA; SP sertraline hcl tabs 100 mg 1 AL(At least 4 SOPK yrs old); MP SPRAVATO 84MG DOSE 1 PA; SP QL(1 ea daily); SOPK sertraline hcl tabs 25 mg 1 AL(At least 4 Selective Serotonin Reuptake Inhibitors (SSRIs) yrs old); MP QL(3 ea daily); citalopram hydrobromide 1 MP soln 10 mg/5ml sertraline hcl tabs 50 mg 1 AL(At least 4 yrs old); MP QL(1 ea daily); citalopram hydrobromide 1 AL(At least 4 Serotonin Modulators tabs 10 mg, 20 mg, 40 mg yrs old); MP AL(At least 4 nefazodone hcl tabs 1 QL(1 ml daily); yrs old); MP escitalopram oxalate soln 5 AL(At least 6 1 trazodone hcl tabs 100 mg, 1 AL(At least 14 mg/5ml yrs old - Up to 50 mg yrs old); MP 18 yrs old); MP QL(1 ea daily); QL(1 ea daily); trazodone hcl tabs 150 mg 1 AL(At least 19 escitalopram oxalate tabs 1 AL(At least 6 10 mg, 20 mg, 5 mg yrs old); MP yrs old); MP QL(2 ea daily); fluoxetine hcl caps 10 mg, 1 AL(At least 4 trazodone hcl tabs 300 mg 1 AL(At least 19 40 mg, 20 mg yrs old); MP yrs old); MP AL(At least 4 fluoxetine hcl cpdr 90 mg 1 QL(1 ea daily); yrs old); MP TRINTELLIX TABS 1 AL(At least 18 yrs old) fluoxetine hcl soln 20 1 MP mg/5ml QL(1 ea daily); VIIBRYD STARTER PACK 1 AL(At least 18 fluoxetine hcl tabs 10 mg, 1 AL(At least 4 KIT 20 mg, 60 mg yrs old); MP yrs old) QL(1 ea daily); fluvoxamine maleate cp24 1 MP 100 mg, 150 mg VIIBRYD TABS 1 AL(At least 18 yrs old) fluvoxamine maleate tabs 1 AL(At least 8 100 mg, 25 mg, 50 mg yrs old); MP Serotonin-Norepinephrine Reuptake Inhibitors QL(6 ea daily); QL(1 ea daily); paroxetine hcl tabs 10 mg 1 AL(At least 13 DESVENLAFAXINE ER 1 TB24 AL(At least 12 yrs old); MP yrs old)

Nebraska Total Care Formulary September 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desvenlafaxine succinate 1 AL(At least 12 Diabetic Other tb24 yrs old) QL(1 ea daily); CVS GLUCOSE CHEW 1 desvenlafaxine tb24 1 AL(At least 12 CVS SOFT GLUCOSE 1 yrs old) CHEW AL(At least 13 duloxetine hcl cpep 1 yrs old); MP DEX4 CHEW 1 AL(At least 18 FETZIMA CP24 1 DEX4 FAST ACTING 1 yrs old) GLUCOSE CHEW FETZIMA TITRATION 1 AL(At least 18 PACK C4PK yrs old) DEX4 NATURALS CHEW 1 AL(At least 13 DEX4 POUCH PACK venlafaxine hcl cp24 1 1 yrs old); MP CHEW AL(At least 13 DEX4 QUICK DISSOLVE venlafaxine hcl tabs 1 1 yrs old); MP GLUCOSE CHEW AL(At least 13 venlafaxine hcl tb24 1 dextrose (diabetic use) gel 1 yrs old); MP Tricyclic Agents GLUCOSE CHEW 1 AL(At least 4 amitriptyline hcl tabs 1 GLUCOSE INSTANT 1 yrs old); MP ENERGY CHEW AL(At least 4 amoxapine tabs 1 yrs old); MP GNP GLUCOSE CHEW 1 AL(At least 4 clomipramine hcl caps 1 GNP QUICK DISSOLVE 1 yrs old); MP GLUCOSE CHEW AL(At least 4 desipramine hcl tabs 1 GOODSENSE GLUCOSE 1 yrs old); MP CHEW doxepin hcl caps 150 mg, AL(At least 4 25 mg, 100 mg, 75 mg, 10 1 yrs old); MP HM GLUCOSE CHEW 1 mg, 50 mg HY-VEE GLUCOSE CHEW 1 doxepin hcl conc 10 mg/ml 1 MP INSTA-GLUCOSE GEL 1 AL(At least 4 imipramine hcl tabs 1 yrs old); MP KROGER GLUCOSE 1 AL(At least 4 CHEW imipramine pamoate caps 1 yrs old); MP LEADER GLUCOSE 1 CHEW nortriptyline hcl caps 10 1 AL(At least 4 mg, 50 mg, 25 mg, 75 mg yrs old); MP LEADER QUICK DISSOLVE GLUCOSE 1 nortriptyline hcl soln 10 1 MP mg/5ml CHEW AL(At least 4 protriptyline hcl tabs 1 LONGS GLUCOSE CHEW 1 yrs old); MP AL(At least 4 MEIJER GLUCOSE CHEW 1 trimipramine maleate caps 1 yrs old); MP PREFERRED PLUS 1 ANTIDIABETICS - Drugs to Regulate Blood GLUCOSE CHEW Sugar

Nebraska Total Care Formulary September 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PX GLUCOSE CHEW 1 deferasirox tabs 1 PA; SP

RA GLUCOSE CHEW 1 Opioid Antagonists QL(1 ea per 28 RELION GLUCOSE CHEW 1 1 days retail); VIVITROL SUSR AL(At least 16 SM GLUCOSE CHEW 1 yrs old); SP ANTIEMETICS - Drugs to Treat Nausea and SMART SENSE 1 GLUCOSE CHEW Vomiting SMART SENSE 5-HT3 Receptor Antagonists GLUCOSE TABLETS 1 QL(16 ml daily) CHEW ondansetron hcl soln 1 TGT GLUCOSE CHEW 1 ANTIHISTAMINES - Drugs to Treat Allergies UP & UP GLUCOSE 1 Antihistamines - Alkylamines CHEW ALA-HIST IR TABS 1 VALUE PLUS GLUCOSE 1 CHEW chlorpheniramine maleate 1 WALGREENS GLUCOSE 1 syrp CHEW chlorpheniramine maleate 1 ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs tabs to Treat Diarrhea chlorpheniramine maleate 1 Antidiarrheal/Probiotic Agents - Misc. tbcr bismuth subsalicylate susp 1 PEDIAVENT SYRP 1 Antidiarrheal/Probiotic Combinations triprolidine hcl liqd 1 lactobacillus acidophilus- 1 TRIPROLIDINE 1 pectin caps HYDROCHLORIDE LIQD Antiperistaltic Agents Antihistamines - Ethanolamines diphenoxylate w/ atropine 1 QL(4 ea daily) liqd clemastine fumarate tabs 1 diphenoxylate w/ atropine 1 diphenhydramine hcl caps 1 QL(4 ea daily) tabs 25 mg QL(8 ea daily); loperamide hcl caps 1 diphenhydramine hcl caps 1 RX/OTC 50 mg QL(8 ea daily) loperamide hcl tabs 1 diphenhydramine hcl elix 1 12.5 mg/5ml ANTIDOTES AND SPECIFIC ANTAGONISTS diphenhydramine hcl liqd 6.25 mg/ml, 12.5 mg/5ml, 1 Antidotes - Chelating Agents 25 mg/10ml, 50 mg/20ml CHEMET CAPS 1 diphenhydramine hcl tabs 1 25 mg PA; SP deferasirox pack 1 DIPHENHYDRAMINE 1 HYDROCHLORIDE LIQD

Nebraska Total Care Formulary September 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antihistamines - Piperidines ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer cyproheptadine hcl syrp 1 Alkylating Agents cyproheptadine hcl tabs 1 GLEOSTINE CAPS 1 ANTIHYPERTENSIVES - Drugs to Treat High Antineoplastic - Hormonal and Related Agents Blood Pressure Antiadrenergic Antihypertensives megestrol acetate susp 1 prazosin hcl caps 1 MP megestrol acetate tabs 1 Vasodilators Chemotherapy Rescue/Antidote/Protective Agents hydralazine hcl tabs 1 MP leucovorin calcium tabs 1 minoxidil tabs 1 MP Mitotic Inhibitors SP ANTIMALARIALS - Drugs to Treat Malaria DOCETAXEL CONC 1 (Parasitic Infections) ANTIPSYCHOTICS/ANTIMANIC AGENTS - Antimalarial Combinations Drugs to Treat Mood Disorders 1 QL(24 ea per Antimanic Agents COARTEM TABS fill retail) AL(At least 4 lithium carbonate caps 1 Antimalarials yrs old); MP AL(At least 4 chloroquine phosphate 1 lithium carbonate tabs 1 tabs yrs old); MP MP AL(At least 4 hydroxychloroquine sulfate 1 lithium carbonate tbcr 1 tabs yrs old); MP mefloquine hcl tabs 1 LITHIUM SOLN 1 MP primaquine phosphate tabs 1 Antipsychotics - Misc. PA; QL(1 ea CAPLYTA CAPS 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS daily) Antimyasthenic/Cholinergic Agents EQUETRO CP12 1 pyridostigmine bromide 1 MP QL(1 ea daily); tabs LATUDA TABS 120 MG, 1 20 MG, 40 MG, 60 MG AL(At least 10 yrs old) pyridostigmine bromide 1 MP tbcr QL(2 ea daily); ANTIMYCOBACTERIAL AGENTS - Drugs to LATUDA TABS 80 MG 1 AL(At least 10 Treat Tuberculosis (Bacterial Infections) yrs old) PA; QL(1 ea Antimycobacterial Agents daily); AL(At NUPLAZID CAPS 1 isoniazid syrp 1 least 18 yrs old) isoniazid tabs 1 rifampin caps 1

Nebraska Total Care Formulary September 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea QL(1 ea daily); paliperidone tb24 1.5 mg, 3 1 AL(At least 12 NUPLAZID TABS 1 daily); AL(At mg, 9 mg least 18 yrs yrs old); MP old) QL(2 ea daily); QL(1 ea daily); paliperidone tb24 6 mg 1 AL(At least 12 VRAYLAR CAPS 1 AL(At least 18 yrs old); MP yrs old) PERSERIS PRSY 1 QL(1 ea per 30 QL(1 ea daily); days retail); SP VRAYLAR CPPK 1 AL(At least 18 RISPERDAL CONSTA 1 QL(1 ea per 14 yrs old) SRER days retail); SP QL(8 ea daily); AL(At least 5 risperidone soln 1 ziprasidone hcl caps 20 mg 1 AL(At least 6 yrs old); MP yrs old); MP AL(At least 5 risperidone tabs 1 QL(4 ea daily); yrs old); MP ziprasidone hcl caps 40 mg 1 AL(At least 6 AL(At least 5 yrs old); MP risperidone tbdp 1 yrs old); MP QL(2.6 ea daily); AL(At Butyrophenones ziprasidone hcl caps 60 mg 1 least 6 yrs old); QL(5 ml per 28 haloperidol decanoate soln 1 MP days retail) QL(2 ea daily); haloperidol lactate conc 1 ziprasidone hcl caps 80 mg 1 AL(At least 6 yrs old); MP haloperidol lactate soln 1 ziprasidone mesylate solr 1 QL(6 ea daily) AL(At least 6 haloperidol tabs 1 Benzisoxazoles yrs old); MP AL(At least 6 Dibenzapines FANAPT TABS 1 yrs old) QL(2 ea daily); asenapine maleate subl 1 AL(At least 10 FANAPT TITRATION 1 AL(At least 6 PACK TABS yrs old) yrs old) AL(At least 6 QL(0..75 ml per clozapine tabs 1 INVEGA SUSTENNA 1 28 days retail); yrs old); MP SUSY 117 MG/0.75ML SP AL(At least 6 clozapine tbdp 1 yrs old); MP INVEGA SUSTENNA 1 QL(1 ml per 28 SUSY 156 MG/ML days retail); SP AL(At least 6 loxapine succinate caps 1 QL(1.5 ml per yrs old); MP INVEGA SUSTENNA 1 28 days retail); AL(At least 6 SUSY 234 MG/1.5ML olanzapine solr im 10 mg 1 SP yrs old) QL(0..25 ml per olanzapine tabs or 10 mg, AL(At least 6 INVEGA SUSTENNA 1 28 days retail); SUSY 39 MG/0.25ML 15 mg, 2.5 mg, 20 mg, 5 1 yrs old); MP SP mg, 7.5 mg QL(0..5 ml per olanzapine tbdp or 10 mg, AL(At least 6 INVEGA SUSTENNA 1 28 days retail); 1 SUSY 78 MG/0.5ML 15 mg, 20 mg, 5 mg yrs old); MP SP quetiapine fumarate tabs AL(At least 6 1 rtl pack lmt 100 mg, 200 mg, 25 mg, 1 yrs old); MP INVEGA TRINZA SUSY 1 amt,90 rtl pack 300 mg, 400 mg, 50 mg lmt day(s),; SP

Nebraska Total Care Formulary September 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); QL(16 ea quetiapine fumarate tb24 1 AL(At least 6 daily); AL(At 150 mg, 200 mg perphenazine tabs 4 mg 1 yrs old); MP least 6 yrs old); QL(2 ea daily); MP quetiapine fumarate tb24 1 AL(At least 6 QL(8 ea daily); 300 mg, 400 mg, 50 mg yrs old); MP perphenazine tabs 8 mg 1 AL(At least 6 QL(2 ea daily); yrs old); MP SAPHRIS SUBL 5 MG 1 AL(At least 10 prochlorperazine edisylate 1 yrs old) soln PA; QL(1 ea AL(At least 6 SECUADO PT24 1 thioridazine hcl tabs 1 daily) yrs old); MP PA AL(At least 6 VERSACLOZ SUSP 1 trifluoperazine hcl tabs 1 yrs old); MP ZYPREXA RELPREVV 1 QL(2 ea per 28 Quinolinone Derivatives SUSR 210 MG, 300 MG days retail); SP QL(1 ea per 28 ABILIFY MAINTENA PRSY 1 ZYPREXA RELPREVV 1 QL(1 ea per 28 days retail); SP SUSR 405 MG days retail); SP ABILIFY MAINTENA SRER 1 QL(1 ea per 28 Dihydroindolones days retail); SP AL(At least 6 molindone hcl tabs 1 MP yrs old); MP aripiprazole soln 1 mg/ml 1 Phenothiazines QL(1.5 ea aripiprazole tabs 10 mg, 15 1 daily); AL(At chlorpromazine hcl soln ij 1 least 6 yrs old); 25 mg/ml, 50 mg/2ml mg, 5 mg MP chlorpromazine hcl tabs or AL(At least 6 1 QL(2 ea daily); 10 mg, 100 mg, 200 mg, 25 yrs old); MP 1 AL(At least 6 mg, 50 mg aripiprazole tabs 2 mg yrs old); MP fluphenazine decanoate 1 AL(At least 6 QL(1 ea daily); soln yrs old); MP aripiprazole tabs 20 mg, 30 1 AL(At least 6 mg fluphenazine hcl conc or 5 1 AL(At least 6 yrs old); MP mg/ml yrs old) QL(1.5 ea fluphenazine hcl elix or 2.5 AL(At least 6 1 aripiprazole tbdp 10 mg, 15 1 daily); AL(At mg/5ml yrs old); MP mg least 6 yrs old); MP fluphenazine hcl soln ij 2.5 1 AL(At least 6 mg/ml yrs old) 1 rtl pack lmt ARISTADA PRSY 1064 1 amt,56 rtl pack fluphenazine hcl tabs or 1 1 AL(At least 6 MG/3.9ML mg yrs old) lmt day(s),; SP ARISTADA PRSY 441 1 rtl pack lmt fluphenazine hcl tabs or 10 1 AL(At least 6 mg, 2.5 mg, 5 mg yrs old); MP MG/1.6ML, 662 MG/2.4ML, 1 amt,28 rtl pack QL(4 ea daily); 882 MG/3.2ML lmt day(s),; SP perphenazine tabs 16 mg 1 AL(At least 6 QL(1 ea daily); yrs old); MP REXULTI TABS 1 AL(At least 18 QL(32 ea yrs old); MP daily); AL(At perphenazine tabs 2 mg 1 Thioxanthenes least 6 yrs old); AL(At least 6 thiothixene caps 1 MP yrs old); MP

Nebraska Total Care Formulary September 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits etonogestrel-ethinyl 1 MP ANTISEPTICS & DISINFECTANTS estradiol ring Antiseptics & Disinfectants Progestin Contraceptives - IUD formaldehyde soln 1 KYLEENA IUD 1 SP Chlorine Antiseptics Progestin Contraceptives - Injectable chlorhexidine gluconate 1 medroxyprogesterone QL(1 ml per fill soln acetate (contraceptive) 1 retail) susp ANTIVIRALS - Drugs to Treat Viral Infections medroxyprogesterone CMV Agents acetate (contraceptive) 1 susy GANCICLOVIR SOLN 1 CORTICOSTEROIDS - Steroid Hormone Drugs to valganciclovir hcl tabs 1 QL(2 ea daily) Treat Systemic Swelling Conditions Glucocorticosteroids CARDIOTONICS - Drugs to Treat Heart Failure dexamethasone sodium and Abnormal Heart Rhythm phosphate soln 20 mg/5ml, 1 Cardiac Glycosides 4 mg/ml digoxin soln 1 MP DEXAMETHASONE SODIUM PHOSPHATE 1 SOLN 4 MG/ML digoxin tabs 1 MP Mineralocorticoids CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions fludrocortisone acetate tabs 1 Prostaglandin Vasodilators COUGH/COLD/ALLERGY - Drugs to Treat Cough, Cold and Allergy Symptoms REMODULIN SOLN 1 PA; SP Antitussives treprostinil soln 1 PA; SP benzonatate caps 100 mg 1 CEPHALOSPORINS - Drugs to Treat Bacterial QL(1 ea daily) Infections benzonatate caps 200 mg 1 Cephalosporins - 3rd Generation dextromethorphan 1 polistirex suer ceftriaxone sodium solr ij 1 1 QL(10 ea per gm, 250 mg, 500 mg fill retail) Cough/Cold/Allergy Combinations ceftriaxone sodium solr ij 2 1 brompheniramine & 1 gm phenyleph elix ceftriaxone sodium solr iv 1 1 brompheniramine & 1 gm pseudoeph elix CONTRACEPTIVES - Drugs to Prevent brompheniramine & 1 Pregnancy pseudoeph liqd Combination Contraceptives - Transdermal chlorpheniramine & 1 phenylephrine tabs norelgestromin-ethinyl 1 MP estradiol ptwk chlorpheniramine & 1 pseudoeph tabs Combination Contraceptives - Vaginal Nebraska Total Care Formulary September 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- guaifenesin soln 100 guaifenesin liqd 10 mg/5ml- mg/5ml, 200 mg/10ml, 300 1 200 mg/5ml, 20 mg/10ml- mg/15ml 400 mg/10ml, 200 mg/5ml- guaifenesin syrp 100 1 10 mg/5ml, 100 mg/5ml-5 mg/5ml mg/5ml, 20 mg/20ml-400 guaifenesin tabs 200 mg 1 mg/20ml, 400 mg/20ml-20 1 mg/20ml, 5 mg/5ml-100 QL(40 ea per mg/5ml, 10 mg/5ml-100 guaifenesin tb12 600 mg 1 mg/5ml, 100 mg/5ml-10 fill retail) mg/5ml, 150 mg/7.5ml-15 Misc. Respiratory Inhalants mg/7.5ml, 20 mg/10ml-200 camphor-eucalyptus- 1 mg/10ml, 200 mg/10ml-20 menthol oint mg/10ml camphor-eucalyptus- dextromethorphan- menthol-turpentine oil-white 1 guaifenesin syrp 10 petrolatum oint mg/5ml-10 mg/5ml-100 1 mg/5ml-100 mg/5ml, 100 CHEST RUB OINT 1 mg/5ml-10 mg/5ml EQ VAPORIZING RUB 1 dextromethorphan- QL(2 ea daily) OINT guaifenesin tb12 30 mg- 1 600 mg, 600 mg-30 mg SM MEDICATED CHEST 1 RUB OINT loratadine & 1 pseudoephedrine tb24 sodium chloride (inhalant) 1 nebu AL(At least 18 M-CLEAR WC SOLN 1 yrs old) Mucolytics phenylephrine w/ dm-gg 1 acetylcysteine soln 1 liqd phenylephrine- 1 DERMATOLOGICALS - Drugs to Treat Skin brompheniramine-dm liqd Conditions phenylephrine-chlorphen- 1 Acne Products dm liqd AKTIPAK PACK 1 phenylephrine-dm-gg w/ 1 apap tabs PA; AL(At least isotretinoin caps 1 promethazine & 1 AL(At least 2 12 yrs old) phenylephrine syrp yrs old) Analgesics - Topical AL(At least 2 promethazine-dm syrp 1 yrs old) menthol (topical analgesic) 1 gel pseudoephed-bromphen- 1 dm syrp menthol (topical analgesic) 1 ptch pseudoephedrine- 1 guaifenesin tb12 Antihistamines-Topical Expectorants diphenhydramine-zinc 1 acetate crea guaifenesin liqd 100 mg/5ml, 200 mg/10ml, 400 1 diphenhydramine-zinc 1 mg/20ml acetate liqd Antineoplastic or Premalignant Lesion Agents -

Nebraska Total Care Formulary September 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluorouracil (topical) crea 1 AQUA GLYCOLIC HAND & 1 AL(Up to 18 yrs BODYLOTION LOTN old ) fluorouracil (topical) soln 1 AQUA LACTEN LOTN 1 AL(Up to 18 yrs old ) Antipruritics - Topical AQUAMED LOTN 1 AL(Up to 18 yrs old ) camphor & menthol lotn 1 AL(Up to 18 yrs AQUAPHILIC OINT 1 camphor & phenol liqd 1 old ) AQUAPHOR ADVANCED 1 AL(Up to 18 yrs Antipsoriatics THERAPY BABY OINT old ) PA; SP STELARA SOLN 1 AQUAPHOR ADVANCED 1 AL(Up to 18 yrs THERAPY HEALING OINT old ) Antiseborrheic Products AQUAPHOR ADVANCED 1 AL(Up to 18 yrs THERAPY OINT old ) pyrithione zinc sham 1 1 AL(Up to 18 yrs AQUAPHOR OINT old ) SEBEX SHAM 1 AVEENO ACTIVE AL(Up to 18 yrs selenium sulfide lotn 1 NATURALS DAILY 1 old ) MOISTURIZING BODY selenium sulfide sham 1 YOGURT LOTN AVEENO ACTIVE AL(Up to 18 yrs Antivirals - Topical NATURALS SKIN RELIEF 1 old ) MOISTURE REPAIR docosanol crea 1 CREA Burn Products AVEENO DAILY AL(Up to 18 yrs MOISTURIZING SHEER 1 old ) silver sulfadiazine crea 1 HYDRATION LOTN AVEENO DAILY AL(Up to 18 yrs Emollient/Keratolytic Agents MOISTURIZINGSPF 15 1 old ) CEROVEL LOTN 1 LOTN AVEENO INTENSE 1 AL(Up to 18 yrs urea crea 20 % 1 RELIEF HAND CREA old ) AVEENO POSITIVELY AL(Up to 18 yrs urea crea 40 % 1 RX/OTC AGELESSFIRMING BODY 1 old ) LOTN urea lotn 40 % 1 AVEENO POSITIVELY 1 AL(Up to 18 yrs RADIANT LOTN old ) Emollients AVEENO POSITIVELY AL(Up to 18 yrs A + D PERSONAL CARE 1 AL(Up to 18 yrs RADIANTINTENSIVE 1 old ) LOTION LOTN old ) NIGHT CREA ALOE AFTERSUN 1 AL(Up to 18 yrs AVEENO POSITIVELY AL(Up to 18 yrs LOTION LOTN old ) RADIANTOVERNIGHT old ) AL(Up to 18 yrs 1 AMLACTIN ULTRA CREA 1 HYDRATING FACIAL old ) MOISTURI CREA AQUA GLYCOLIC FACE 1 AL(Up to 18 yrs AVEENO RESTORATIVE AL(Up to 18 yrs CREAM CREA old ) SKIN THERAPY OAT 1 old ) REPAIRING CREA

Nebraska Total Care Formulary September 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVEENO STRESS RELIEF 1 AL(Up to 18 yrs CETAPHIL DAILY AL(Up to 18 yrs MOISTURIZING LOTN old ) ADVANCE ULTRA 1 old ) AL(Up to 18 yrs HYDRATING LOTN BAG BALM OINT 1 old ) CETAPHIL DAILY FACIAL 1 AL(Up to 18 yrs AL(Up to 18 yrs MOISTURIZER LOTN old ) BASLE CREA 1 old ) CETAPHIL AL(Up to 18 yrs DERMACONTROL old ) BETA CARE CREA 1 AL(Up to 18 yrs 1 old ) MOISTURIZER/SPF 30 LOTN AL(Up to 18 yrs BETA CARE LOTN 1 old ) CETAPHIL 1 AL(Up to 18 yrs MOISTURIZING LOTN old ) AL(Up to 18 yrs BETA XMA CREA 1 old ) CETAPHIL 1 AL(Up to 18 yrs RESTORADERM LOTN old ) BOUDREAUXS BABY AL(Up to 18 yrs BUTT SMOOTH DRY SKIN 1 old ) CETAPHIL THERAPEUTIC 1 AL(Up to 18 yrs OINT HAND CREA old ) CICAPLAST BAUME B5 AL(Up to 18 yrs CAM LOTN 1 AL(Up to 18 yrs old ) SOOTHING MULTI- 1 old ) PURPOSE BALM CREA CERAVE AM FACIAL AL(Up to 18 yrs MOISTURIZING 1 old ) CLN FACIAL AL(Up to 18 yrs LOTION/SPF30 LOTN MOISTURIZER 1 old ) NOURISHING LOTN CERAVE AM SPF 30 1 AL(Up to 18 yrs LOTN old ) COCOA BUTTER HAND & 1 AL(Up to 18 yrs BODYLOTION LOTN old ) AL(Up to 18 yrs CERAVE CREA 1 old ) COCOA BUTTER LOTN 1 AL(Up to 18 yrs old ) CERAVE DAILY 1 AL(Up to 18 yrs MOISTURIZING LOTN old ) COCONUT OIL BEAUTY 1 AL(Up to 18 yrs CREA old ) AL(Up to 18 yrs CERAVE HEALING OINT 1 old ) CVS BEAUTY 360 DRY 1 AL(Up to 18 yrs SKIN LOTN old ) AL(Up to 18 yrs CERAVE LOTN 1 old ) CVS DAILY ULTRA 1 AL(Up to 18 yrs MOISTURELOTION LOTN old ) CERAVE MOISTURIZING 1 AL(Up to 18 yrs CREA old ) CVS DRY SKIN THERAPY 1 AL(Up to 18 yrs CREA old ) CERAVE PM FACIAL AL(Up to 18 yrs CVS MOISTURIZING AL(Up to 18 yrs MOISTURIZING LOTION 1 old ) 1 ULTRA LIGHTWEIGHT CREAM CREA old ) LOTN DAILY CONDITIONING 1 AL(Up to 18 yrs AL(Up to 18 yrs TREATMENT OINT old ) CERAVE PM LOTN 1 old ) DAILY MOISTURIZING 1 AL(Up to 18 yrs LOTION LOTN old ) CERAVE RENEWING SA 1 AL(Up to 18 yrs CREA old ) DAILY MOISTURIZING 1 AL(Up to 18 yrs LOTN old ) CERAVE SA RENEWING 1 AL(Up to 18 yrs LOTN old ) DERMABASEOIL IN 1 AL(Up to 18 yrs WATER CREA old ) CERAVE SA/ROUGH AND 1 AL(Up to 18 yrs BUMPYSKIN CREA old ) DERMAIDE ALOE CREA 1 AL(Up to 18 yrs old ) CERAVE SA/ROUGH AND 1 AL(Up to 18 yrs BUMPYSKIN LOTN old )

Nebraska Total Care Formulary September 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMAL THERAPY AL(Up to 18 yrs AL(Up to 18 yrs emollient oint 1 EXTRA STRENGTH BODY 1 old ) old ) LOTION LOTN AL(Up to 18 yrs EPILYT LOTN 1 DERMAL THERAPY FACE AL(Up to 18 yrs old ) CAREMOISTURIZING 1 old ) EQ THERAPEUTIC DRY 1 AL(Up to 18 yrs LOTION LOTN SKIN CREA old ) DERMAL THERAPY FOOT 1 AL(Up to 18 yrs EQ THERAPEUTIC AL(Up to 18 yrs MASSAGE LOTN old ) MOISTURIZING CREAM 1 old ) DERMAL THERAPY HAND AL(Up to 18 yrs CREA ELBOW & KNEE CREAM 1 old ) EQL ADVANCED AL(Up to 18 yrs LOTN RECOVERY SKIN CARE 1 old ) DERMAL THERAPY HEEL 1 AL(Up to 18 yrs LOTN CARE LOTN old ) EQL MOISTURIZING 1 AL(Up to 18 yrs DERMEND ALPHA + AL(Up to 18 yrs CREAM CREA old ) BETA HYDROXY 1 old ) EQL ULTRA AL(Up to 18 yrs THERAPY CREA MOISTURIZING DAILY 1 old ) DERMEND ALPHA + AL(Up to 18 yrs LOTION LOTN BETA HYDROXY 1 old ) EUCERIN ADVANCED 1 AL(Up to 18 yrs THERAPY LOTN REPAIR CREA old ) DERMEND FRAGILE SKIN AL(Up to 18 yrs EUCERIN BABY LOTN 1 AL(Up to 18 yrs MOISTURIZING 1 old ) old ) FORMULA CREA EUCERIN DAILY AL(Up to 18 yrs DERMEND AL(Up to 18 yrs PROTECTION/SPF 30 1 old ) MOISTURIZING BRUISE 1 old ) LOTN FORMULA CREA EUCERIN INTENSIVE 1 AL(Up to 18 yrs DIABETIDERM CREA 1 AL(Up to 18 yrs REPAIR LOTN old ) old ) EUCERIN INTENSIVE 1 AL(Up to 18 yrs DIABETIDERM FOOT 1 AL(Up to 18 yrs REPAIRHAND CREA old ) REJUVENATING CREA old ) AL(Up to 18 yrs EUCERIN LOTN 1 DIABETIDERM HAND & 1 AL(Up to 18 yrs old ) BODY LOTN old ) EUCERIN ORIGINAL AL(Up to 18 yrs AL(Up to 18 yrs DIABETIDERM LOTN 1 HEALINGSOOTHING 1 old ) old ) REPAIR LOTN AL(Up to 18 yrs DMAE CREA 1 EUCERIN PLUS CREA 1 AL(Up to 18 yrs old ) old ) AL(Up to 18 yrs DML FORTE CREA 1 EUCERIN PLUS LOTN 1 AL(Up to 18 yrs old ) old ) ELON SKIN REPAIR 1 AL(Up to 18 yrs EUCERIN AL(Up to 18 yrs SYSTEM CREA old ) PROFESSIONAL REPAIR 1 old ) EMOLLIA-CREME CREA 1 AL(Up to 18 yrs RICH FEEL LOTN old ) EUCERIN ROUGHNESS 1 AL(Up to 18 yrs EMOLLIA-LOTION LOTN 1 AL(Up to 18 yrs RELIEF CREA old ) old ) EUCERIN ROUGHNESS 1 AL(Up to 18 yrs AL(Up to 18 yrs RELIEF LOTN old ) emollient crea 1 old ) EUCERIN SMOOTHING AL(Up to 18 yrs AL(Up to 18 yrs REPAIRADVANCED 1 old ) emollient lotn 1 old ) FORMULA LOTN Nebraska Total Care Formulary September 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(Up to 18 yrs AL(Up to 18 yrs GENTLE CREA 1 HYDRASYN25 CREA 1 old ) old ) glycerin (topical) liqd 1 HYDRAZONE LOTION 1 AL(Up to 18 yrs LOTN old ) GOLD BOND MEDICATED AL(Up to 18 yrs J & J BURN CREAM CREA 1 AL(Up to 18 yrs BODYLOTION EXTRA 1 old ) old ) STRENGTH LOTN JOHNSONS SKIN AL(Up to 18 yrs GOLD BOND MEDICATED 1 AL(Up to 18 yrs NOURISH VANILLA OAT 1 old ) BODYLOTION LOTN old ) LOTION LOTN GOLD BOND ULTIMATE AL(Up to 18 yrs AL(Up to 18 yrs KERADAN CREA 1 DIABETICS DRY SKIN 1 old ) old ) RELIEF LOTN KERI ADVANCED AL(Up to 18 yrs GOLD BOND ULTIMATE AL(Up to 18 yrs MOISTURE THERAPY 1 old ) DIABETICS' DRY RELIEF 1 old ) LOTN LOTN KERI BASIC ESSENTIALS 1 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs LOTN old ) HEALING CREA old ) KERI LONG LASTING 1 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs CREA old ) HEALING LOTN old ) KERI NOURISHING SHEA 1 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs BUTTER LOTN old ) HEALING OINT old ) KERI ORIGINAL DAILY 1 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs MOISTURE LOTN old ) LOTN old ) AL(Up to 18 yrs KERI ORIGINAL LOTN 1 GOLD BOND ULTIMATE 1 AL(Up to 18 yrs old ) OVERNIGHT LOTN old ) AL(Up to 18 yrs KERI OVERNIGHT LOTN 1 GOLD BOND ULTIMATE 1 AL(Up to 18 yrs old ) PROTECTION LOTN old ) KERI RENEWAL MILK 1 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs BODY LOTN old ) RESTORING LOTN old ) KERI RENEWAL SKIN 1 AL(Up to 18 yrs GOLD BOND ULTIMATE AL(Up to 18 yrs FIRMING LOTN old ) ROUGH& BUMPY SKIN 1 old ) KERI RENEWAL AL(Up to 18 yrs CREA STRETCH MARK 1 old ) GOLD BOND ULTIMATE AL(Up to 18 yrs MINIMIZER LOTN SHEERRIBBONS 1 old ) KERI SENSITIVE SKIN 1 AL(Up to 18 yrs PEARLRADIANCE LOTN LOTN old ) GOLD BOND ULTIMATE AL(Up to 18 yrs lactic acid (ammonium 1 AL(Up to 18 yrs SHEERRIBBONS 1 old ) lactate) crea old ); RX/OTC SILKSOFTNESS LOTN lactic acid (ammonium 1 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs lactate) lotn old ); RX/OTC SOFTENING LOTN old ) AL(Up to 18 yrs LACTINOL HX CREA 1 GOLD BOND ULTIMATE 1 AL(Up to 18 yrs old ) SOOTHING CREA old ) LADY ESTHER 4 AL(Up to 18 yrs GOLD BOND ULTIMATE 1 AL(Up to 18 yrs PURPOSE FACE CREAM 1 old ) SOOTHING LOTN old ) CREA AL(Up to 18 yrs GRX VITAMIN E LOTN 1 LANAPHILIC OINT 1 AL(Up to 18 yrs old ) old )

Nebraska Total Care Formulary September 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER FINGER CREAM 1 AL(Up to 18 yrs NEUTROGENA HEALTHY 1 AL(Up to 18 yrs CREA old ) SKIN CREA old ) LUBRIDERM ADVANCED 1 AL(Up to 18 yrs NEUTROGENA HEALTHY 1 AL(Up to 18 yrs THERAPY LOTN old ) SKIN FACE SPF 15 LOTN old ) LUBRIDERM DAILY AL(Up to 18 yrs NEUTROGENA AL(Up to 18 yrs MOISTURE/NORMAL TO 1 old ) MOISTURE SENSITIVE 1 old ) DRY SKIN LOTN SKIN LOTN LUBRIDERM DAILY AL(Up to 18 yrs NISEKO HYDRATING AL(Up to 18 yrs MOISTURESHEA + 1 old ) FACIAL MOISTURIZER 1 old ) CALMING LAVENDER CREA JASMINE LOTN AL(Up to 18 yrs NIVEA CREA 1 LUBRIDERM INTENSE 1 AL(Up to 18 yrs old ) SKIN REPAIR LOTN old ) NIVEA EXTRA ENRICHED 1 AL(Up to 18 yrs LUBRIDERM LOTN 1 AL(Up to 18 yrs LOTION LOTN old ) old ) NIVEA EXTRA ENRICHED 1 AL(Up to 18 yrs LUBRIDERM MENS 3-IN-1 1 AL(Up to 18 yrs LOTN old ) LOTN old ) NIVEA GENTLE BODY 1 AL(Up to 18 yrs LUBRIDERM SERIOUSLY 1 AL(Up to 18 yrs EXFOLIATOR LOTN old ) SENSITIVE LOTN old ) NIVEA LIGHT CREA 1 AL(Up to 18 yrs LUBRIDERM SKIN AL(Up to 18 yrs old ) NOURISHINGWITH SHEA old ) 1 NIVEA LIGHT LOTN 1 AL(Up to 18 yrs AND COCOA BUTTERS old ) LOTN AL(Up to 18 yrs NIVEA LOTN 1 LUBRISOFT LOTN 1 AL(Up to 18 yrs old ) old ) AL(Up to 18 yrs NIVEA ORIGINAL LOTN 1 MAXAM LOTN 1 AL(Up to 18 yrs old ) old ) NIVEA ORIGINAL 1 AL(Up to 18 yrs MEDERMA AG FACE 1 AL(Up to 18 yrs MOISTURE LOTN old ) CREAM CREA old ) AL(Up to 18 yrs NIVEA SOFT CREA 1 MEDERMA AG HAND & 1 AL(Up to 18 yrs old ) BODY LOTION LOTN old ) AL(Up to 18 yrs NIVEA VISAGE CREA 1 MEDERMA STRETCH 1 AL(Up to 18 yrs old ) MARKS THERAPY CREA old ) NIVEA VISAGE INNER AL(Up to 18 yrs MOISTURIZING CREAM 1 AL(Up to 18 yrs BEAUTY NIGHTTIME 1 old ) CREA old ) RENEWAL CREA AL(Up to 18 yrs MOTHERS FRIEND CREA 1 NIVEA VISAGE LOTN 1 AL(Up to 18 yrs old ) old ) AL(Up to 18 yrs MOTHERS FRIEND LOTN 1 NUTRADERM ADVANCED 1 AL(Up to 18 yrs old ) FORMULA LOTN old ) AL(Up to 18 yrs MSM SKIN LOTION LOTN 1 NUTRADERM CREA 1 AL(Up to 18 yrs old ) old ) NEUTROGENA BODY AL(Up to 18 yrs NUTRADERM LOTN 1 AL(Up to 18 yrs LIGHT SESAME 1 old ) old ) FORMULA LOTN AL(Up to 18 yrs OINTMENT BASE OINT 1 NEUTROGENA HAND 1 AL(Up to 18 yrs old ) CREA old )

Nebraska Total Care Formulary September 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OKEEFFES WORKING AL(Up to 18 yrs 1 PRETTY FEET & HANDS 1 AL(Up to 18 yrs HANDS CREA old ) CREA old ) PALMERS COCOA AL(Up to 18 yrs RA ADVANCED HEALING 1 AL(Up to 18 yrs BUTTER FORMULA 1 old ) OINT old ) CONCENTRATED CREAM RA DAYLOGIC HEALING AL(Up to 18 yrs CREA DRY SKIN THERAPY 1 old ) PALMERS COCOA AL(Up to 18 yrs LOTN BUTTER FORMULA 1 old ) RA RENEWAL DRY SKIN 1 AL(Up to 18 yrs CREAM CREA THERAPY LOTN old ) PALMERS COCOA AL(Up to 18 yrs RADIAGUARD 1 AL(Up to 18 yrs BUTTER FORMULA 1 old ) ADVANCED LOTN old ) INTENSIVE RELIEF HAND CREAM CREA RESTA CREA 1 AL(Up to 18 yrs old ) PALMERS COCOA AL(Up to 18 yrs AL(Up to 18 yrs BUTTER FORMULA 1 old ) RESTA LITE LOTN 1 LOTION FRAGRANCE old ) AL(Up to 18 yrs FREE LOTN RISABAL-PH CREA 1 PALMERS COCOA AL(Up to 18 yrs old ) BUTTER FORMULA 1 old ) ROC DEEP WRINKLE 1 AL(Up to 18 yrs LOTION LOTN SERUM LOTN old ) PALMERS COCOA AL(Up to 18 yrs ROC MULTI CORREXION AL(Up to 18 yrs BUTTER FORMULA old ) 5 IN1 RESTORING EYE 1 old ) MASSAGE 1 CREAM CREA CREAM/STRETCH ROC MULTI CORREXION AL(Up to 18 yrs MARKS CREA 5 IN1 RESTORING NIGHT 1 old ) PALMERS COCOA AL(Up to 18 yrs CREAM CREA BUTTER FORMULA old ) ROC RETINOL 1 AL(Up to 18 yrs MASSAGE 1 CORREXION CREA old ) LOTION/STRETCH ROC RETINOL 1 AL(Up to 18 yrs MARKS LOTN CORREXION MAX CREA old ) PALMERS COCOA AL(Up to 18 yrs ROC RETINOL AL(Up to 18 yrs BUTTER FORMULA 1 old ) CORREXION NIGHT 1 old ) NIGHT CREAM CREA MOISTURE RICH CREA ROC RETINOL AL(Up to 18 yrs PALMERS COCONUT OIL AL(Up to 18 yrs CORREXION SENSITIVE 1 old ) FORMULA BODY LOTION 1 old ) EYE CREA LOTN ROC RETINOL AL(Up to 18 yrs PALMERS COCONUT OIL AL(Up to 18 yrs CORREXION SENSITIVE 1 old ) FORMULA HAND CREAM 1 old ) NIGHT CREA CREA AL(Up to 18 yrs ROSE MILK LOTN 1 PEN-KERA CREA 1 AL(Up to 18 yrs old ) old ) AL(Up to 18 yrs SKIN REPAIR LOTN 1 PENTRAVAN CREA 1 AL(Up to 18 yrs old ) old ) SOOTHE & COOL AL(Up to 18 yrs AL(Up to 18 yrs PENTRAVAN PLUS CREA 1 MOISTURIZING BODY 1 old ) old ) LOTION WITH ALOE PETROLATUM OINT 1 AL(Up to 18 yrs LOTN old )

Nebraska Total Care Formulary September 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOOTHE & COOL SKIN AL(Up to 18 yrs SANTYL OINT 1 PA CREAMWITH ALOE & 1 old ) VITAMINS A, D & E CREA Keratolytic/Antimitotic Agents SORBOLENE CREA 1 AL(Up to 18 yrs old ) DUOFILM SOLN 1 SPECIAL CARE CREAM 1 AL(Up to 18 yrs CREA old ) salicylic acid liqd 1 ST IVES SWISS AL(Up to 18 yrs salicylic acid soln 1 FORMULA 24HOUR 1 old ) MOISTURE LOTN Liniments STUDIO 35 EXTRA AL(Up to 18 yrs camphor-menthol-methyl 1 MOISTURIZING LOTION 1 old ) salicylate crea LOTN COATS ALOE LINIMENT 1 STUDIO 35 AL(Up to 18 yrs LOTN MOISTURIZING SKIN 1 old ) CREA menthol-methyl salicylate 1 (liniments) crea THERABETIC SKIN CARE 1 AL(Up to 18 yrs LOTN old ) menthol-methyl salicylate 1 (liniments) oint THERAPEUTIC 1 AL(Up to 18 yrs MOISTURIZING CREA old ) trolamine salicylate crea 1 THERAPLEX AL(Up to 18 yrs 1 ZIKS ARTHRITIS PAIN 1 HYDROLOTION LOTN old ) RELIEF CREA UDDERLY SMOOTH 1 AL(Up to 18 yrs CREA old ) Local Anesthetics - Topical ARTHRITIS PAIN UDDERLY SMOOTH 1 AL(Up to 18 yrs 1 EXTRA CARE CREA old ) RELIEVING CREA benzocaine-isopropyl UDDERLY SMOOTH 1 AL(Up to 18 yrs 1 EXTRA CARE20 CREA old ) alcohol pads benzocaine-triclosan aero 1 VANICREAM CREA 1 AL(Up to 18 yrs old ) capsaicin crea 1 VANICREAM LOTN 1 AL(Up to 18 yrs old ) AL(Up to 18 yrs CAPZASIN LIQD 1 VANICREAM OINT 1 old ) CVS AFTERSUN ALOE VERA COOLING 1 VELVACHOL CREA 1 AL(Up to 18 yrs old ) GEL/LIDOCAINE GEL VITAMIN E WITH 1 AL(Up to 18 yrs CVS CAPSAICIN LIQD 1 PANTHENOL CREA old ) AL(Up to 18 yrs vitamins a & d (topical) oint 1 dibucaine oint 1 old ) WIBI LOTN 1 AL(Up to 18 yrs GNP CAPSAICIN LIQD 1 old ) GOODSENSE CAPSAICIN ZIMS CRACK CREME 1 AL(Up to 18 yrs ARTHRITIS PAIN RELIEF 1 DAYTIME CREA old ) LIQD Enzymes - Topical ITCH-X GEL 1

Nebraska Total Care Formulary September 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ITCH-X SOLN 1 CARRINGTON MOISTURE 1 AL(Up to 18 yrs BARRIER CREA old ) lidocaine aero 0.5 % 1 CARRINGTON MOISTURE 1 AL(Up to 18 yrs BARRIER/ZINC CREA old ) LIDOCAINE CREA 3 %, 5 1 % CERAVE OINT 1 lidocaine crea 4 % 1 CHAPSTICK OVERNIGHT 1 OINT lidocaine hcl crea 3 % 1 RX/OTC CHAPSTICK ULTRASMOOTH FORTIFY 1 lidocaine hcl crea 4 % 1 OINT CHAPSTICK lidocaine hcl gel 2 % 1 ULTRASMOOTH 1 NOURISH OINT lidocaine hcl prsy 2 % 1 CHAPSTICK RX/OTC ULTRASMOOTH 1 lidocaine ptch 4 % 1 REJUVENATE OINT QL(90 ea per CHAPSTICK lidocaine ptch 5 % 1 fill retail) ULTRASMOOTH SOOTHE 1 OINT lidocaine-prilocaine crea 1 CVS ISOPROPYL 1 QL(13.34 ea ALCOHOL WIPES MISC daily) pramoxine-calamine lotn 1 DERMADROX OINT 1 pramoxine-zinc acetate lotn 1 dimethicone (topical) lotn 1 QC PAIN RELIEF LIQUID 1 CAPSAICIN LIQD DR SMITHS ADULT 1 BARRIER OINT Misc. Topical DR SMITHS DIAPER OINT 1 A+D FIRST AID OINT 1 DR SMITHS DIAPER 1 ABSORBASE OINT 1 QUICK RELIEF OINT

ALCOHOL WIPES MISC 1 QL(13.34 ea DRYSOL SOLN 1 daily) GERI PROTECT OINT 1 ALOE VESTA 1 PROTECTIVE OINT GNP ISOPROPYL 1 QL(13.34 ea AMERIDERM 1 ALCOHOL WIPES MISC daily) PERISHIELD OINT AL(Up to 18 yrs HYDROCERIN CREA 1 AQUAPHOR LIP REPAIR 1 old ) OINT ISOPROPYL ALCOHOL 1 QL(13.34 ea BASIS FACIAL 1 AL(Up to 18 yrs WIPES MISC daily) MOISTURIZER CREA old ) LANTISEPTIC SKIN 1 BASIS OVERNIGHT CREA 1 AL(Up to 18 yrs PROTECTANT OINT old ) lubricants gel 1 CARMEX CLASSIC LIP 1 BALM OINT

Nebraska Total Care Formulary September 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDPURA ALCOHOL 1 QL(13.34 ea Scabicides & Pediculicides PADS MISC daily) NEOSPORIN LIP HEALTH LYCELLE GEL 1 OVERNIGHT RENEWAL 1 THERAPY OINT nit remover gel 1 PALOMAR E OINT 1 pyrethrins-piperonyl butoxide-permethrin-nit 1 PETROLEUM JELLY LIP 1 remover kit TREATMENT OINT Tar Products RA ISOPROPYL 1 QL(13.34 ea ALCOHOL WIPES MISC daily) coal tar extract sham 1 REMEDY CLEAR-AID 1 OINT DIAGNOSTIC PRODUCTS REMEDY PHYTOPLEX 1 AL(Up to 18 yrs Diagnostic Tests HYDRAGUARD CREA old ) CHEMSTRIP-K STRP 1 SENSI-CARE 1 AL(Up to 18 yrs MOISTURIZING CREA old ) FORA GTEL BLOOD AL(Up to 18 yrs skin protectants, misc. crea 1 KETONE TEST STRIPS 1 old ) STRP skin protectants, misc. oint 1 GOJJI BLOOD KETONE 1 TEST STRIPS STRP SOOTHE & COOL FREE 1 MEDSEPTIC OINT KETONE STRP 1 SOOTHE & COOL FREE KETONE TEST STRIPS 1 MOISTURE BARRIER 1 STRP OINT SOOTHE & COOL KETOSTIX STRP 1 MOISTURE BARRIER 1 NOVA MAX PLUS OINT KETONE TESTSTRIPS 1 SOOTHE & COOL STRP PROTECT MOISTURE 1 BARRIER OINT PRECISION XTRA STRP 1 SORBIDON HYDRATE AL(Up to 18 yrs 1 PTS PANELS KETONE 1 CREA old ) TEST STRP witch hazel (hamamelis 1 RELION KETONE TEST 1 virginiana) pads STRIPS STRP witch hazel-glycerin pads 1 RELION TRUE METRIX RX/OTC BLOODGLUCOSE TEST 1 zinc oxide (topical) oint 1 STRIPS STRP TRUE METRIX BLOOD RX/OTC Rosacea Agents GLUCOSETEST STRIPS 1 STRP metronidazole (topical) 1 crea TRUE METRIX SELF RX/OTC MONITORING BLOOD 1 metronidazole (topical) gel 1 GLUCOSE STRIPS STRP RX/OTC metronidazole (topical) lotn 1 TRUETEST STRIPS STRP 1

Nebraska Total Care Formulary September 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUETRACK BLOOD 1 RX/OTC Posterior Pituitary Hormones GLUCOSE TEST STRP desmopressin acetate 1 PA TRUETRACK TEST STRP 1 RX/OTC spray refrigerated soln desmopressin acetate 1 PA DIGESTIVE AIDS - Drugs to Treat Low Digestive spray soln Enzymes desmopressin acetate tabs 1 MP Digestive Enzymes lactase chew 1 Somatostatic Agents SIGNIFOR LAR SRER 1 PA; SP lactase tabs 1 ESTROGENS - Hormone Replacement/Modifying DIURETICS - Drugs to Treat Heart, Circulation Drugs Conditions and Blood Pressure Estrogen Combinations Carbonic Anhydrase Inhibitors estradiol & norethindrone 1 acetazolamide cp12 1 MP acetate tabs PREMPRO TABS 1 acetazolamide tabs 1 MP Estrogens methazolamide tabs 1 MP ALORA PTTW 1 MP Loop Diuretics estradiol pttw 1 MP furosemide soln 1 MP ENDOCRINE AND METABOLIC AGENTS - estradiol ptwk 1 MISC. - Drugs to Treat Bone Disease and MP Regulate Hormones estradiol tabs 1 LHRH/GnRH Agonist Analog Pituitary PREMARIN TABS 1 PA; SP TRIPTODUR SRER 1 GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs Metabolic Modifiers Antiflatulents calcitriol caps 0.25 mcg 1 MP simethicone caps 1 calcitriol caps 0.5 mcg 1 PA; MP simethicone chew 1 AL(Up to 11 yrs calcitriol soln 1 mcg/ml 1 old ); MP simethicone liqd 1 cinacalcet hcl tabs 1 SP simethicone susp 1 levocarnitine (metabolic 1 modifiers) soln Inflammatory Bowel Agents levocarnitine (metabolic 1 INFLECTRA SOLR 1 PA; SP modifiers) tabs PA; SP NITYR TABS 1 PA; SP RENFLEXIS SOLR 1

RAYALDEE CPCR 1 PA; QL(2 ea Intestinal Acidifiers daily) Nebraska Total Care Formulary September 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lactulose (encephalopathy) 1 folic acid tabs or 1 mg 1 RX/OTC; MP soln Tryptophan Hydroxylase Inhibitors folic acid tabs or 800 mcg, 1 400 mcg XERMELO TABS 1 PA; QL(3 ea daily); SP Hematopoietic Mixtures GENITOURINARY AGENTS - MISCELLANEOUS folic acid-vitamin b6-vitamin 1 - Miscellaneous Drugs to Treat Reproductive b12 tabs Organs and Urinary System FUSION CAPS 1 Alkalinizers INTEGRA CAPS 1 potassium citrate 1 MP (alkalinizer) tbcr iron-docusate-b12-folic RX/OTC acid-vit c-vit e-copper-biotin 1 sodium citrate & citric acid 1 RX/OTC soln tabs Genitourinary Irrigants iron-vitamin c tabs 1 neomycin/polymyxin b gu 1 soln Iron sodium chloride (gu 1 carbonyl iron susp 1 irrigant) soln Interstitial Cystitis Agents EZFE 200 CAPS 1 ELMIRON CAPS 1 FERRETTS IPS SOLN 1

Urinary Analgesics FERRETTS TABS 1 phenazopyridine hcl tabs 1 ferrous fumarate tabs 1 HEMATOLOGICAL AGENTS - MISC. - Drugs to FERROUS GLUCONATE Treat Blood Disorders 1 TABS 324 MG Hematorheologic Agents ferrous gluconate tabs 324 1 pentoxifylline tbcr 1 MP mg, 240 mg, 27 mg ferrous sulfate elix 220 1 Platelet Aggregation Inhibitors mg/5ml cilostazol tabs 1 MP FERROUS SULFATE LIQD 1 220 MG/5ML HEMATOPOIETIC AGENTS - Drugs to Treat ferrous sulfate soln 15 1 Blood Disorders mg/ml Cobalamins ferrous sulfate syrp 300 1 mg/5ml cyanocobalamin soln ij 1 QL(1 ml per fill 1000 mcg/ml retail) ferrous sulfate tabs 325 1 MP mg, 65 mg cyanocobalamin tabs or 250 mcg, 1000 mcg, 100 1 ferrous sulfate tbcr 142 mg, 1 mcg, 500 mcg 45 mg FERROUS SULFATE 1 Folic Acid/Folates TBEC 324 MG folic acid soln ij 5 mg/ml 1 ferrous sulfate tbec 325 mg 1 MP

Nebraska Total Care Formulary September 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits polysaccharide iron 1 KONSYL DAILY 1 complex caps PSYLLIUM FIBER PACK HEMOSTATICS - Drugs to Stop Bleeding/Treat KONSYL ORIGINAL DAILY 1 Blood Disorders FIBER PACK Hemostatics - Systemic KONSYL-D POWD 1 SP aminocaproic acid soln 1 methylcellulose (laxative) 1 powd aminocaproic acid tabs 1 SP methylcellulose (laxative) 1 tabs tranexamic acid tabs 1 psyllium caps 1 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS psyllium powd 1 Antihistamine Hypnotics wheat dextrin powd 1 diphenhydramine hcl 1 (sleep) caps 25 mg Laxative Combinations diphenhydramine hcl 1 peg 3350-kcl-nacl-na (sleep) liqd 50 mg/30ml sulfate-na ascorbate- 1 ascorbic acid solr diphenhydramine hcl 1 QL(1 ea daily) (sleep) tabs 25 mg peg 3350-kcl-sod bicarb- diphenhydramine- sod chloride-sod sulfate 1 acetaminophen (sleep) 1 solr tabs peg 3350-potassium chloride-sod bicarbonate- 1 doxylamine succinate 1 (sleep) tabs sod chloride solr sennosides-docusate QL(4 ea daily) ibuprofen-diphenhydramine 1 1 citrate tabs sodium tabs Barbiturate Hypnotics Laxatives - Miscellaneous FLEET LIQUID GLYCERIN phenobarbital elix 20 1 MP 1 mg/5ml SUPPOSITORIES ENEM phenobarbital soln 20 1 MP glycerin (laxative) supp 1 mg/5ml phenobarbital tabs 100 mg, MP lactulose soln 1 60 mg, 64.8 mg, 97.2 mg, 1 15 mg, 16.2 mg, 30 mg polyethylene glycol 3350 1 pack 17 gm phenobarbital tabs 32.4 mg 1 polyethylene glycol 3350 1 QL(34 gm powd 17 gm/scoop daily) LAXATIVES - Bowel Treatment Drugs Lubricant Laxatives Bulk Laxatives mineral oil enem re 100 % 1 calcium polycarbophil tabs 1 MINERAL OIL OIL OR 1 RX/OTC KONSYL DAILY FIBER 1 PACK mineral oil oil or 100 %, 1 RX/OTC 99.9 %

Nebraska Total Care Formulary September 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Saline Laxatives docusate sodium tabs or 1 100 mg magnesium citrate soln 1 DOCUSOL PLUS MINI- 1 magnesium hydroxide susp QL(32 ml daily) ENEMA ENEM 1200 mg/15ml, 2400 1 ENEMEEZ PLUS ENEM 1 mg/30ml, 400 mg/5ml, 7.75 %, PEDIA-LAX LIQD 1 magnesium hydroxide susp 1 2400 mg/10ml MEDICAL DEVICES AND SUPPLIES magnesium sulfate 1 (laxative) gran Blood Pressure Devices 10 SERIES BLOOD PEDIA-LAX CHEW 1 PRESSUREMONITOR/UP 1 PER ARM DEVI sodium phosphates enem 1 3 SERIES BLOOD Stimulant Laxatives PRESSURE 1 MONITOR/WRIST DEVI bisacodyl supp 1 ADVOCATE ARM BLOOD PRESSURE 1 bisacodyl tbec 1 MONITOR/LARGE DEVI AUTOMATIC BLOOD castor oil oil 1 PRESSUREMONITOR 1 DEVI FLEET BISACODYL ENEM 1 BLOOD PRESSURE 1 sennosides chew 1 MONITOR 3SERIES DEVI BLOOD PRESSURE sennosides liqd 1 MONITOR AUTOMATIC 1 WRIST MISC sennosides syrp 1 BLOOD PRESSURE MONITOR 1 sennosides tabs 1 AUTOMATIC/ARM DEVI BLOOD PRESSURE Surfactant Laxatives MONITOR 1 docusate calcium caps 1 AUTOMATIC/ARM MISC BLOOD PRESSURE docusate sodium caps or 1 QL(3 ea daily) MONITOR 1 100 mg AUTOMATIC/WRIST MISC docusate sodium caps or 1 BLOOD PRESSURE 250 mg MONITOR PREMIUM 1 ARM/VOICE ASSIST MISC docusate sodium enem re 1 283 mg/5ml BLOOD PRESSURE docusate sodium liqd or MONITOR/AUTO ARM 1 100 mg/10ml, 150 1 DEVI mg/15ml, 50 mg/5ml BLOOD PRESSURE MONITOR/AUTOMATIC 1 docusate sodium syrp or 1 60 mg/15ml DELUXE MISC

Nebraska Total Care Formulary September 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BLOOD PRESSURE CLEVER CHOICE MONITOR/AUTOMATIC 1 PREMIUM BLOOD MISC PRESSURE 1 BLOOD PRESSURE MONITOR/UPPER ARM MONITOR/AUTOMATIC/W 1 DEVI RIST DEVI CVS ADVANCED BLOOD BLOOD PRESSURE PRESSURE MONITOR 1 MONITOR/BASIC ARM 1 DEVI DEVI CVS BLOOD PRESSURE BLOOD PRESSURE MONITOR 1 MONITOR/DELUXE ARM 1 PREMIUM/WRIST MISC DEVI CVS BLOOD PRESSURE BLOOD PRESSURE MONITOR 1 MONITOR/DELUXE ARM 1 PROFESSIONAL/ARM MISC MISC BLOOD PRESSURE CVS BLOOD PRESSURE MONITOR/DELUXE 1 MONITOR/AUTOMATIC 1 WRIST DEVI MISC BLOOD PRESSURE CVS SERIES 100 BLOOD MONITOR/FULLY 1 PRESSURE MONITOR 1 AUTOMATIC DEVI DEVI BLOOD PRESSURE CVS SERIES 400 BLOOD MONITOR/PREMIUM ARM 1 PRESSURE 1 DEVI MONITOR/UPPER ARM DEVI BLOOD PRESSURE MONITORDIGITAL/AUTO 1 CVS SERIES 400W MATIC MISC BLOOD PRESSURE 1 MONITOR/WRIST DEVI CARETOUCH BLOOD PRESSUREMONITOR/AU 1 CVS SERIES 600 BLOOD TOMATIC/ARM DEVI PRESSURE MONITOR 1 DEVI CARETOUCH BLOOD PRESSUREMONITOR/AU 1 FORA P20 BLOOD TOMATIC/WRIST DEVI PRESSURE MONITORING 1 SYSTEM DEVI CLEVER CHOICE BLOOD PRESSURE 1 FORA TEST N' GO BP MONITOR/ARM DEVI BLOODPRESSURE 1 MONITORING SYSTEM CLEVER CHOICE BLOOD DEVI PRESSURE 1 MONITOR/UPPER ARM H-E-B INCONTROL FULLY DEVI AUTOMATIC BLOOD 1 PRESSURE MONITOR CLEVER CHOICE MISC ELECTRONICBLOOD 1 PRESSURE HEALTH SENSE BLOOD MONITOR/WRIST DEVI PRESSURE 1 MONITOR/UPPER-ARM DEVI

Nebraska Total Care Formulary September 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTH SENSE BLOOD MICROLIFE DELUXE PRESSURE MONITOR/XL 1 BLOOD PRESSURE 1 SIZE CUFF DEVI MONITOR DEVI HEART CHECK BLOOD OMRON 10 SERIES QL(1 ea per PRESSURE 1 BLOOD PRESSURE 1 730 days retail) MONITOR/WRIST DEVI MONITOR/ARM/BLUETOO HM ADVANCED BLOOD TH SMART DEVI PRESSURE MONITOR 1 OMRON 10 SERIES QL(1 ea per AUTOMATIC DEVI BLOOD PRESSURE 1 730 days retail) HM AUTOMATIC BLOOD MONITOR/UPPER PRESSURE MONITOR 1 ARM/BLUETOOTH DEVI DELUXE DEVI OMRON 3 SERIES QL(1 ea per HM BLOOD PRESSURE BLOOD PRESSURE 1 730 days retail) MONITORFULLY 1 MONITOR/UPPER ARM AUTOMATIC DEVI DEVI HM DELUXE BLOOD OMRON 3 SERIES QL(1 ea per PRESSUREMONITOR/WR 1 BLOOD PRESSURE 1 730 days retail) IST DEVI MONITOR/WRIST DEVI KROGER BLOOD OMRON 5 SERIES QL(1 ea per BLOOD PRESSURE 730 days retail) PRESSURE 1 1 MONITOR/AUTOMATIC MONITOR/UPPER DEVI ARM/BLUETOOTH DEVI KROGER BLOOD OMRON 7 SERIES QL(1 ea per BLOOD PRESSURE 1 730 days retail) PRESSURE 1 MONITOR/DELUXE MONITOR DEVI WRIST DEVI OMRON 7 SERIES QL(1 ea per KROGER BLOOD BLOOD PRESSURE 1 730 days retail) MONITOR/UPPER PRESSURE 1 MONITOR/PREMIUM ARM/BLUETOOTH DEVI AUTOMATIC DEVI OMRON 7 SERIES QL(1 ea per MICROLIFE BLOOD BLOOD PRESSURE 1 730 days retail) MONITOR/WRIST/BLUET PRESSUREMONITOR/AD 1 VANCED AUTOMATIC OOTH DEVI DEVI PROCARE UPPER ARM QL(1 ea per MICROLIFE BLOOD BLOOD PRESSURE 1 730 days retail) PRESSUREMONITOR/AD 1 MONITOR DEVI VANCED WRIST DEVI PROCARE WRIST BLOOD QL(1 ea per MICROLIFE BLOOD PRESSURE MONITOR 1 730 days retail) PRESSUREMONITOR/AU 1 DEVI TOMATIC DELUXE DEVI QC BLOOD PRESSURE QL(1 ea per MICROLIFE BLOOD MONITOR/AUTOMATIC 1 730 days retail) PRESSUREMONITOR/AU 1 MISC TOMATIC DEVI RA BLOOD PRESSURE QL(1 ea per MICROLIFE BPM 6 CUFF MONITOR 1 730 days retail) AUTOMATIC MISC PREMIUM BLOOD 1 PRESSURE MONITOR RA BLOOD PRESSURE QL(1 ea per DEVI CUFF MONITOR DELUXE 1 730 days retail) AUTOMATIC DEVI

Nebraska Total Care Formulary September 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA BLOOD PRESSURE QL(1 ea per SURELIFE BLOOD QL(1 ea per CUFF MONITOR 1 730 days retail) PRESSURE 1 730 days retail) PREMIUM AUTOMATIC MONITOR/WRIST/CLASSI DEVI C DEVI RELION BLOOD QL(1 ea per SURELIFE BLOOD QL(1 ea per PRESSURE 1 730 days retail) PRESSURE 1 730 days retail) MONITOR/AUTOMATIC MONITOR/WRIST/PREMI DEVI UM DEVI RELION BP100 UPPER QL(1 ea per TALKING SENSE BLOOD QL(1 ea per 1 ARM BLOOD PRESSURE 730 days retail) PRESSURE 1 730 days retail) MONITOR DEVI MONITOR/REGULAR RELION BP200W WRIST QL(1 ea per SIZE CUFF DEVI BLOOD PRESSURE 1 730 days retail) TALKING SENSE BLOOD QL(1 ea per MONITOR DEVI PRESSURE MONITOR/XL 1 730 days retail) RELION BP300W WRIST QL(1 ea per SIZE CUFF DEVI BLOOD PRESSURE 1 730 days retail) WRIST CUFF BLOOD 1 QL(1 ea per MONITOR DEVI PRESSUREUNIT MISC 730 days retail) RELION PREMIUM QL(1 ea per Contraceptives BLOOD PRESSURE 1 730 days retail) MONITOR/UPPER ARM AIMSCO LUBRICATED 1 MISC DEVI DUREX EXTRA SM BLOOD PRESSURE QL(1 ea per 1 SENSITIVE DEVI MONITOR/ADVANCED 1 730 days retail) AUTOMATIC DEVI FANTASY LUBRICATED 1 MISC SM BLOOD PRESSURE QL(1 ea per MONITOR/AUTOMATIC 1 730 days retail) FANTASY INFLATION MISC LUBRICATED/SPERMICID 1 E MISC SM BLOOD PRESSURE QL(1 ea per MONITOR/DELUXE 1 730 days retail) K-Y ME & YOU EXTRA 1 AUTOMATIC DEVI LUBRICATED DEVI SM BLOOD PRESSURE QL(1 ea per K-Y ME & YOU INTENSE 1 MONITOR/DELUXE 1 730 days retail) DEVI WRIST DEVI KAMELEON LUBRICATED 1 SM BLOOD PRESSURE QL(1 ea per MISC MONITOR/FULLY 1 730 days retail) KIMONO COLORS DEVI 1 AUTOMATIC DEVI SM BLOOD PRESSURE QL(1 ea per KIMONO LUBRICATED 1 MONITORSERIES 600 1 730 days retail) MISC DEVI KIMONO MICRO THIN SURELIFE BLOOD QL(1 ea per PLUS SPERMICIDE 1 PRESSURE 1 730 days retail) LUBRICATED MISC MONITOR/ARM DEVI KIMONO PLUS SURELIFE BLOOD QL(1 ea per SPERMICIDE 1 LUBRICATED MISC PRESSURE 1 730 days retail) MONITOR/ARM/PREMIUM KIMONO PLUS DEVI SPERMICIDE/LUBRICATE 1 D MISC

Nebraska Total Care Formulary September 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO PS LUBRICATED 1 TRUSTEX NATURAL MISC CONDOMS 1 KIMONO PS PLUS +LUBE/LUBRICATED SPERMICIDE/LUBRICATE 1 MISC D MISC TRUSTEX WITH NONOXYNOL- KIMONO SENSATION 1 1 LUBRICATED MISC 9/RIBBED/STUDDED MISC KIMONO SENSATION PLUS SPERMICIDE 1 TRUSTEX/RIA 1 LUBRICATED MISC LUBRICATED MISC TRUSTEX/RIA KIMONO SPECIAL DEVI 1 LUBRICATED 1 SPERMICIDE MISC MAXX LUBRICATED MISC 1 TRUSTEX/RIA LUBRICATED/SPERMICID 1 MAXX PLUS SPERMICIDE 1 LUBRICATED MISC E MISC PREMIUM CONDOMS 1 Diabetic Supplies LUBRICATED MISC 1ST TIER UNILET QL(6.67 ea REALITY LATEX COMFORTOUCH 1 daily) CONDOMS/LUBRICATED 1 LANCETS 28G MISC MISC 1ST TIER UNILET QL(6.67 ea REALITY LATEX/ULTRA 1 COMFORTOUCH 1 daily) TEXTURED DEVI LANCETS 30G MISC REALITY LATEX/ULTRA 1 ACCU-CHEK FASTCLIX 1 THIN DEVI LANCETDEVICE KIT KIT TRUSTEX COLOR 1 ACCU-CHEK FASTCLIX 1 QL(6.67 ea CONDOMS + LUBE MISC LANCETS MISC daily) TRUSTEX LUBRICATED 1 ACCU-CHEK MULTICLIX 1 EXTRALARGE MISC LANCET DEVICE KIT KIT TRUSTEX LUBRICATED 1 ACCU-CHEK MULTICLIX 1 QL(6.67 ea EXTRASTRENGTH MISC LANCETS MISC daily) TRUSTEX LUBRICATED 1 ACCU-CHEK SAFE-T-PRO 1 QL(6.67 ea MISC LANCETS MISC daily) TRUSTEX ACCU-CHEK SAFE-T-PRO 1 QL(6.67 ea LUBRICATED/RIBBED/ST 1 PLUSLANCETS MISC daily) UDDED MISC ACCU-CHEK SOFTCLIX 1 TRUSTEX LANCETDEVICE KIT KIT LUBRICATED/SPERMICID 1 ACCU-CHEK SOFTCLIX 1 QL(6.67 ea E EXTRA LARGE MISC LANCETS MISC daily) TRUSTEX ACTI-LANCE LANCETS 1 QL(6.67 ea LUBRICATED/SPERMICID 1 28G MISC daily) E EXTRA STRENGTH MISC ACTI-LANCE LITE QL(6.67 ea SAFETY LANCETS 28G 1 daily) TRUSTEX MISC LUBRICATED/SPERMICID 1 E MISC ACTI-LANCE SPECIAL QL(6.67 ea SAFETY LANCETS 17G 1 daily) MISC Nebraska Total Care Formulary September 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTI-LANCE SPECIAL QL(6.67 ea ASSURE HAEMOLANCE QL(6.67 ea SAFETYLANCETS 17G 1 daily) PLUS NORMAL FLOW 1 daily) MISC 21G MISC ACTI-LANCE UNIVERSAL QL(6.67 ea ASSURE HAEMOLANCE QL(6.67 ea SAFETY LANCETS 23G 1 daily) PLUS PEDIATRIC BLADE 1 daily) MISC MISC ADJUSTABLE LANCING 1 QL(1 ea per ASSURE LANCE 1 QL(6.67 ea DEVICE MISC 160 days retail) LANCETS 21G MISC daily) ADVANCED MOBILE 1 QL(6.67 ea ASSURE LANCE 1 QL(6.67 ea LANCET 30G MISC daily) LANCETS MISC daily) ADVOCATE LANCETS 1 QL(6.67 ea ASSURE LANCE PLUS QL(6.67 ea 30G MISC daily) SAFETYLANCETS 25G 1 daily) MISC ADVOCATE LANCETS 1 QL(6.67 ea MISC daily) ASSURE LANCE PLUS QL(6.67 ea SAFETYLANCETS 30G 1 daily) ADVOCATE LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) MISC ASSURE LANCE SAFETY QL(6.67 ea ADVOCATE RAPID-SAFE 1 QL(1 ea per 1 LANCING DEVICE MISC 160 days retail) LANCET 28G MISC daily) QL(6.67 ea ADVOCATE SAFETY 1 QL(6.67 ea ASSURE LANCETS MISC 1 LANCETS 26G MISC daily) daily) AURORA LANCET SUPER QL(6.67 ea ADVOCATE SAFETY 1 QL(6.67 ea 1 LANCETS MISC daily) THIN30G MISC daily) AURORA LANCET THIN QL(6.67 ea AGAMATRIX ULTRA-THIN 1 QL(6.67 ea 1 LANCETS 33G MISC daily) 23G MISC daily) QL(1 ea per AIMSCO TWIST LANCETS 1 QL(6.67 ea AUTO-LANCET MINI MISC 1 32G MISC daily) 160 days retail) QL(1 ea per AIMSCO TWIST LANCETS 1 QL(6.67 ea AUTO-LANCET MISC 1 33G MISC daily) 160 days retail) AUTOLET II CLINISAFE ALTERNATE SITE 1 QL(1 ea per 1 LANCING DEVICE MISC 160 days retail) KIT AQUA LANCE QL(1 ea per AUTOLET IMPRESSION 1 QL(1 ea per ADJUSTABLE LANCING 1 160 days retail) LANCING DEVICE MISC 160 days retail) DEVICE DEVI AUTOLET LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) AQUALANCE LANCETS 1 QL(6.67 ea ULTRA THIN 30G MISC daily) AUTOLET LITE 1 ASSURE COMFORT QL(6.67 ea CLINISAFE KIT LANCETS ULTRA THIN 1 daily) AUTOLET LITE STARTER 1 28G MISC PACK KIT ASSURE HAEMOLANCE QL(6.67 ea QL(1 ea per AUTOLET MINI MISC 1 PLUS HIGH FLOW 18G 1 daily) 160 days retail) MISC QL(1 ea per AUTOLET PLUS MISC 1 ASSURE HAEMOLANCE QL(6.67 ea 160 days retail) PLUS LOW FLOW 25G 1 daily) BD LANCET ULTRAFINE 1 QL(6.67 ea MISC 30G MISC daily) ASSURE HAEMOLANCE QL(6.67 ea BD LANCET ULTRAFINE 1 QL(6.67 ea PLUS MICRO FLOW 28G 1 daily) 33G MISC daily) MISC Nebraska Total Care Formulary September 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD MICROTAINER 1 QL(6.67 ea COAGUCHEK LANCETS 1 QL(6.67 ea LANCETS MISC daily) MISC daily) BULLSEYE MINI SAFETY 1 QL(6.67 ea COMFORT ASSURED QL(6.67 ea LANCETS MISC daily) LANCETS MICRO THIN 1 daily) 33G MISC BULLSEYE SAFETY 1 QL(6.67 ea LANCETS MISC daily) COMFORT ASSURED QL(6.67 ea LANCETS SUPER THIN 1 daily) CARDIOCOM LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) 28G MISC COMFORT LANCETS QL(6.67 ea CAREONE ADVANCED 1 QL(1 ea per 1 LANCINGDEVICE MISC 160 days retail) MISC daily) COMFORT TOUCH QL(6.67 ea CAREONE LANCET 1 QL(6.67 ea SUPER THIN/30G MISC daily) LANCETS ULTRA THIN 1 daily) 31G MISC CAREONE LANCET THIN 1 QL(6.67 ea MISC daily) COMFORT TOUCH PLUS QL(6.67 ea SAFETY LANCETS 1 daily) CARESENS LANCETS 1 QL(6.67 ea PRESSURE ACTIVATED MISC daily) 30G MISC CARETOUCH LANCING QL(1 ea per CVS LANCETS 21G MISC 1 QL(6.67 ea DEVICEWITH EJECTOR 1 160 days retail) daily) MISC CVS LANCETS MICRO 1 QL(6.67 ea CARETOUCH SAFETY 1 QL(6.67 ea THIN 33G MISC daily) LANCETS/26G MISC daily) CVS LANCETS MICRO- 1 QL(6.67 ea CARETOUCH SAFETY 1 QL(6.67 ea THIN 33G MISC daily) LANCETS/28G MISC daily) CVS LANCETS ORIGINAL 1 QL(6.67 ea CARETOUCH SAFETY 1 QL(6.67 ea MISC daily) LANCETS/30G MISC daily) CVS LANCETS THIN 26G 1 QL(6.67 ea CARETOUCH TWIST 1 QL(6.67 ea MISC daily) LANCETS 28G MISC daily) CVS LANCETS ULTRA 1 QL(6.67 ea CARETOUCH TWIST 1 QL(6.67 ea THIN 30G MISC daily) LANCETS 30G MISC daily) CVS LANCETS ULTRA- 1 QL(6.67 ea CARETOUCH TWIST 1 QL(6.67 ea THIN 30G MISC daily) LANCETS 33G MISC daily) CVS LANCING DEVICE 1 QL(1 ea per CLEANLET LANCETS 28G 1 QL(6.67 ea MISC 160 days retail) MISC daily) CVS ULTRA THIN 1 QL(6.67 ea CLEVER CHEK LANCETS 1 QL(6.67 ea LANCETS MISC daily) ULTRATHIN 30G MISC daily) DIATHRIVE LANCETS 1 QL(6.67 ea CLEVER CHEK LANCETS 1 QL(6.67 ea MISC daily) ULTRATHIN MISC daily) DIATHRIVE LANCETS 1 QL(6.67 ea CLEVER CHOICE QL(6.67 ea ULTRA THIN 30G MISC daily) COMFORT EZLANCETS 1 daily) 21G MISC DIATHRIVE LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) CLEVER CHOICE QL(6.67 ea COMFORT EZLANCETS 1 daily) DROPLET GENTEEL 1 QL(1 ea per 23G MISC LANCING DEVICE MISC 160 days retail) CLEVER CHOICE QL(6.67 ea DROPLET LANCETS 1 QL(6.67 ea COMFORT EZLANCETS 1 daily) ULTRA THIN 30G MISC daily) 28G MISC

Nebraska Total Care Formulary September 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET LANCING QL(1 ea per 1 EASY MINI LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) DEVICE MISC 160 days retail) DROPLET PERSONAL 1 QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea LANCETS30G MISC daily) 21G/PRESSURE 1 daily) DRUG MART QL(1 ea per ACTIVATED MISC ADJUSTABLE LANCING 1 160 days retail) EASY TOUCH LANCETS QL(6.67 ea DEVICE MISC 23G/PRESSURE 1 daily) ACTIVATED MISC DRUG MART LANCETS 1 QL(6.67 ea THIN MISC daily) EASY TOUCH LANCETS QL(6.67 ea DRUG MART ON-THE-GO QL(6.67 ea 26G/PRESSURE 1 daily) LANCETS GENTLE 30G 1 daily) ACTIVATED MISC MISC EASY TOUCH LANCETS 1 QL(6.67 ea DRUG MART UNILET QL(6.67 ea 26G/PULL-TOP MISC daily) LANCETSSUPER THIN 1 daily) EASY TOUCH LANCETS QL(6.67 ea 30G MISC 28G/PRESSURE 1 daily) DRUG MART UNILET QL(6.67 ea ACTIVATED MISC 1 LANCETSULTRA THIN daily) EASY TOUCH LANCETS 1 QL(6.67 ea 28G MISC 28G/PULL-TOP MISC daily) DRUG MART UNILET QL(6.67 ea EASY TOUCH LANCETS 1 QL(6.67 ea MICRO THIN LANCETS 1 daily) 28G/TWIST MISC daily) 33G MISC EASY TOUCH LANCETS QL(6.67 ea E-Z JECT LANCETS 21G 1 QL(6.67 ea 30G/BUTTON-ACTIVATED 1 daily) MISC daily) MISC E-Z JECT LANCETS 1 QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea COLOR MISC daily) 30G/PRESSURE 1 daily) ACTIVATED MISC 1 QL(6.67 ea E-Z JECT LANCETS MISC daily) EASY TOUCH LANCETS 1 QL(6.67 ea 30G/PULL-TOP MISC daily) E-Z JECT LANCETS 1 QL(6.67 ea SUPER THIN 30G MISC daily) EASY TOUCH LANCETS 1 QL(6.67 ea 30G/TWIST MISC daily) E-Z JECT LANCETS THIN 1 QL(6.67 ea 26G MISC daily) EASY TOUCH LANCETS QL(6.67 ea 32G/PRESSURE 1 daily) E-ZJECT LANCETS 1 QL(6.67 ea MICRO-THIN 33G MISC daily) ACTIVATED MISC EASY COMFORT QL(6.67 ea EASY TOUCH LANCETS 1 QL(6.67 ea LANCETS 30G/PULL TOP 1 daily) 32G/PULL-TOP MISC daily) MISC EASY TOUCH LANCETS 1 QL(6.67 ea EASY COMFORT QL(6.67 ea 32G/TWIST MISC daily) LANCETS 30G/THIN TOP 1 daily) EASY TOUCH LANCETS 1 QL(6.67 ea MISC 33G/TWIST MISC daily) EASY COMFORT 1 QL(6.67 ea EASY TOUCH LANCING 1 QL(1 ea per LANCETS MISC daily) DEVICE/EJECTOR MISC 160 days retail) EASY COMFORT QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea LANCETS TWIST TOP 1 daily) LANCETS21G/PRESSURE 1 daily) MISC ACTIVATED MISC EASY MINI EJECT 1 QL(1 ea per EASY TOUCH SAFETY QL(6.67 ea LANCING DEVICE MISC 160 days retail) LANCETS23G/PRESSURE 1 daily) ACTIVATED MISC Nebraska Total Care Formulary September 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH SAFETY QL(6.67 ea FINE 30 MISC 1 QL(6.67 ea LANCETS26G/BUTTON 1 daily) daily) ACTIVATED MISC FINGERSTIX LANCETS 1 QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea MISC daily) LANCETS26G/PRESSURE 1 daily) FORA LANCETS MISC 1 QL(6.67 ea ACTIVATED MISC daily) EASY TOUCH SAFETY QL(6.67 ea FORA LANCING DEVICE 1 QL(1 ea per LANCETS28G/BUTTON 1 daily) MISC 160 days retail) ACTIVATED MISC FORA LANCING 1 QL(1 ea per EASY TOUCH SAFETY QL(6.67 ea DEVICE/CLEARCAP MISC 160 days retail) LANCETS28G/PRESSURE 1 daily) ACTIVATED MISC FREDS PHARMACY QL(1 ea per AUTOLET LANCING 1 160 days retail) EASY TWIST & CAP 1 QL(6.67 ea DEVICE MISC LANCETS MISC daily) FREDS PHARMACY QL(6.67 ea EMBRACE LANCETS 1 QL(6.67 ea UNILET LANCETS SUPER 1 daily) ULTRA THIN 30G MISC daily) THIN 30G MISC EMBRACE LANCING QL(1 ea per FREDS PHARMACY QL(6.67 ea DEVICE WITH EJECTOR 1 160 days retail) UNILET LANCETS ULTRA 1 daily) MISC THIN 28G MISC EMBRACE PRESSURE QL(6.67 ea FREESTYLE LANCETS 1 QL(6.67 ea ACTIVATED SAFETY 1 daily) MISC daily) LANCET/21G MISC FREESTYLE UNISTICK II 1 QL(6.67 ea EMBRACE PRESSURE QL(6.67 ea LANCETS MISC daily) ACTIVATED SAFETY 1 daily) LANCET/28G MISC GENTEEL BUTTERFLY 1 QL(6.67 ea TOUCH LANCETS MISC daily) EQL COLOR LANCETS 1 QL(6.67 ea 21G MISC daily) GENTEEL LANCING QL(1 ea per DEVICE/GLORIOUS 1 160 days retail) EQL COLOR LANCETS 1 QL(6.67 ea GOLD MISC MICRO THIN 33G MISC daily) GENTEEL LANCING QL(1 ea per EQL SUPER THIN 1 QL(6.67 ea DEVICE/PRECIOUS 1 160 days retail) LANCETS 30G MISC daily) PLATINUM MISC EQL THIN LANCETS 26G 1 QL(6.67 ea GENTEEL LANCING QL(1 ea per MISC daily) DEVICE/STATELY SILVER 1 160 days retail) EZ-LETS LANCETS 21G 1 QL(6.67 ea MISC MISC daily) GENTEEL LANCING EZ-LETS LANCETS 26G 1 QL(6.67 ea KIT/BUTTERFLY BLUE 1 SUPER-SOFT MISC daily) KIT EZ-LETS LANCETS 28G 1 QL(6.67 ea GENTEEL PLUS LANCING QL(1 ea per ULTRA-SOFT MISC daily) DEVICE/BUFF BLACK 1 160 days retail) MISC EZ-LETS LANCETS 30G 1 QL(6.67 ea MISC daily) GENTEEL PLUS LANCING QL(1 ea per DEVICE/BUTTERFLY 1 160 days retail) FIFTY50 SAFETY SEAL 1 QL(6.67 ea LANCETS 30G MISC daily) BLUE MISC GENTEEL PLUS LANCING QL(1 ea per FIFTY50 SAFETY SEAL 1 QL(6.67 ea LANCETS 32G MISC daily) DEVICE/PLAYFUL 1 160 days retail) PURPLE MISC FIFTY50 UNILET 1 QL(6.67 ea LANCETS 33G MISC daily) Nebraska Total Care Formulary September 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTEEL PLUS LANCING QL(1 ea per GNP STERILE LANCETS 1 QL(6.67 ea DEVICE/PRINCESS PINK 1 160 days retail) 33G MISC daily) MISC GOJJI LANCING QL(1 ea per GENTEEL PLUS LANCING QL(1 ea per DEVICE/CLEAR CAP 1 160 days retail) DEVICE/WILLOWY WHITE 1 160 days retail) MISC MISC GOJJI STERILE LANCETS 1 QL(6.67 ea GENTLE-LET GP 1 QL(6.67 ea 30G MISC daily) LANCETS MISC daily) GOODSENSE COLOR QL(6.67 ea GENTLE-LET LANCETS QL(6.67 ea LANCETS MICRO-THIN 1 daily) GENERAL PURPOSE 1 daily) 33G UNIVERSAL MISC STYLE/FINE POINT MISC GOODSENSE LANCETS 1 QL(6.67 ea GENTLE-LET LANCETS QL(6.67 ea MICRO-THIN 33G MISC daily) GENERAL PURPOSE 1 daily) GOODSENSE LANCETS QL(6.67 ea STYLE/MEDIUM POINT MICRO-THIN 33G 1 daily) MISC UNIVERSAL MISC GENTLE-LET LANCETS QL(6.67 ea GOODSENSE LANCETS QL(6.67 ea SAFETY STYLE/FINE 1 daily) ULTRA-THIN 26G 1 daily) POINT MISC UNIVERSAL MISC GENTLE-LET LANCETS QL(6.67 ea GOODSENSE LANCETS 1 QL(6.67 ea SAFETY STYLE/MEDIUM 1 daily) ULTRA-THIN 30G MISC daily) POINT MISC GOODSENSE LANCETS QL(6.67 ea GLOBAL INJECT EASE 1 QL(6.67 ea ULTRA-THIN 30G 1 daily) LANCETS 28G MISC daily) UNIVERSAL MISC GLOBAL INJECT EASE QL(6.67 ea 1 GOODSENSE LANCING 1 QL(1 ea per LANCETS 30G MISC daily) DEVICE MISC 160 days retail) GLOBAL LANCING 1 QL(1 ea per H-E-B INCONTROL QL(1 ea per DEVICE MISC 160 days retail) ADVANCEDLANCING 1 160 days retail) GLUCOCOM LANCETS 1 QL(6.67 ea DEVICE MISC 28G MISC daily) H-E-B INCONTROL QL(6.67 ea GLUCOCOM LANCETS 1 QL(6.67 ea LANCETS MICRO THIN 1 daily) 30G MISC daily) 33G MISC GLUCOCOM LANCETS 1 QL(6.67 ea H-E-B INCONTROL QL(6.67 ea 33G MISC daily) LANCETS SUPER THIN 1 daily) QL(6.67 ea 30G MISC GNP LANCETS 21G MISC 1 daily) H-E-B INCONTROL QL(6.67 ea LANCETS ULTRA THIN 1 daily) GNP LANCETS MICRO 1 QL(6.67 ea THIN 33G MISC daily) 28G MISC HAEMOLANCE LOW QL(6.67 ea GNP LANCETS SUPER 1 QL(6.67 ea 1 THIN 30G MISC daily) FLOW LANCETS MISC daily) QL(6.67 ea GNP LANCETS THIN 26G 1 QL(6.67 ea HAEMOLANCE MISC 1 MISC daily) daily) HAEMOLANCE PLUS QL(6.67 ea GNP LANCETS THIN 1 QL(6.67 ea 1 MISC daily) HIGH FLOW MISC daily) HAEMOLANCE PLUS QL(6.67 ea GNP STERILE LANCETS 1 QL(6.67 ea 1 28G MISC daily) LOW FLOW MISC daily) HAEMOLANCE PLUS QL(6.67 ea GNP STERILE LANCETS 1 QL(6.67 ea 1 30G MISC daily) MAX FLOW MISC daily) Nebraska Total Care Formulary September 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HAEMOLANCE PLUS 1 QL(6.67 ea KROGER LANCING 1 QL(1 ea per MISC daily) DEVICE MISC 160 days retail) HAEMOLANCE PLUS 1 QL(6.67 ea LANCET DEVICE 1 QL(1 ea per PEDIATRIC FLOW MISC daily) ADJUSTABLE MISC 160 days retail) HEALTH CARE LANCING 1 QL(1 ea per LANCET DEVICE WITH 1 QL(1 ea per DEVICE MISC 160 days retail) EJECTOR MISC 160 days retail) HEALTHY ACCENTS QL(1 ea per LANCETS 26G TWIST 1 QL(6.67 ea AUTOLET IMPRESSION 1 160 days retail) TOP MISC daily) LANCING DEVICE MISC QL(6.67 ea LANCETS 28G MISC 1 HEALTHY ACCENTS QL(6.67 ea daily) UNILET LANCETS SUPER 1 daily) LANCETS 30G MISC 1 QL(6.67 ea THIN 30G MISC daily) QL(6.67 ea HY-VEE LANCETS MISC 1 LANCETS 30G TWIST 1 QL(6.67 ea daily) TOP MISC daily) HY-VEE THIN LANCETS QL(6.67 ea 1 LANCETS 30G/TWIST 1 QL(6.67 ea MISC daily) TOP MISC daily) HYPOLANCE AST 1 LANCETS 31G TWIST 1 QL(6.67 ea LANCING KIT KIT TOP MISC daily) IN TOUCH LANCING QL(1 ea per 1 LANCETS 33G EXTRA 1 QL(6.67 ea DEVICE MISC 160 days retail) FINE MISC daily) IN TOUCH STERILE 1 QL(6.67 ea LANCETS 33G QL(6.67 ea LANCETS30G MISC daily) UNIVERSAL DESIGN 1 daily) KINNEY LANCETS MISC 1 QL(6.67 ea MISC daily) LANCETS MICRO THIN 1 QL(6.67 ea KINNEY THIN LANCETS 1 QL(6.67 ea 33G MISC daily) MISC daily) QL(6.67 ea LANCETS MISC 1 KROGER AUTOLET 1 QL(1 ea per daily) LANCING DEVICE MISC 160 days retail) LANCETS SAFETY SEAL 1 QL(6.67 ea KROGER HEALTHPRO QL(6.67 ea 21G MISC daily) TWIST LANCETS/26G 1 daily) LANCETS SAFETY SEAL 1 QL(6.67 ea MISC 26G MISC daily) KROGER LANCETS 21G QL(6.67 ea 1 LANCETS SAFETY SEAL 1 QL(6.67 ea MISC daily) 28G MISC daily) KROGER LANCETS QL(6.67 ea 1 LANCETS SAFETY SEAL 1 QL(6.67 ea MICRO THIN33G MISC daily) 30G MISC daily) QL(6.67 ea KROGER LANCETS MISC 1 LANCETS SUPER THIN 1 QL(6.67 ea daily) 28G MISC daily) KROGER LANCETS QL(6.67 ea 1 LANCETS THIN MISC 1 QL(6.67 ea SUPER THIN MISC daily) daily) KROGER LANCETS THIN QL(6.67 ea 1 LANCETS TWIST TOP 1 QL(6.67 ea 26G MISC daily) MISC daily) KROGER LANCETS THIN QL(6.67 ea 1 LANCETS ULTRA FINE 1 QL(6.67 ea MISC daily) MISC daily) KROGER LANCETS QL(6.67 ea 1 LANCETS ULTRA THIN 1 QL(6.67 ea ULTRATHIN30G MISC daily) 30G MISC daily)

Nebraska Total Care Formulary September 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCETS ULTRA THIN 1 QL(6.67 ea MEDICHOICE PRE-SET QL(6.67 ea MISC daily) SAFETY LANCET 1 daily) MEDIUM FLOW MISC LANCETSBULLSEYE 1 QL(6.67 ea SAFETY MISC daily) MEDICHOICE PRE-SET QL(6.67 ea SAFETY LANCET 1 daily) LANCING DEVICE 1 QL(1 ea per ADJUSTABLE MISC 160 days retail) MODERATE FLOW MISC MEDICHOICE SAFETY QL(6.67 ea LANCING DEVICE MISC 1 QL(1 ea per 1 160 days retail) LANCETEXTRA MISC daily) QL(1 ea per MEDICHOICE SAFETY QL(6.67 ea LANZO MISC 1 1 160 days retail) LANCETNORMAL MISC daily) MEDISENSE THIN QL(6.67 ea LEADER ADVANCED 1 QL(1 ea per 1 LANCING DEVICE MISC 160 days retail) LANCETS MISC daily) MEDLANCE PLUS EXTRA QL(6.67 ea LIBERTY MEDICAL 1 QL(6.67 ea 1 LANCETS 30G MISC daily) LANCETS 21G MISC daily) MEDLANCE PLUS QL(6.67 ea LIBERTY MINI LANCING 1 QL(1 ea per 1 DEVICE MISC 160 days retail) LANCETS LITE 25G MISC daily) LIFESCAN UNISTIK 2 QL(6.67 ea MEDLANCE PLUS 1 QL(6.67 ea DEEP PENETRATION 1 daily) LANCETS MISC daily) MISC MEDLANCE PLUS LITE 1 QL(6.67 ea LANCETS 25G MISC daily) LIFESCAN UNISTIK II 1 QL(6.67 ea LANCETS MISC daily) MEDLANCE PLUS QL(6.67 ea SPECIAL LANCETS 1 daily) LITE TOUCH LANCETS 1 QL(6.67 ea MISC daily) 0.8MM MISC MEDLANCE PLUS QL(6.67 ea LITE TOUCH LANCING 1 QL(1 ea per 1 PEN MISC 160 days retail) SUPERLITE 30G MISC daily) MEDLANCE PLUS QL(6.67 ea LITETOUCH LANCETS 1 QL(6.67 ea MICRO THIN 33G MISC daily) SUPERLITE 1 daily) 30G/COMFORT MAX LIVE BETTER ADVANCED 1 QL(1 ea per MISC LANCING DEVICE MISC 160 days retail) MEDLANCE PLUS QL(6.67 ea LIVE BETTER LANCET 1 QL(6.67 ea UNIVERSAL LANCETS 1 daily) SUPERTHIN 30G MISC daily) 21G MISC LIVE BETTER LANCET QL(6.67 ea 1 MEDLANCE PLUS/LITE 1 QL(6.67 ea ULTRATHIN 28G MISC daily) 25G MISC daily) LONGS LANCETS QL(6.67 ea 1 MEDLANCE/EXTRA MISC 1 QL(6.67 ea STANDARD MISC daily) daily) LONGS LANCETS THIN QL(6.67 ea 1 MEDLANCE/LITE MISC 1 QL(6.67 ea MISC daily) daily) LONGS LANCETS ULTRA QL(6.67 ea 1 MEDLANCE/UNIVERSAL 1 QL(6.67 ea THIN MISC daily) MISC daily) MEDICHOICE PRE-SET QL(6.67 ea MEIJER COLOR QL(6.67 ea SAFETY LANCET DUAL 1 daily) LANCETS UNIVERSAL 1 daily) USE MISC 33G MISC MEDICHOICE PRE-SET QL(6.67 ea MEIJER LANCETS MISC 1 QL(6.67 ea SAFETY LANCET LOW 1 daily) daily) FLOW MISC MEIJER LANCETS THIN 1 QL(6.67 ea MISC daily) Nebraska Total Care Formulary September 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEIJER LANCETS 1 QL(6.67 ea NOVA SAFETY LANCETS 1 QL(6.67 ea UNIVERSAL21G MISC daily) 28G MISC daily) MEIJER LANCETS 1 QL(6.67 ea NOVA SUREFLEX 1 QL(6.67 ea UNIVERSAL30G MISC daily) LANCETS MISC daily) MEIJER LANCETS 1 QL(6.67 ea NOVA SUREFLEX 1 QL(1 ea per UNIVERSAL33G MISC daily) LANCING DEVICE MISC 160 days retail) MEIJER SUPER THIN 1 QL(6.67 ea OMNIPOD 5 PACK MISC 1 PA LANCETS MISC daily) OMNIPOD DASH 5 PACK PA MICROLET LANCETS 1 QL(6.67 ea 1 MISC daily) MISC OMNIPOD DASH SYSTEM PA MICROLET NEXT MISC 1 QL(1 ea per 1 160 days retail) KIT MICROTAINER SAFETY QL(6.67 ea OMNIPOD STARTER KIT 1 PA KIT FLOW 1 daily) LANCET/STERILE/SINGL ON CALL LANCETS MISC 1 QL(6.67 ea E-USE MISC daily) MINI LANCING DEVICE QL(1 ea per 1 ON CALL LANCING 1 QL(1 ea per MISC 160 days retail) DEVICE MISC 160 days retail) MM LANCING DEVICE QL(1 ea per 1 ON CALL PLUS LANCETS 1 QL(6.67 ea MISC 160 days retail) MISC daily) MM TWIST LANCETS QL(6.67 ea 1 ON CALL PLUS LANCING 1 QL(1 ea per MISC daily) DEVICE MISC 160 days retail) MONOLET LANCETS 1 QL(6.67 ea ONETOUCH CLUB QL(6.67 ea MISC daily) LANCETS FINE POINT 1 daily) MISC MONOLET OPD LANCETS 1 QL(6.67 ea MISC daily) ONETOUCH DELICA QL(6.67 ea LANCETS EXTRA FINE 1 daily) MONOLETTOR SAFETY 1 QL(6.67 ea LANCETS MISC daily) 33G MISC ONETOUCH DELICA QL(6.67 ea MPD SAFETY LANCET 1 QL(6.67 ea 1 21G/1.8MM MISC daily) LANCETS FINE 30G MISC daily) ONETOUCH DELICA QL(1 ea per MPD SAFETY LANCET 1 QL(6.67 ea 1 28G/1.8MM MISC daily) LANCING DEVICE MISC 160 days retail) ONETOUCH DELICA QL(6.67 ea MPD SAFETY LANCET 1 QL(6.67 ea 30G/1.8MM MISC daily) PLUS LANCETS EXTRA 1 daily) FINE 33G MISC MPD SAFETY LANCETS 1 QL(6.67 ea 23G/1.8MM MISC daily) ONETOUCH DELICA QL(6.67 ea PLUS LANCETS FINE 30G 1 daily) MULTI-LANCET DEVICE 2 1 KIT MISC ONETOUCH DELICA QL(1 ea per MULTI-LANCET DEVICE 1 QL(1 ea per MISC 160 days retail) PLUS LANCING DEVICE 1 160 days retail) MISC MYGLUCOHEALTH MGH QL(6.67 ea SOFTLANCE LANCETS 1 daily) ONETOUCH DELICA QL(1 ea per 30G MISC SAFETY LACING DEVICE 1 160 days retail) MISC NOVA SAFETY LANCETS 1 QL(6.67 ea 23G MISC daily) ONETOUCH FINEPOINT 1 QL(6.67 ea LANCETS MISC daily)

Nebraska Total Care Formulary September 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONETOUCH ULTRASOFT 1 QL(6.67 ea PRO COMFORT 1 QL(6.67 ea LANCETS MISC daily) LANCETS 31G MISC daily) PC LANCETS SUPER 1 QL(6.67 ea PRODIGY LANCING 1 QL(1 ea per THIN 30G MISC daily) DEVICE MISC 160 days retail) PENLET II AUTOMATIC 1 PRODIGY PRESSURE QL(6.67 ea BLOODSAMPLER KIT ACTIVATED SAFETY 1 daily) LANCETS MISC PERFECT LANCETS 30G 1 QL(6.67 ea MISC daily) PRODIGY SAFETY 1 QL(6.67 ea PERFECT PRESSURE QL(6.67 ea LANCETS MISC daily) ACTIVATED SAFETY 1 daily) PRODIGY TWIST TOP 1 QL(6.67 ea LANCETS 28G MISC LANCETS MISC daily) PHARMACIST CHOICE QL(6.67 ea PSS SELECT GP 1 QL(6.67 ea ULTRA THIN LANCETS 1 daily) LANCETS MISC daily) 28G MISC PSS SELECT SAFETY 1 QL(6.67 ea PHARMACIST CHOICE QL(6.67 ea LANCETS MISC daily) ULTRA THIN LANCETS 1 daily) PURE COMFORT 1 QL(6.67 ea 30G MISC LANCETS 30G MISC daily) PHARMACIST CHOICE QL(6.67 ea PUSH BUTTON SAFETY 1 QL(6.67 ea ULTRA THIN LANCETS 1 daily) LANCETS 21G MISC daily) 31G MISC PUSH BUTTON SAFETY 1 QL(6.67 ea PHARMACIST CHOICE QL(6.67 ea LANCETS 28G MISC daily) ULTRA THIN LANCETS 1 daily) 33G MISC PX ADVANCED LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) PHARMACIST CHOICE QL(6.67 ea ULTRA THIN LANCETS 1 daily) PX LANCET AUTO 1 QL(1 ea per MISC INJECTOR MISC 160 days retail) PX LANCETS MICROTHIN QL(6.67 ea PHARMACY COUNTER 1 QL(6.67 ea 1 LANCETS MISC daily) 33G MISC daily) PX LANCETS ULTRA QL(6.67 ea PIP LANCETS/28G MISC 1 QL(6.67 ea 1 daily) THIN 28G MISC daily) PX LANCETS ULTRA QL(6.67 ea PIP LANCETS/30G MISC 1 QL(6.67 ea 1 daily) THIN MISC daily) QC ADVANCED LANCING QL(1 ea per PRECISION THINS GP 1 QL(6.67 ea 1 LANCET MISC daily) DEVICE MISC 160 days retail) PREFERRED PLUS QL(6.67 ea QC LANCETS SUPER 1 QL(6.67 ea LANCETS COLORED 21G 1 daily) THIN MISC daily) MISC QC LANCETS ULTRA 1 QL(6.67 ea PREFERRED PLUS QL(6.67 ea THIN MISC daily) LANCETS SUPER THIN 1 daily) QC UNILET LANCETS 1 QL(6.67 ea 30G MISC 28G/ULTRA THIN MISC daily) QC UNILET LANCETS QL(6.67 ea PREFERRED PLUS 1 QL(6.67 ea 1 LANCETS THIN 26G MISC daily) 33G/MICRO THIN MISC daily) PRESSURE ACTIVATED QL(6.67 ea RA E-ZJECT LANCETS 1 QL(6.67 ea SAFETYLANCET 21G 1 daily) 28G MISC daily) MISC RA E-ZJECT LANCETS 1 QL(6.67 ea THIN 26G MISC daily) PRO COMFORT 1 QL(6.67 ea LANCETS 30G MISC daily) Nebraska Total Care Formulary September 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA E-ZJECT LANCETS 1 QL(6.67 ea RELION ULTRA THIN QL(6.67 ea THIN 28G MISC daily) PLUS LANCETS 33G 1 daily) MISC RA E-ZJECT LANCETS 1 QL(6.67 ea ULTRATHIN 30G MISC daily) REXALL LANCETS ULTRA 1 QL(6.67 ea READYLANCE SAFETY QL(6.67 ea THIN MISC daily) 1 LANCETS/21G/2.2MM daily) RIGHTEST GD500 1 QL(1 ea per MISC LANCING DEVICE MISC 160 days retail) READYLANCE SAFETY QL(6.67 ea RIGHTEST GL300 1 QL(6.67 ea LANCETS/23G/1.8MM 1 daily) LANCETS MISC daily) MISC SAFE-T-LANCE LOW 1 QL(6.67 ea READYLANCE SAFETY QL(6.67 ea FLOW 25G MISC daily) LANCETS/26G/1.8MM 1 daily) SAFE-T-LANCE NORMAL 1 QL(6.67 ea MISC FLOW21G MISC daily) READYLANCE SAFETY QL(6.67 ea SAFE-T-LANCE PLUS QL(6.67 ea LANCETS/28G/1.8MM 1 daily) SAFETYLANCET HIGH 1 daily) MISC FLOW MISC READYLANCE SAFETY QL(6.67 ea SAFE-T-LANCE PLUS QL(6.67 ea LANCETS/30G/1.6MM 1 daily) SAFETYLANCET LOW 1 daily) MISC FLOW MISC QL(6.67 ea REALITY LANCETS MISC 1 SAFE-T-LANCE PLUS QL(6.67 ea daily) SAFETYLANCET 1 daily) REALITY TRIGGER 1 QL(6.67 ea NORMAL FLOW MISC LANCETS MISC daily) SAFETY LANCET QL(6.67 ea 1 RELION 2-IN-1 LANCET 1 QL(1 ea per 21G/PRESSURE daily) DEVICES 30G MISC 160 days retail) ACTIVATED MISC RELION 2-IN-1 LANCING 1 QL(1 ea per SAFETY LANCET QL(6.67 ea DEVICE 25G MISC 160 days retail) 23G/PRESSURE 1 daily) ACTIVATED MISC RELION 2-IN-1 LANCING 1 QL(1 ea per DEVICE 30G MISC 160 days retail) SAFETY LANCET QL(6.67 ea 28G/PRESSURE 1 daily) RELION LANCETS 1 QL(6.67 ea MICRO-THIN33G MISC daily) ACTIVATED MISC SAFETY LANCET QL(6.67 ea RELION LANCETS THIN 1 QL(6.67 ea 26G MISC daily) 30G/PRESSURE 1 daily) ACTIVATED MISC RELION LANCETS 1 QL(6.67 ea ULTRA-THIN30G MISC daily) SAFETY LANCETS 21G 1 QL(6.67 ea MISC daily) RELION LANCING 1 DEVICE KIT SAFETY LANCETS 28G 1 QL(6.67 ea MISC daily) RELION LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) SAFETY LANCETS MISC 1 QL(6.67 ea daily) RELION ULTRA THIN 1 QL(6.67 ea LANCETS/30G MISC daily) SAFETY LET LANCETS 1 QL(6.67 ea MISC daily) RELION ULTRA THIN 1 QL(6.67 ea LANCETS30G MISC daily) SAFETY SEAL LANCETS 1 QL(6.67 ea 28G MISC daily) RELION ULTRA THIN QL(6.67 ea PLUS LANCETS 32G 1 daily) SAFETY SEAL LANCETS 1 QL(6.67 ea MISC 30G MISC daily)

Nebraska Total Care Formulary September 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAPS HEALTH CARE QL(6.67 ea SMART SENSE SUPER QL(6.67 ea TWIST TOP LANCETS 1 daily) THIN LANCETS 1 daily) MISC UNIVERSAL 30G MISC SAPS HEALTH TWIST 1 QL(6.67 ea SMART SENSE THIN QL(6.67 ea TOP LANCETS 30G MISC daily) LANCETSUNIVERSAL 1 daily) 26G MISC SAPSCARE TWIST TOP 1 QL(6.67 ea LANCETS 30G MISC daily) SMARTEST LANCETS 1 QL(6.67 ea QL(6.67 ea 28G MISC daily) SB LANCETS THIN MISC 1 daily) SOLUS V2 LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) SB LANCETS ULTRA 1 QL(6.67 ea THIN MISC daily) SOLUS V2 PRESSURE QL(6.67 ea ACTIVATED SAFETY 1 daily) SELECT-LITE 1 DEVICE/LANCETS KIT LANCETS 28G MISC SOLUS V2 TWIST QL(6.67 ea SELECT-LITE LANCING 1 QL(1 ea per 1 DEVICE MISC 160 days retail) LANCETS 30G MISC daily) QL(6.67 ea SHOPKO AUTOLET 1 QL(1 ea per STERILANCE PA MISC 1 LANCING DEVICE MISC 160 days retail) daily) QL(6.67 ea SHOPKO ON-THE-GO QL(6.67 ea STERILANCE TL MISC 1 COMFORTLANCETS 30G 1 daily) daily) MISC SUPER THIN LANCETS 1 QL(6.67 ea SHOPKO UNILET QL(6.67 ea MISC daily) LANCETS SUPER THIN 1 daily) SURE COMFORT 1 QL(6.67 ea 30G MISC LANCETS 18G MISC daily) SHOPKO UNILET QL(6.67 ea SURE COMFORT 1 QL(6.67 ea LANCETS ULTRA THIN 1 daily) LANCETS 21G MISC daily) 28G MISC SURE COMFORT 1 QL(6.67 ea SIDE BUTTON SAFETY 1 QL(6.67 ea LANCETS 23G MISC daily) LANCET21G MISC daily) SURE COMFORT 1 QL(6.67 ea SIMPLE DIAGNOSTICS 1 QL(1 ea per LANCETS 28G MISC daily) LANCING DEVICE MISC 160 days retail) SURE COMFORT 1 QL(6.67 ea SINGLE-LET MISC 1 QL(6.67 ea LANCETS 30G MISC daily) daily) SURE COMFORT 1 QL(1 ea per SM MICRO THIN 1 QL(6.67 ea LANCING PEN MISC 160 days retail) LANCETS 33G MISC daily) SURE-LANCE FLAT 1 QL(6.67 ea SM TRUEDRAW LANCING 1 QL(1 ea per LANCETS MISC daily) DEVICE MISC 160 days retail) SURE-LANCE LANCETS 1 QL(6.67 ea SMART DIABETES QL(1 ea per 26G MISC daily) VANTAGE LANCING 1 160 days retail) SURE-LANCE THIN 1 QL(6.67 ea DEVICE MISC LANCETS 28G MISC daily) SMART SENSE COLOR QL(6.67 ea SURE-LANCE ULTRA 1 QL(6.67 ea LANCETS UNIVERSAL 1 daily) THIN LANCETS MISC daily) 33G MISC SURE-PEN MISC 1 QL(1 ea per SMART SENSE QL(6.67 ea 160 days retail) STANDARD LANCETS 1 daily) UNIVERSAL 21G MISC SURE-TOUCH LANCETS 1 QL(6.67 ea UNIVERSAL MISC daily)

Nebraska Total Care Formulary September 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURELITE LANCETS 1 QL(6.67 ea TRUECONTROL QL(1 ea per 75 MISC daily) GLUCOSE CONTROL 1 days retail) LEVEL 1 LIQD TECHLITE AST LANCETS 1 QL(6.67 ea MISC daily) TRUEDRAW LANCING 1 QL(1 ea per DEVICE MISC 160 days retail) TECHLITE LANCETS 30G 1 QL(6.67 ea MISC daily) TRUEPLUS LANCETS 1 QL(6.67 ea 26G MISC daily) TECHLITE LANCETS 1 QL(6.67 ea MISC daily) TRUEPLUS LANCETS 1 QL(6.67 ea 28G MISC daily) TGT LANCET MICRO 1 QL(6.67 ea THIN 33G MISC daily) TRUEPLUS LANCETS 1 QL(6.67 ea 28G SUPER THIN MISC daily) TGT LANCET THIN 26G 1 QL(6.67 ea MISC daily) TRUEPLUS LANCETS 1 QL(6.67 ea 30G MISC daily) TGT LANCET ULTRA 1 QL(6.67 ea THIN 30G MISC daily) TRUEPLUS LANCETS 1 QL(6.67 ea 30G ULTRA THIN MISC daily) TGT LANCING DEVICE 1 QL(1 ea per MISC 160 days retail) TRUEPLUS LANCETS 1 QL(6.67 ea 33G MICRO THIN MISC daily) THINLETS GP LANCETS 1 QL(6.67 ea MISC daily) TRUEPLUS LANCETS 1 QL(6.67 ea TODAYS HEALTH QL(1 ea per 33G MISC daily) 1 ADVANCED LANCING 160 days retail) TRUEPLUS SAFETY 1 QL(6.67 ea DEVICE MISC LANCETS 28G MISC daily) TODAYS HEALTH SUPER 1 QL(6.67 ea ULTI-LANCE AUTOMATIC/ 1 QL(1 ea per THINLANCETS 30G MISC daily) CLEAR TIP MISC 160 days retail) TODAYS HEALTH ULTRA 1 QL(6.67 ea ULTILET CLASSIC 1 QL(6.67 ea THINLANCETS 28G MISC daily) LANCETS MISC daily) TOPCARE LANCETS 1 QL(6.67 ea ULTILET LANCETS 33G 1 QL(6.67 ea MICRO-THIN 33G MISC daily) MISC daily) TRAVEL LANCETS 30G QL(6.67 ea QL(6.67 ea 1 ULTILET LANCETS MISC 1 MISC daily) daily) TRAVEL LANCETS 1 QL(6.67 ea ULTILET SAFETY QL(6.67 ea ADVANCED 28G MISC daily) LANCETS 21G X 2.2MM 1 daily) MISC TRUE COMFORT TWIST 1 QL(6.67 ea TOP LANCETS 30G MISC daily) ULTILET SAFETY 1 QL(6.67 ea TRUE METRIX CONTROL LANCETS 23G MISC daily) SOLUTION LEVEL 1 1 ULTRA THIN LANCETS 1 QL(6.67 ea SOLN 31G MISC daily) TRUE METRIX CONTROL QL(1 ea per 75 ULTRA-CARE LANCETS 1 QL(6.67 ea SOLUTION LEVEL 2 1 days retail) 30G MISC daily) SOLN ULTRA-THIN II AUTO 1 QL(6.67 ea TRUE METRIX CONTROL QL(1 ea per 75 LANCET MISC daily) SOLUTION LEVEL 3 1 days retail) ULTRA-THIN II LANCETS 1 QL(6.67 ea SOLN 28G MISC daily) TRUECONTROL QL(1 ea per 75 ULTRA-THIN II LANCETS 1 QL(6.67 ea GLUCOSE CONTROL 1 days retail) 30G MISC daily) LEVEL 0 LIQD UNILET COMFORTOUCH 1 QL(6.67 ea LANCET MISC daily)

Nebraska Total Care Formulary September 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea UNIVERSAL 1 QL(6.67 ea UNILET EXCELITE II MISC 1 daily) LANCETS/33G/MICRO- 1 daily) QL(6.67 ea THIN MISC UNILET EXCELITE MISC 1 daily) V-GO 20 KIT 1 PA UNILET G.P. LANCET 1 QL(6.67 ea MISC daily) V-GO 30 KIT 1 PA UNILET G.P. SUPERLITE 1 QL(6.67 ea LANCET MISC daily) V-GO 40 KIT 1 PA UNILET GP 28 ULTRA QL(6.67 ea 1 VALUE PLUS LANCETS 1 QL(6.67 ea THIN MISC daily) STANDARD 21G MISC daily) QL(6.67 ea UNILET LANCET MISC 1 VALUE PLUS LANCETS 1 QL(6.67 ea daily) SUPERTHIN 30G MISC daily) UNILET LANCETS QL(6.67 ea 1 VALUE PLUS LANCETS 1 QL(6.67 ea MICRO-THIN33G MISC daily) THIN 26G MISC daily) UNILET LANCETS QL(6.67 ea 1 VALUE PLUS LANCING 1 QL(1 ea per SUPER-THIN30G MISC daily) DEVICE MISC 160 days retail) UNILET LANCETS QL(6.67 ea 1 VALUMARK LANCET 1 QL(6.67 ea ULTRA-THIN 28G MISC daily) SUPER THIN 30G MISC daily) UNILET SUPERLITE QL(6.67 ea 1 VALUMARK LANCET 1 QL(6.67 ea LANCET MISC daily) ULTRA THIN 28G MISC daily) QL(6.67 ea UNISTIK 3 GENTLE MISC 1 VIDA MIA AUTOLET 1 QL(1 ea per daily) LANCINGDEVICE MISC 160 days retail) UNISTIK PRO SAFETY 1 QL(6.67 ea VIDA MIA UNILET QL(6.67 ea LANCET 21G MISC daily) LANCETS SUPER THIN 1 daily) UNISTIK PRO SAFETY 1 QL(6.67 ea 30G MISC LANCET 25G MISC daily) VIDA MIA UNILET QL(6.67 ea UNISTIK PRO SAFETY 1 QL(6.67 ea LANCETS ULTRA THIN 1 daily) LANCET 28G MISC daily) 28G MISC UNISTIK SAFETY QL(6.67 ea 1 VITALET PRO LANCETS 1 QL(6.67 ea LANCETS 28G MISC daily) MISC daily) UNISTIK SAFETY QL(6.67 ea 1 VITALET PRO PLUS 1 QL(6.67 ea LANCETS 30G MISC daily) LANCETS MISC daily) UNISTIK TOUCH SAFETY QL(6.67 ea 1 VIVAGUARD LANCETS 1 QL(6.67 ea LANCETS 21G MISC daily) MISC daily) UNISTIK TOUCH SAFETY QL(6.67 ea 1 VIVAGUARD LANCING 1 QL(1 ea per LANCETS 23G MISC daily) DEVICE MISC 160 days retail) UNISTIK TOUCH SAFETY 1 QL(6.67 ea WALGREENS ADVANCED QL(6.67 ea LANCETS 28G MISC daily) TRAVELLANCETS 28G 1 daily) MISC UNISTIK TOUCH SAFETY 1 QL(6.67 ea LANCETS 30G MISC daily) WALGREENS COMFORT QL(6.67 ea ASSUREDLANCETS 1 daily) UNIVERSAL 1 LANCETS 1 QL(6.67 ea THIN26G MISC daily) MICRO THIN/33G MISC WALGREENS COMFORT QL(6.67 ea UNIVERSAL 1 LANCETS 1 QL(6.67 ea ULTRA THIN 30G MISC daily) ASSUREDLANCETS 1 daily) SUPER THIN/28G MISC

Nebraska Total Care Formulary September 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WALGREENS LANCETS 1 QL(6.67 ea ULTICARE ALCOHOL 1 QL(13.34 ea MISC daily) SWABS PADS daily); RX/OTC WALGREENS THIN 1 QL(6.67 ea ULTRA-CARE ALCOHOL 1 QL(13.34 ea LANCETS MISC daily) PREP PADS PADS daily); RX/OTC WALGREENS ULTRA 1 QL(6.67 ea Parenteral Therapy Supplies THIN LANCETS MISC daily) ADVOCATE INSULIN QL(5 ea daily); ZEVRX TWIST TOP 1 QL(6.67 ea SYRINGE/U- 1 RX/OTC; MP LANCETS 30G MISC daily) 100/0.3ML/29GX1/2" MISC Misc. Devices ADVOCATE INSULIN QL(5 ea daily); QL(13.34 ea SYRINGE/U- RX/OTC; MP ALCOHOL PADS PADS 1 1 daily); RX/OTC 100/0.3ML/30GX5/16" MISC ALCOHOL PREP PADS 1 QL(13.34 ea PADS daily); RX/OTC ADVOCATE INSULIN QL(5 ea daily) SYRINGE/U- QL(13.34 ea 1 ALCOHOL PREPS PADS 1 100/0.3ML/31GX5/16" daily); RX/OTC MISC QL(13.34 ea ALCOHOL SWABS PADS 1 ADVOCATE INSULIN QL(5 ea daily); daily); RX/OTC SYRINGE/U- 1 RX/OTC; MP CVS ALCOHOL PREP 1 QL(13.34 ea 100/0.5ML/29GX1/2" MISC PADS PADS daily); RX/OTC ADVOCATE INSULIN QL(5 ea daily); QL(13.34 ea CVS PREP PADS PADS 1 SYRINGE/U- 1 RX/OTC; MP daily); RX/OTC 100/0.5ML/30GX5/16" MISC FIFTY50 ALCOHOL PREP 1 QL(13.34 ea PADS PADS daily); RX/OTC ADVOCATE INSULIN QL(5 ea daily) SYRINGE/U- GNP ALCOHOL SWABS 1 QL(13.34 ea 1 PADS daily); RX/OTC 100/0.5ML/31GX5/16" MISC HM STERILE ALCOHOL 1 QL(13.34 ea PREP PADS PADS daily); RX/OTC ADVOCATE INSULIN QL(5 ea daily); PHARMACIST CHOICE QL(13.34 ea SYRINGE/U- 1 RX/OTC; MP ALCOHOL PRED PADS 1 daily); RX/OTC 100/1ML/29GX1/2" MISC PADS ADVOCATE INSULIN QL(5 ea daily); PHARMACIST CHOICE QL(13.34 ea SYRINGE/U- 1 RX/OTC; MP ALCOHOLPREP PADS 1 daily); RX/OTC 100/1ML/30GX5/16" MISC PADS ADVOCATE INSULIN QL(5 ea daily) SYRINGE/U- 1 QC ALCOHOL SWABS 1 QL(13.34 ea PADS daily); RX/OTC 100/1ML/31GX5/16" MISC ASSURE ID INSULIN QL(5 ea daily); RA ALCOHOL SWABS 1 QL(13.34 ea PADS daily); RX/OTC SAFETYSYRINGE/U- 1 RX/OTC; MP 100/0.5ML/29G X 1/2" RELION ALCOHOL 1 QL(13.34 ea MISC SWABS PADS daily); RX/OTC ASSURE ID INSULIN QL(5 ea daily); SAPS HEALTH ALCOHOL 1 QL(13.34 ea SAFETYSYRINGE/U- 1 RX/OTC; MP PREPPADS PADS daily); RX/OTC 100/1ML/29G X 1/2" MISC SAPS HEALTH CARE QL(13.34 ea B-D INSULIN SYRINGE QL(5 ea daily) ALCOHOLPREP PADS 1 daily); RX/OTC ULTRAFINE II/0.3ML/31G 1 PADS X 5/16" MISC SM ALCOHOL PREP 1 QL(13.34 ea PADS PADS daily); RX/OTC Nebraska Total Care Formulary September 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/0.5ML/31G 1 ULTRA-FINE/0.3ML/30G X 1 X 5/16" MISC 12.7MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/1ML/31G X 1 ULTRA-FINE/0.3ML/31G X 1 5/16" MISC 8MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.3ML/30G X 1 ULTRA-FINE/0.5ML/30G X 1 MP 1/2" MISC 12.7MM MISC B-D INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X 1 MP ULTRA-FINE/0.5ML/31G X 1 1/2" MISC 8MM MISC BD LO-DOSE INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE MICROFINE 1 RX/OTC; MP ULTRA-FINE/1/2 1 IV/0.5ML/28G X 1/2" MISC UNIT/0.3ML/31G X 8MM MISC BD AUTOSHIELD 29G X 1 QL(5 ea daily) 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); ULTRA-FINE/1ML/30G X 1 MP BD AUTOSHIELD DUO 1 QL(5 ea daily) 30G X 5MM MISC 12.7MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) LUER-LOK/U-100/1ML 1 RX/OTC; MP ULTRA-FINE/1ML/31G X 1 MISC 8MM MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE HALF- MICROFINE IV/U- 1 RX/OTC; MP 1 100/0.5ML/28G X 1/2" UNIT/0.3ML/31G X 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 1 ULTRAFINE/0.3ML/30G X 1 100/1ML/27G X 5/8" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- 1 RX/OTC; MP ULTRAFINE/0.3ML/31G X 1 100/1ML/28G X 1/2" MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.5ML/30G X 1 MP MICROFINE/U- 1 RX/OTC; MP 100/0.5ML/28G X 1/2" 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/31G X 1 MICROFINE/U- 1 5/16" MISC 100/1ML/27G X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/1ML/30G X 1 MP MICROFINE/U- 1 RX/OTC; MP 1/2" MISC 100/1ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- 1 RX/OTC; MP SAFETYGLIDE/1ML/29G X 1 RX/OTC; MP 100/0.3ML/29G X 1/2" 1/2" MISC MISC BD INSULIN SYRINGE 1 QL(5 ea daily); SLIP TIP/U-100/1ML MISC RX/OTC; MP

Nebraska Total Care Formulary September 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily); BD PEN QL(5 ea daily); ULTRAFINE/U- 1 RX/OTC; MP NEEDLE/NANO/ULTRA- 1 RX/OTC 100/0.5ML/29G X 1/2" FINE/32G X 4MM MISC MISC BD PEN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); NEEDLE/ORIGINAL/ULTR 1 ULTRAFINE/U- 1 RX/OTC; MP A-FINE/29G X 12.7MM 100/1ML/29G X 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD PEN QL(5 ea daily); ULTRAFINE/U- 1 NEEDLE/SHORT/ULTRA- 1 RX/OTC; MP 100/1ML/31G X 5/16" FINE/31G X 8MM MISC MISC BD SAFETY-GLIDE QL(5 ea daily); BD INSULIN QL(5 ea daily); INSULIN 1 RX/OTC; MP SYRINGE/0.3ML/29G X 1 RX/OTC; MP SYRINGE/0.5ML/29G X 12.7MM MISC 1/2" MISC BD INSULIN QL(5 ea daily); BD SAFETY-LOK INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC; MP SYRINGE/PERM 1 RX/OTC; MP 12.7MM MISC NEEDLE/UF/1ML/29G X BD INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/1ML/27G X 1 RX/OTC BD SAFETYGLIDE QL(5 ea daily); 12.7MM MISC INSULIN 1 RX/OTC; MP BD INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X SYRINGE/1ML/29G X 1 RX/OTC; MP 1/2" MISC 12.7MM MISC BD SAFETYGLIDE QL(5 ea daily) BD INSULIN QL(5 ea daily) INSULIN 1 SYRINGE/0.3ML/31G X SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/25G 5/16" MISC X 1" MISC BD SAFETYGLIDE BD INSULIN QL(5 ea daily) INSULIN 1 SYRINGE/0.5ML/31G X SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/25G 15/64" MISC X 5/8" MISC BD SAFETYGLIDE QL(5 ea daily) BD INSULIN QL(5 ea daily) INSULIN 1 SYRINGE/1ML/31G X SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/26G 15/64" MISC X 1/2" MISC BD SAFETYGLIDE QL(5 ea daily); INSULIN RX/OTC; MP BD INSULIN SYRINGE/U- 1 QL(5 ea daily); 1 100/1ML/27G X 1/2" MISC RX/OTC SYSYRINGE/0.5ML/30G X 5/16" MISC BD NESTABLE SHARPS 1 RX/OTC COLLECTOR MISC BD SHARPS COLLECTOR 1 RX/OTC MISC BD PEN QL(5 ea daily) NEEDLE/MICRO/ULTRA- 1 BD SHARPS RX/OTC FINE/32G X 6MM MISC COLLECTOR/EXTRALAR 1 GE MISC BD PEN QL(5 ea daily); NEEDLE/MINI/ULTRA- 1 RX/OTC; MP BD SHARPS RX/OTC FINE/31G X 5MM MISC COLLECTOR/SMALL 1 MISC BD PEN NEEDLE/NANO QL(5 ea daily); 2ND GEN/32G X 5/32" 1 RX/OTC BD SHARPS CONTAINER 1 RX/OTC MISC HOME MISC

Nebraska Total Care Formulary September 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD SHARPS DISPOSAL 1 RX/OTC CLEVER CHOICE QL(5 ea daily) BY MAIL 1.4 QUART MISC COMFORT EZINSULIN 1 BD VEO INSULIN SYRINGE/0.3ML/31G X 5/16" MISC SYRINGE ULTR-FINE/U- 1 100/0.5ML/31G X 15/64" CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 1 RX/OTC; MP BD VEO INSULIN SYRINGE/0.5ML/28G X 1/2" MISC SYRINGE ULTRA- 1 FINE/0.5ML/31G X 6MM CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 1 RX/OTC; MP BD VEO INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 1/2" MISC SYRINGE ULTRA- 1 FINE/1ML/31G X 6MM CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 1 MP BD VEO INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1/2" MISC SYRINGE ULTRA-FINE/U- 1 100/1ML/31G X 15/64" CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 1 RX/OTC; MP CAREONE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X SYRINGES/0.3ML/30G X 1 5/16" MISC 1/2" MISC CLEVER CHOICE QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) COMFORT EZINSULIN 1 SYRINGES/0.3ML/31G X 1 SYRINGE/0.5ML/31G X 5/16" MISC 5/16" MISC CAREONE INSULIN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); SYRINGES/0.5ML/30G X 1 MP COMFORT EZINSULIN 1 MP 1/2" MISC SYRINGE/1.0ML/30G X 1/2" MISC CAREONE INSULIN QL(5 ea daily) SYRINGES/0.5ML/31G X 1 CLEVER CHOICE QL(5 ea daily); 5/16" MISC COMFORT EZINSULIN 1 RX/OTC; MP SYRINGE/1ML/28G X 1/2" CAREONE INSULIN QL(5 ea daily); MISC SYRINGES/1ML/30G X 1 MP 1/2" MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC; MP CAREONE INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" SYRINGES/1ML/31GX5/16 1 MISC " MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC; MP COMFORT EZINSULIN 1 RX/OTC; MP SYRINGE/1ML/30G X SYRINGE/0.3ML/29G X 5/16" MISC 1/2" MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 1 COMFORT EZINSULIN 1 SYRINGE/U- SYRINGE/0.3ML/30G X 100/1ML/31GX5/16" MISC 1/2" MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); INSULIN SYRINGE 1 RX/OTC; MP COMFORT EZINSULIN 1 RX/OTC; MP 0.3ML/29G X 1/2" MISC SYRINGE/0.3ML/30G X 5/16" MISC

Nebraska Total Care Formulary September 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); INSULIN 1 RX/OTC; MP SYRINGE 1ML/29G X 1/2" 1 RX/OTC; MP SYRINGE/0.3ML/30G X MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily) COMFORT ASSIST QL(5 ea daily) SYRINGE U-100/0.3/31G X 1 INSULIN 1 5/16" MISC SYRINGE/0.3ML/31G X DROPLET INSULIN QL(5 ea daily) 5/16" MISC SYRINGE U- 1 COMFORT ASSIST QL(5 ea daily); 100/0.3ML/30G X 1/2" INSULIN 1 RX/OTC; MP MISC SYRINGE/0.5ML/29G X DROPLET INSULIN QL(5 ea daily); 1/2" MISC SYRINGE U- 1 RX/OTC; MP COMFORT ASSIST QL(5 ea daily); 100/0.3ML/30G X 5/16" INSULIN 1 RX/OTC; MP MISC SYRINGE/0.5ML/30G X DROPLET INSULIN QL(5 ea daily); 5/16" MISC SYRINGE U- 1 MP COMFORT ASSIST QL(5 ea daily) 100/0.5ML/30G X 1/2" INSULIN 1 MISC SYRINGE/0.5ML/31G X DROPLET INSULIN QL(5 ea daily); 5/16" MISC SYRINGE U- 1 RX/OTC; MP COMFORT ASSIST QL(5 ea daily); 100/0.5ML/30G X 5/16" INSULIN 1 RX/OTC; MP MISC SYRINGE/1ML/29G X 1/2" DROPLET INSULIN QL(5 ea daily) MISC SYRINGE U- 1 COMFORT ASSIST QL(5 ea daily); 100/0.5ML/31G X 5/16" INSULIN 1 RX/OTC; MP MISC SYRINGE/1ML/30G X DROPLET INSULIN QL(5 ea daily); 5/16" MISC SYRINGE U-100/1ML/30G 1 MP COMFORT ASSIST QL(5 ea daily) X 1/2" MISC INSULIN 1 DROPLET INSULIN QL(5 ea daily); SYRINGE/1ML/31G X SYRINGE U-100/1ML/30G 1 RX/OTC; MP 5/16" MISC X 5/16" MISC COMFORT EZ INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) SYRINGE/U- 1 SYRINGE U-100/1ML/31G 1 100/0.5ML/31G X 5/16" X 15/64" MISC MISC DROPLET INSULIN QL(5 ea daily) COMFORT EZ INSULIN QL(5 ea daily) SYRINGE U-100/1ML/31G 1 SYRINGE/U-100/1ML/31G 1 X 5/16" MISC X 5/16" MISC DROPLET INSULIN QL(5 ea daily) COMPLETE NEEDLE RX/OTC SYRINGE/U- 1 COLLECTION & 1 100/0.3ML/31G X 5/16" DISPOSAL SYSTEM MISC MISC DROPLET INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); SYRINGE 0.3ML/29G X 1 RX/OTC; MP SYRINGE/U- 1 MP 1/2" MISC 100/0.5ML/30G X 1/2" DROPLET INSULIN QL(5 ea daily); MISC SYRINGE 0.5ML/29G X 1 RX/OTC; MP 1/2" MISC

Nebraska Total Care Formulary September 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN EASY TOUCH FLIPLOCK QL(5 ea daily) SYRINGE/U- 1 SAFETY INSULIN 1 100/0.5ML/31G X 15/64" SYRINGE 1ML/31GX5/16" MISC MISC DROPLET INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.3ML/30G X 1 RX/OTC; MP 100/0.5ML/31G X 5/16" 5/16" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 1 SYRINGE/U-100/1ML/30G 1 MP 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 1 RX/OTC; MP SYRINGE/U-100/1ML/31G 1 1/2" MISC X 15/64" MISC EASY TOUCH INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC; MP SYRINGE/U-100/1ML/31G 1 5/16" MISC X 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC; MP SYRINGE/0.5ML/30G X 1 RX/OTC; MP 5/16" MISC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- 1 RX/OTC; MP SYRINGE/0.5ML/31G X 1 100/0.5ML/29G X 1/2" 5/16" MISC MISC EASY COMFORT INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); 1 SYRINGE/1ML/30G X RX/OTC; MP SYRINGE/SAFETY/U- 1 RX/OTC; MP 5/16" MISC 100/0.5ML/30G X 5/16" EASY COMFORT INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X 1 EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/SAFETY/U- 1 RX/OTC; MP EASY COMFORT INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC SYRINGE/U- 1 MP EASY TOUCH INSULIN QL(5 ea daily); 100/0.5ML/30G X 1/2" SYRINGE/SAFETY/U- 1 MP MISC 100/1ML/30G X 1/2" MISC EASY COMFORT INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) 1 SYRINGE/U-100/1ML/30G MP SYRINGE/U- 1 X 1/2" MISC 100/0.3ML/30G X 1/2" EASY TOUCH FLIPLOCK QL(5 ea daily); MISC SAFETY INSULIN 1 RX/OTC; MP EASY TOUCH INSULIN QL(5 ea daily) SYRINGE 1ML/29GX1/2" SYRINGE/U- 1 MISC 100/0.5ML/27G X 1/2" EASY TOUCH FLIPLOCK QL(5 ea daily); MISC SAFETY INSULIN 1 MP EASY TOUCH INSULIN QL(5 ea daily); SYRINGE 1ML/30GX1/2" SYRINGE/U- 1 RX/OTC; MP MISC 100/0.5ML/28G X 1/2" EASY TOUCH FLIPLOCK QL(5 ea daily); MISC SAFETY INSULIN 1 RX/OTC; MP SYRINGE 1ML/30GX5/16" MISC

Nebraska Total Care Formulary September 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGE/0.5ML/29G X 1 RX/OTC; MP 100/0.5ML/29G X 1/2" 1/2" MISC MISC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC; MP SYRINGE/U- 1 MP 5/16" MISC 100/0.5ML/30G X 1/2" ELITE-THIN INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 1 RX/OTC; MP EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 ELITE-THIN INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/U- 1 RX/OTC; MP MISC 100/0.5ML/28G X 1/2" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/27G 1 RX/OTC ELITE-THIN INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/U- 1 EASY TOUCH INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/U-100/1ML/28G 1 RX/OTC; MP MISC X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC; MP SYRINGE/U-100/1ML/29G 1 RX/OTC; MP X 1/2" MISC X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G 1 RX/OTC; MP SYRINGE/U-100/1ML/30G 1 MP X 1/2" MISC X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 SYRINGE/U-100/1ML/31G 1 X 5/16" MISC X 5/16" MISC EQL INSULIN QL(5 ea daily); EASY TOUCH QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC; MP SHEATHLOCK SAFETY 1 RX/OTC; MP 1/2" MISC INSULIN SYRINGE EQL INSULIN QL(5 ea daily); 1ML/29GX1/2" MISC SYRINGE/0.3ML/30G X 1 RX/OTC; MP EASY TOUCH QL(5 ea daily); 5/16" MISC SHEATHLOCK SAFETY 1 RX/OTC; MP EQL INSULIN QL(5 ea daily) INSULIN SYRINGE SYRINGE/0.3ML/31G X 1 1ML/30GX5/16" MISC 5/16" MISC EASY TOUCH QL(5 ea daily) EQL INSULIN QL(5 ea daily); SHEATHLOCK SAFETY 1 SYRINGE/0.5ML/29G X 1 RX/OTC; MP INSULIN SYRINGE 1/2" MISC 1ML/31GX5/16" MISC EQL INSULIN QL(5 ea daily); EASY TOUCH QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC; MP SHEATHLOCK SAFETY 1 MP 5/16" MISC SYRINGE 1ML/30GX1/2" MISC EQL INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 1 ELITE-THIN INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.3ML/31G X 1 5/16" MISC EQL INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP MISC

Nebraska Total Care Formulary September 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL INSULIN QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) 1 SYRINGE/1ML/30G X RX/OTC; MP COMFORTINSULIN 1 5/16" MISC SYRINGE/1ML/31G X EQL INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/1ML/31G X 1 FREESTYLE PRECISION QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC; MP EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/30G X 5/16" MISC INSULIN 1 RX/OTC; MP SYRINGE/0.3ML/29G X FREESTYLE PRECISION QL(5 ea daily) 1/2" MISC INSULIN SYRINGE/U- 1 EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/31G X 5/16" MISC INSULIN 1 RX/OTC; MP SYRINGE/0.3ML/30G X FREESTYLE PRECISION QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 1 EXEL COMFORT POINT QL(5 ea daily); 100/1ML/31G X 5/16" MISC INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/28G X FREESTYLE PRECISION QL(5 ea daily); 1/2" MISC INSULIN SYRINGES/U- 1 RX/OTC; MP EXEL COMFORT POINT QL(5 ea daily); 100/1ML/30G X 5/16" MISC INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/29G X GLOBAL EASY GLIDE 1/2" MISC INSULIN 1 EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.5ML/31G X 15/64" MISC INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/30G X GLOBAL EASY GLIDE QL(5 ea daily) 5/16" MISC INSULIN 1 EXEL COMFORT POINT QL(5 ea daily); SYRINGE/1ML/31G X 15/64" MISC INSULIN 1 RX/OTC; MP SYRINGE/1ML/28G X 1/2" GLOBAL EASY GLIDE QL(5 ea daily) MISC INSULINSYRINGE/U- 1 EXEL COMFORT POINT QL(5 ea daily); 100/0.3ML/31G X 5/16" MISC INSULIN 1 RX/OTC; MP SYRINGE/1ML/29G X 1/2" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC; MP EXEL COMFORT POINT QL(5 ea daily); 100/0.3ML/29G X 1/2" MISC INSULIN 1 RX/OTC; MP SYRINGE/1ML/30G X GLOBAL INJECT EASE QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 1 FIFTY50 SUPERIOR QL(5 ea daily) 100/0.3ML/30G X 1/2" MISC COMFORTINSULIN 1 SYRINGE/0.3ML/31G X GLOBAL INJECT EASE QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC; MP FIFTY50 SUPERIOR QL(5 ea daily) 100/0.3ML/30G X 5/16" MISC COMFORTINSULIN 1 SYRINGE/0.5ML/31G X GLOBAL INJECT EASE QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 1 100/0.3ML/31G X 5/16" MISC

Nebraska Total Care Formulary September 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE/U- 1 100/0.5ML/28G X 1/2" 100/0.3ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 MP SYRINGE/U- 1 100/0.5ML/30G X 1/2" 100/0.3ML/31G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE/U- 1 MP 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) 1 INSULIN SYRINGE/U- RX/OTC; MP SYRINGE/U- 1 100/1ML/28G X 1/2" MISC 100/0.5ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC; MP GLUCOPRO INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G 1 MP GLOBAL INJECT EASE QL(5 ea daily); X 1/2" MISC INSULIN SYRINGE/U- 1 MP GLUCOPRO INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G 1 RX/OTC; MP GLOBAL INJECT EASE QL(5 ea daily); X 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC; MP GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" SYRINGE/U-100/1ML/31G 1 MISC X 5/16" MISC GLOBAL INJECT EASE QL(5 ea daily) GNP INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 SYRINGE/0.3ML/29G X 1 RX/OTC; MP 100/1ML/31G X 5/16" 1/2" MISC MISC GNP INSULIN QL(5 ea daily); GLOBAL INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC; MP SYRINGE/U- 1 5/16" MISC 100/0.3ML/30G X 1/2" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 1 GLOBAL INSULIN QL(5 ea daily); 5/16" MISC SYRINGES/U- 1 RX/OTC; MP GNP INSULIN QL(5 ea daily); 100/0.3ML/30GX5/16" SYRINGE/0.5ML/28G X 1 RX/OTC; MP MISC 1/2" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC; MP 1/2" MISC

Nebraska Total Care Formulary September 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP INSULIN QL(5 ea daily); GUARDIAN SHARPS RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC; MP COLLECTORHORIZONTA 1 5/16" MISC L NESTABLE 5.4 QT MISC GNP INSULIN QL(5 ea daily) GUARDIAN SHARPS RX/OTC 1 SYRINGE/0.5ML/31G X COLLECTORHORIZONTA 1 5/16" MISC L PRE-ASSEMBLED 5.4 GNP INSULIN QL(5 ea daily); QT MISC SYRINGE/1ML/28G X 1/2" 1 RX/OTC; MP GUARDIAN SHARPS RX/OTC MISC COLLECTORNESTABLE 1 GNP INSULIN QL(5 ea daily); 16 GAL MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP GUARDIAN SHARPS RX/OTC MISC COLLECTORNESTABLE 8 1 GNP INSULIN QL(5 ea daily); QT MISC SYRINGE/1ML/30G X 1 RX/OTC; MP GUARDIAN SHARPS RX/OTC 5/16" MISC COLLECTORNESTABLE 1 GNP INSULIN QL(5 ea daily) LARGE FUNNEL 14 QT SYRINGE/1ML/31G X 1 MISC 5/16" MISC GUARDIAN SHARPS RX/OTC GNP INSULIN QL(5 ea daily); COLLECTORNESTABLE 1 SYRINGES/1ML/28GX1/2" 1 RX/OTC; MP LARGE FUNNEL 6 GAL MISC MISC GNP INSULIN QL(5 ea daily) GUARDIAN SHARPS RX/OTC SYRINGES/3ML/31GX5/16 1 COLLECTORNESTABLE 1 " MISC NON-VENTED 8 QT MISC GNP ULTRA COMFORT QL(5 ea daily); GUARDIAN SHARPS RX/OTC COLLECTORNESTABLE 1 INSULIN 1 RX/OTC; MP SYRINGE/0.3ML/29G X OPEN 14 QT MISC 1/2" MISC GUARDIAN SHARPS RX/OTC GNP ULTRA COMFORT QL(5 ea daily); COLLECTORNESTABLE 1 OPEN TOP 6 GAL MISC INSULIN 1 RX/OTC; MP SYRINGE/0.3ML/30G X GUARDIAN SHARPS RX/OTC 5/16" SHORT MISC COLLECTORNESTABLE 1 GNP ULTRA COMFORT QL(5 ea daily); OPEN TOP NV 6 GAL MISC INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/28G X GUARDIAN SHARPS RX/OTC 1/2" MISC COLLECTORNESTABLE 1 GNP ULTRA COMFORT QL(5 ea daily); SMALL FUNNEL 14 QT MISC INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/29G X GUARDIAN SHARPS RX/OTC 1/2" MISC COLLECTORNESTABLE 1 GNP ULTRA COMFORT QL(5 ea daily); SMALL FUNNEL NV 14 QT MISC INSULIN 1 RX/OTC; MP SYRINGE/1ML/28G X 1/2" GUARDIAN SHARPS RX/OTC MISC COLLECTORONE-PIECE 1 GNP ULTRA COMFORT QL(5 ea daily); HOME CARE 1QT MISC INSULIN 1 RX/OTC; MP GUARDIAN SHARPS RX/OTC SYRINGE/1ML/29G X 1/2" COLLECTORONE-PIECE 1 MISC LARGE 8.2 QT MISC

Nebraska Total Care Formulary September 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GUARDIAN SHARPS RX/OTC HEALTHWISE INSULIN QL(5 ea daily) COLLECTORONE-PIECE 1 SYRINGE/U- 1 LARGE NON-VENTED 8.2 100/0.3ML/31G X 5/16" QT MISC MISC GUARDIAN SHARPS RX/OTC HEALTHWISE INSULIN QL(5 ea daily); 1 COLLECTORONE-PIECE SYRINGE/U- 1 RX/OTC; MP MEDIUM 6.9 QT MISC 100/0.5ML/30G X 5/16" GUARDIAN SHARPS RX/OTC MISC COLLECTORONE-PIECE 1 HEALTHWISE INSULIN QL(5 ea daily) MEDIUM NON-VENTED SYRINGE/U- 1 6.9 QT MISC 100/0.5ML/31G X 5/16" GUARDIAN SHARPS RX/OTC MISC COLLECTORONE-PIECE 1 HEALTHWISE INSULIN QL(5 ea daily); OFFSET NECK 9.2 QT SYRINGE/U-100/1ML/30G 1 RX/OTC; MP MISC X 5/16" MISC GUARDIAN SHARPS RX/OTC HEALTHWISE INSULIN QL(5 ea daily) COLLECTORONE-PIECE 1 SYRINGE/U-100/1ML/31G 1 PHLEBOTOMY 1QT MISC X 5/16" MISC GUARDIAN SHARPS RX/OTC HM ULTICARE INSULIN QL(5 ea daily); COLLECTORONE-PIECE 1 SYRINGE/1ML/30G X 1/2" 1 MP X-L LARGE FUNNEL 5 MISC GAL MISC HM ULTICARE INSULIN QL(5 ea daily) GUARDIAN SHARPS RX/OTC SYRINGE/U- 1 COLLECTORONE-PIECE 1 100/0.3ML/31G X 5/16" X-L OPEN TOP 5 GAL MISC MISC INSULIN QL(5 ea daily); GUARDIAN SHARPS RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC; MP COLLECTORONE-PIECE 1 1/2" MISC X-L OPEN TOP NV 5 GAL INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X 1 RX/OTC; MP GUARDIAN SHARPS RX/OTC 5/16" MISC COLLECTORSIDE ENTRY 1 INSULIN QL(5 ea daily) NESTABLE 5.4 QT MISC SYRINGE/0.3ML/31G X 1 GUARDIAN SHARPS RX/OTC 5/16" MISC COLLECTORSIDE ENTRY 1 INSULIN QL(5 ea daily) PRE-ASSEMBLED 5.4 QT SYRINGE/0.5ML/27G X 1 MISC 1/2" MISC GUARDIAN SHARPS RX/OTC INSULIN QL(5 ea daily); COLLECTORVERTICAL 1 SYRINGE/0.5ML/28G X 1 RX/OTC; MP ENTRY 3.2 QT MISC 1/2" MISC GUARDIAN SHARPS RX/OTC INSULIN QL(5 ea daily); COLLECTORVERTICAL 1 SYRINGE/0.5ML/30G X 1 MP ENTRY NON-VENTED 3.2 1/2" MISC QT MISC INSULIN QL(5 ea daily); HEALTHWISE INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC; MP SYRINGE/U- 1 RX/OTC; MP 5/16" MISC 100/0.3ML/30G X 5/16" MISC

Nebraska Total Care Formulary September 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/31G X 1 100/1ML/30G X 5/16" 1 RX/OTC; MP 5/16" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/1ML/28G X 1/2" 1 RX/OTC; MP 100/1ML/31G X 5/16" 1 MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP SYRINGES/0.5ML/27GX1/ 1 MISC 2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC; MP SYRINGES/0.5ML/28GX1/ 1 RX/OTC; MP 5/16" MISC 2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC; MP SYRINGES/0.5ML/29GX1/ 1 RX/OTC; MP 0.3ML/30G X 5/16" MISC 2" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 SYRINGES/0.5ML/30GX5/ 1 RX/OTC; MP 0.3ML/31G X 5/16" MISC 16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 RX/OTC; MP SYRINGES/0.5ML/31GX 1 0.5ML/29G X 1/2" MISC 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 RX/OTC; MP SYRINGES/0.5ML/31GX5/ 1 0.5ML/30G X 5/16" MISC 16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 SYRINGES/1ML/27GX/1/2" 1 RX/OTC 0.5ML/31G X 5/16" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC; MP SYRINGES/1ML/27GX1/2" 1 RX/OTC 1ML/29G X 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC; MP SYRINGES/1ML/28GX1/2" 1 RX/OTC; MP 1ML/30G X 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 SYRINGES/1ML/29GX1/2" 1 RX/OTC; MP 1ML/31G X 5/16" MISC MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily); 100/0.3ML/29G X 1/2" 1 RX/OTC; MP SYRINGES/1ML/30GX1/2" 1 MP MISC MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" 1 RX/OTC; MP SYRINGES/1ML/31GX5/16 1 MISC " MISC INSULIN SYRINGE/U- 1 QL(5 ea daily); KINRAY INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC RX/OTC; MP SYRINGE PREFERRED 1 INSULIN SYRINGE/U- QL(5 ea daily) PLUS/0.3ML/31G X 5/16" 100/1ML/30G X 5/16" 1 MISC MISC

Nebraska Total Care Formulary September 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KINRAY INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE PREFERRED 1 SYRINGE/0.3ML/29G X 1 RX/OTC; MP PLUS/0.5ML/31G X 5/16" 1/2" MISC MISC LEADER INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC; MP SYRINGE PREFERRED 1 5/16" MISC PLUS/1ML/31G X 5/16" LEADER INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 1 KINRAY INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/29G X 1 RX/OTC; MP LEADER INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.5ML/28G X 1 RX/OTC; MP KMART VALU PLUS QL(5 ea daily) 1/2" MISC INSULIN 1 LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G SYRINGE/0.5ML/29G X 1 RX/OTC; MP MISC 1/2" MISC KMART VALU PLUS QL(5 ea daily); LEADER INSULIN QL(5 ea daily); INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/30G X 1 RX/OTC; MP SYRINGE/1ML/29G MISC 5/16" MISC KMART VALU PLUS QL(5 ea daily); LEADER INSULIN QL(5 ea daily) INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/31G X 1 SYRINGE/1ML/30G MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC; MP SYRINGE/1ML/28G X 1/2" 1 RX/OTC; MP 1/2" MISC MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC; MP SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP 5/16" MISC MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 1 SYRINGE/1ML/30G X 1 RX/OTC; MP 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 1 RX/OTC; MP SYRINGE/1ML/31G X 1 1/2" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC; MP SYRINGE/0.3ML/29G X 1 RX/OTC; MP 5/16" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X 1 SYRINGE/0.3ML/30G X 1 RX/OTC; MP 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP SYRINGE/0.3ML/31G X 1 MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC; MP SYRINGE/0.5ML/30G X 1 RX/OTC; MP 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 SYRINGE/0.5ML/31G X 1 5/16" MISC 5/16" MISC Nebraska Total Care Formulary September 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); 1 SYRINGE/1ML/30G X RX/OTC; MP SAFETY SYRINGE/U- 1 RX/OTC; MP 5/16" MISC 100/0.3ML/30G X 5/16" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC; MP MAGELLAN INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SAFETY SYRINGE/U- 1 RX/OTC; MP MISC 100/0.5ML/29G X 1/2" LITETOUCH INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 MAGELLAN INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" SAFETY SYRINGE/U- 1 RX/OTC; MP MISC 100/0.5ML/30G X 5/16" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC; MP MAGELLAN INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SAFETY SYRINGE/U- 1 RX/OTC; MP MISC 100/1ML/29G X 1/2" MISC LITETOUCH INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SAFETY SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/29G X 1/2" 100/1ML/30G X 5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); MAXI-COMFORT INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/30G X 5/16" 100/0.5ML/28GX1/2" MISC MISC MAXI-COMFORT INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC; MP SYRINGE/U- 1 100/1ML/28GX1/2" MISC 100/0.5ML/31G X 5/16" MAXICOMFORT INSULIN QL(5 ea daily) MISC SYRINGES 27G X 1/2" 1 LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G 1 RX/OTC; MP MAXICOMFORT INSULIN QL(5 ea daily); X 1/2" MISC SYRINGES 27G X 1/2" 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G 1 RX/OTC; MP MEDIC INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/0.3ML/30G X 1 RX/OTC; MP LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/30G 1 RX/OTC; MP MEDIC INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/0.5ML/30G X 1 RX/OTC; MP LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/31G 1 MM INSULIN SYRINGE/U- QL(5 ea daily); X 5/16" MISC 100/0.3ML/30G X 5/16" 1 RX/OTC; MP LONGS INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 MM INSULIN SYRINGE/U- QL(5 ea daily) 5/16" MISC 100/0.3ML/31G X 5/16" 1 MAGELLAN INSULIN QL(5 ea daily); MISC SAFETY SYRINGE/U- 1 RX/OTC; MP MM INSULIN SYRINGE/U- QL(5 ea daily); 100/0.3ML/29G X 1/2" 100/1/2ML/30G X 5/16" 1 RX/OTC; MP MISC MISC

Nebraska Total Care Formulary September 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/1/2ML/31G X 5/16" 1 SYRINGE/SOFTPACK/1M 1 RX/OTC MISC L/27G X 1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 1 100/1ML/30G X 5/16" RX/OTC; MP SYRINGE/SOFTPACK/U- 1 RX/OTC; MP MISC 100/0.5ML/28G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 1 MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC; MP 100/0.3ML/30G X 5/16" MONOJECT INSULIN 1 QL(5 ea daily); SYRINGE/1ML MISC RX/OTC; MP MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 1 SYRINGE/U- 1 RX/OTC; MP 5/16" MISC 100/0.5ML/30G X 5/16" MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/DETACH 1 NEEDLE/1ML/25G X 5/8" SYRINGE/U-100/1ML/28G 1 RX/OTC; MP MISC X 1/2" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC; MP SYRINGE/DETACH 1 RX/OTC NEEDLE/1ML/27G X 1/2" X 5/16" MISC MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGEREGULAR LUER 1 RX/OTC; MP TIP/SOFTPACK/1ML MISC SYRINGE/PERM 1 RX/OTC; MP NEEDLE/1ML/28G X 1/2" MONOJECT SHARPS RX/OTC MISC CONTAINER/14 QUART 1 MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/PERM 1 RX/OTC; MP MONOJECT ULTRA QL(5 ea daily); NEEDLE/U-100/0.5ML/28G COMFORT INSULIN 1 RX/OTC; MP X 1/2" MISC SYRINGE/0.3ML/29G X MONOJECT INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/SAFETY/PERM 1 RX/OTC; MP MONOJECT ULTRA QL(5 ea daily); NEEDLE/0.3ML/29G X 1/2" COMFORT INSULIN 1 RX/OTC; MP MISC SYRINGE/0.3ML/30G X MONOJECT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/SAFETY/PERM 1 RX/OTC; MP MONOJECT ULTRA QL(5 ea daily) NEEDLE/0.3ML/29GX1/2" COMFORT INSULIN 1 MISC SYRINGE/0.3ML/31G X MONOJECT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/SAFETY/PERM 1 RX/OTC; MP MONOJECT ULTRA QL(5 ea daily); NEEDLE/0.5ML/29G X 1/2" COMFORT INSULIN 1 RX/OTC; MP MISC SYRINGE/0.5ML/28G X MONOJECT INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/SAFETY/PERM 1 RX/OTC; MP MONOJECT ULTRA QL(5 ea daily); NEEDLE/1ML/29G X 1/2" COMFORT INSULIN 1 RX/OTC; MP MISC SYRINGE/0.5ML/29G X 1/2" MISC

Nebraska Total Care Formulary September 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); COMFORT INSULIN 1 RX/OTC; MP PLUSINSULIN 1 RX/OTC; MP SYRINGE/0.5ML/30G X SYRINGE/1ML/29G X 1/2" 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily) PREFERRED PLUS QL(5 ea daily); COMFORT INSULIN 1 INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE/0.5ML/31G X 100/0.3ML/29G X 1/2" 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); COMFORT INSULIN 1 RX/OTC; MP INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE/1ML/28G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); COMFORT INSULIN 1 RX/OTC; MP INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE/1ML/29G X 1/2" 100/0.5ML/28G X 1/2" MISC MISC MS INSULIN QL(5 ea daily) PREFERRED PLUS QL(5 ea daily); SYRINGE/0.3ML/31G X 1 INSULIN SYRINGE/U- 1 RX/OTC; MP 5/16" MISC 100/0.5ML/29G X 1/2" MS INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 PREFERRED PLUS QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC; MP MS INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/1ML/31G X 1 MISC 5/16" MISC PREFERRED PLUS QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP PHLEBOTOMY SHARPS 1 RX/OTC CONTAINER MISC 100/1ML/28G X 1/2" MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP INSULIN 1 RX/OTC; MP SYRINGE/0.3ML/30G X 100/1ML/29G X 1/2" MISC 5/16" MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP 100/1ML/30G X 5/16" INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/28G X MISC 1/2" MISC PRO COMFORT INSULIN QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); SYRINGES/0.5ML/30G X 1 MP 1/2" MISC INSULIN 1 RX/OTC; MP SYRINGE/0.5ML/29G X PRO COMFORT INSULIN QL(5 ea daily); 1/2" MISC SYRINGES/0.5ML/30G X 1 RX/OTC; MP PRECISION SURE-DOSE QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC; MP PRO COMFORT INSULIN QL(5 ea daily) SYRINGE/1ML/28G X 1/2" SYRINGES/0.5ML/31G X 1 MISC 5/16" MISC PRECISION SURE-DOSE QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); PLUSINSULIN 1 RX/OTC; MP SYRINGES/1ML/30G X 1 MP SYRINGE/0.3ML/29G X 1/2" MISC 1/2" MISC

Nebraska Total Care Formulary September 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGES/1ML/30G X 1 RX/OTC; MP SYRINGE 1 5/16" MISC 1ML/31GX15/64" MISC PRO COMFORT INSULIN QL(5 ea daily) RELION INSULIN QL(5 ea daily) SYRINGES/1ML/31G X 1 SYRINGE/U- 1 5/16" MISC 100/0.3ML/31G X 5/16" PRODIGY INSULIN QL(5 ea daily) MISC SYRING/U-100/0.3ML/31G 1 RELION INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/U- 1 RX/OTC; MP PRODIGY INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGE/1/2ML/31G X 1 MISC 5/16" MISC RELION INSULIN QL(5 ea daily) PRODIGY INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/1ML/28G X 1/2" 1 RX/OTC; MP 100/0.5ML/31G X 5/16" MISC MISC PX INSULIN SYRINGE/U- QL(5 ea daily); RELION INSULIN QL(5 ea daily) 100/0.5ML/30G X 1/2" 1 MP SYRINGE/U-100/1ML/31G 1 MISC X 15/64" MISC RA INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 1 RX/OTC; MP SYRINGE/U-100/1ML/31G 1 1/2" MISC X 5/16" MISC RA INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP SYRINGE/0.3ML/30G X 1 RX/OTC; MP MISC 5/16" MISC RA INSULIN SYRINGE/U- QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" 1 RX/OTC; MP SYRINGE/0.5ML/29G X 1 RX/OTC; MP MISC 1/2" MISC RA INSULIN SYRINGE/U- QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); 100/1 ML/30G X 5/16" 1 RX/OTC; MP SYRINGE/0.5ML/30G X 1 RX/OTC; MP MISC 5/16" MISC REALITY INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC; MP SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/28G X 1/2" MISC MISC SAFESNAP INSULIN QL(5 ea daily); REALITY INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP MISC SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/29G X 1/2" SAFETY INSULIN QL(5 ea daily); MISC SYRINGES 1 RX/OTC; MP REALITY INSULIN QL(5 ea daily); 0.5ML/29GX1/2" MISC SYRINGE/U-100/1ML/28G 1 RX/OTC; MP SAFETY INSULIN QL(5 ea daily); X 1/2" MISC SYRINGES 1 RX/OTC; MP REALITY INSULIN QL(5 ea daily); 0.5ML/30GX5/16" MISC SYRINGE/U-100/1ML/29G 1 RX/OTC; MP SAFETY INSULIN QL(5 ea daily); X 1/2" MISC SYRINGES 1ML/27GX1/2" 1 RX/OTC RELION INSULIN MISC SYRINGE 0.5ML/31G X 1 SAFETY INSULIN QL(5 ea daily); 15/64" MISC SYRINGES 1ML/29GX1/2" 1 RX/OTC; MP MISC

Nebraska Total Care Formulary September 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily); SYRINGES 1ML/30GX1/2" 1 MP INSULIN SYRINGE/U- 1 RX/OTC; MP MISC 100/0.5ML/28G X 1/2" SB INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.5ML/29G X 1/2" 1 RX/OTC; MP SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC; MP SB INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/29G X 1/2" 100/0.5ML/30G X 5/16" 1 RX/OTC; MP MISC MISC SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U- MP SB INSULIN SYRINGE/U- 1 QL(5 ea daily); 1 100/1ML/29G X 1/2" MISC RX/OTC; MP 100/0.5ML/30G X 1/2" MISC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/1ML/30G X 5/16" 1 RX/OTC; MP SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/30G X 5/16" SB INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 1 MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- 1 SECURESAFE SAFETY QL(5 ea daily); 100/0.5ML/31G X 5/16 INSULIN SYRINGES/U- 1 RX/OTC; MP MISC 100/0.5ML/29GX1/2" MISC SURE COMFORT QL(5 ea daily); SECURESAFE SAFETY QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP INSULIN SYRINGES/U- 1 RX/OTC; MP 100/1ML/28G X 1/2" MISC 100/1ML/29GX1/2" MISC SURE COMFORT QL(5 ea daily); SHARP CONTAINER 1 RX/OTC INSULIN SYRINGE/U- 1 RX/OTC; MP MISC 100/1ML/29G X 1/2" MISC SHARPS DISPOSAL BY 1 RX/OTC SURE COMFORT QL(5 ea daily); MAIL SYSTEM MISC INSULIN SYRINGE/U- 1 MP SURE COMFORT QL(5 ea daily); 100/1ML/30G X 1/2" MISC INSULIN SYRINGE/U- 1 RX/OTC; MP SURE COMFORT QL(5 ea daily); 100/0.3ML/29G X 1/2" INSULIN SYRINGE/U- 1 RX/OTC; MP MISC 100/1ML/30G X 5/16" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 SURE COMFORT QL(5 ea daily) 100/0.3ML/30G X 1/2" INSULIN SYRINGE/U- 1 MISC 100/1ML/31G X 5/16" SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC; MP SURE-JECT INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGE/U- 1 RX/OTC; MP MISC 100/0.3ML/29G X 1/2" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 SURE-JECT INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16 RX/OTC; MP SYRINGE/U- 1 MISC 100/0.3ML/30G X 5/16" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 100/0.3ML/31G X 5/16" MISC

Nebraska Total Care Formulary September 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGEU- 1 RX/OTC; MP 100/0.3ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGEU- 1 MP 100/0.5ML/28G X 1/2" 100/0.5ML/30G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGEU- 1 RX/OTC; MP 100/0.5ML/29G X 1/2" 100/0.5ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGEU- 1 100/0.5ML/30G X 5/16" 100/0.5ML/31G X 15/64" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- 1 SYRINGEU- 1 100/0.5ML/31G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC; MP SYRINGEU-100/1ML/29G 1 RX/OTC; MP X 1/2" MISC X 1/2" MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G 1 RX/OTC; MP SYRINGEU-100/1ML/30G 1 MP X 1/2" MISC X 1/2" MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC; MP SYRINGEU-100/1ML/30G 1 RX/OTC; MP X 5/16" MISC X 5/16" MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 SYRINGEU-100/1ML/31G 1 X 5/16" MISC X 15/64" MISC TECHLITE INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) 1 SYRINGEU- 1 RX/OTC; MP SYRINGEU-100/1ML/31G 100/0.3ML/29G X 1/2" X 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) COMFORT INSULIN 1 RX/OTC; MP SYRINGEU- 1 SYRINGE/0.3ML/30G X 100/0.3ML/30G X 1/2" 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); COMFORT INSULIN 1 SYRINGEU- 1 RX/OTC; MP SYRINGE/0.3ML/31G X 100/0.3ML/30G X 5/16" 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) COMFORT INSULIN 1 RX/OTC; MP SYRINGEU- 1 SYRINGE/0.5ML/30G X 100/0.3ML/31G X 5/16" 5/16" MISC MISC

Nebraska Total Care Formulary September 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPCARE ULTRA QL(5 ea daily) TRUE COMFORT PRO QL(5 ea daily); COMFORT INSULIN 1 INSULINSYRINGE/U- 1 MP SYRINGE/0.5ML/31G X 100/1ML/30G X 1/2" MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP COMFORT INSULIN 1 RX/OTC; MP 100/0.3ML/29G X 1/2" SYRINGE/1ML/30G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) SYRINGE/U- 1 RX/OTC; MP COMFORT INSULIN 1 100/0.3ML/30G X 5/16" SYRINGE/1ML/31G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- 1 COMFORT INSULIN RX/OTC; MP 100/0.3ML/31G X 5/16" SYRINGE/U- 1 MISC 100/0.3ML/29G X 1/2" TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC; MP TOPCARE ULTRA QL(5 ea daily); 100/0.5ML/28G X 1/2" COMFORT INSULIN RX/OTC; MP MISC SYRINGE/U- 1 TRUEPLUS INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2" SYRINGE/U- 1 RX/OTC; MP MISC 100/0.5ML/29G X 1/2" TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN 1 RX/OTC; MP TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G SYRINGE/U- 1 RX/OTC; MP X 1/2" MISC 100/0.5ML/30G X 5/16" TRUE COMFORT INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 TRUEPLUS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- 1 TRUE COMFORT INSULIN QL(5 ea daily) 100/0.5ML/31G X 5/16" SYRINGE/1ML/31G X 1 MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC; MP INSULINSYRINGE/0.5ML/ 1 RX/OTC; MP X 1/2" MISC 30G X 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily) SYRINGE/U-100/1ML/29G 1 RX/OTC; MP INSULINSYRINGE/0.5ML/ 1 X 1/2" MISC 31G X 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC; MP INSULINSYRINGE/1ML/30 1 RX/OTC; MP X 5/16" MISC G X 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) TRUE COMFORT PRO QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 INSULINSYRINGE/1ML/31 1 X 5/16" MISC G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); TRUE COMFORT PRO QL(5 ea daily); SAFETY 1 RX/OTC; MP INSULINSYRINGE/U- 1 MP SYRINGE/0.5ML/29G X 100/0.5ML/30G X 1/2" 1/2" MISC MISC

Nebraska Total Care Formulary September 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SAFETY 1 RX/OTC; MP SYRINGE/SHORT/0.5ML/3 1 SYRINGE/1ML/29G X 1/2" 1G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/30 1 RX/OTC; MP SYRINGE/0.3ML/29G X 1 RX/OTC; MP G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/SHORT/1ML/31 1 SYRINGE/0.3ML/30G X 1 G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.3ML/30G X 1 RX/OTC; MP 100/0.3ML/30G X 1/2" 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X 1 RX/OTC; MP SYRINGE/U- 1 1/2" MISC 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X 1 RX/OTC; MP ULTICARE INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- 1 MP ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/30G X 1/2" SYRINGE/0.5ML/30G X 1 MP MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.5ML/30G X 1 RX/OTC; MP 100/0.5ML/31G X 5/16" 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC; MP SYRINGE/U-100/1ML/30G 1 MP MISC X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP SYRINGE/U-100/1ML/31G 1 MISC X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1/2" 1 MP SYRINGEULTRAFINE U- 1 MISC 100/0.3ML/31G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC; MP ULTICARE INSULIN QL(5 ea daily) 5/16" MISC SYRINGEULTRAFINE U- 1 100/0.5ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.3ML/3 1 RX/OTC; MP 0G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) SYRINGEULTRAFINE U- 1 ULTICARE INSULIN QL(5 ea daily) 100/1ML/31G X 5/16" SYRINGE/SHORT/0.3ML/3 1 MISC 1G X 5/16" MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); INSULIN SYRINGE 1 SYRINGE/SHORT/0.5ML/3 1 RX/OTC; MP 0.3ML/30G X 1/2"/SHARPS 0G X 5/16" MISC C MISC

Nebraska Total Care Formulary September 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTIGUARD SAFEPACK QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); INSULIN SYRINGE 1/2ML 1 MP SYRINGE/SHORT/0.3ML/3 1 RX/OTC; MP 30G X 1/2"/SHARPS C 0G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 1 INSULIN SYRINGE 1ML 1 MP 1G X 5/16" MISC 30G X 1/2"/SHARPS CON ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.5ML/3 1 RX/OTC; MP ULTIGUARD SAFEPACK QL(5 ea daily) 0G X 5/16" MISC INSULIN SYRINGE 1ML 1 ULTILET INSULIN QL(5 ea daily) 31G X 5/16"/SHARPS CO SYRINGE/SHORT/0.5ML/3 1 MISC 1G X 5/16" MISC ULTIGUARD SAFEPACK QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); INSULIN 1 SYRINGE/SHORT/1ML/30 1 RX/OTC; MP SYRINGE/0.3ML/30G X G X 5/16" MISC 1/2"/SHARPS C MISC ULTILET INSULIN QL(5 ea daily) ULTIGUARD SAFEPACK QL(5 ea daily) SYRINGE/SHORT/1ML/31 1 INSULIN 1 G X 5/16" MISC SYRINGE/0.3ML/31G X 5/16"/SHARPS MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/U- 1 MP ULTIGUARD SAFEPACK QL(5 ea daily); 100/0.5ML/30G X 1/2" INSULIN 1 MP MISC SYRINGE/0.5ML/30G X 1/2"/SHARPS C MISC ULTILET INSULIN SYRINGE/U- 1 ULTIGUARD QL(5 ea daily) 100/0.5ML/31GX6MM SAFEPACK/SYRINGE/NE MISC EDLE/31G X 1 5/16"/SHARPS CONTAIN ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 1 MP X 1/2" MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC; MP ULTILET SHARPS RX/OTC 8MM MISC CONTAINER1 QUART 1 MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 1 ULTILET SHARPS RX/OTC 8MM MISC CONTAINER2 QUART 1 MISC ULTILET INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC; MP ULTRA COMFORT QL(5 ea daily); 8MM MISC INSULIN SYRINGE/U- 1 RX/OTC; MP 100/0.3ML/30G X 5/16" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X 1 RX/OTC; MP 8MM MISC ULTRA FLO INSULIN QL(5 ea daily); SYRINGE 0.3ML/29G X 1 RX/OTC; MP ULTILET INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/1ML/31G X 1 8MM MISC ULTRA FLO INSULIN QL(5 ea daily) SYRINGE 0.3ML/30GX1/2" 1 ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/0.3ML/3 1 0G X 12.7MM MISC ULTRA FLO INSULIN QL(5 ea daily); SYRINGE 1 RX/OTC; MP 0.3ML/30GX5/16" MISC

Nebraska Total Care Formulary September 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily) 1 SYRINGE INSULIN SYRINGE/U- 1 0.3ML/31GX5/16" MISC 100/0.3ML/31G X 5/16" ULTRA FLO INSULIN QL(5 ea daily); MISC SYRINGE 0.5ML/29GX1/2" 1 RX/OTC; MP ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC; MP ULTRA FLO INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE 0.5ML/30GX1/2" 1 MP MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE 1 RX/OTC; MP 100/0.5ML/29G X 1/2" 0.5ML/30GX5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE 1 INSULIN SYRINGE/U- 1 RX/OTC; MP 0.5ML/31GX5/16" MISC 100/0.5ML/30G X 5/16" MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily) SYRINGE 1/2 1 UNIT/0.3ML/30GX1/2" INSULIN SYRINGE/U- 1 MISC 100/0.5ML/31G X 5/16" MISC ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE 1/2 1 RX/OTC; MP UNIT/0.3ML/30GX5/16" INSULIN SYRINGE/U- 1 RX/OTC; MP MISC 100/1ML/28G X 1/2" MISC ULTRA FLO INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE 1/2 1 UNIT/0.3ML/31GX5/16" 100/1ML/29G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA FLO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC; MP SYRINGE 1M/29GX1/2" 1 RX/OTC; MP 100/1ML/30G X 5/16" MISC MISC ULTRA FLO INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) SYRINGE 1ML/30GX1/2" 1 MP INSULIN SYRINGE/U- 1 MISC 100/1ML/31G X 5/16" MISC ULTRA FLO INSULIN QL(5 ea daily); SYRINGE 1ML/30GX5/16" 1 RX/OTC; MP ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE SHORT/U- 1 RX/OTC; MP 100/0.3ML/30GX5/16" ULTRA FLO INSULIN QL(5 ea daily) MISC SYRINGE 1ML/31GX5/16" 1 MISC ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE SHORT/U- 1 ULTRA-COMFORT QL(5 ea daily); 100/0.3ML/31GX5/16" INSULIN SYRINGE/U- 1 RX/OTC; MP MISC 100/0.3ML/29G X 1/2" MISC ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 RX/OTC; MP ULTRA-COMFORT QL(5 ea daily); 100/0.5ML/30GX5/16" INSULIN SYRINGE/U- 1 RX/OTC; MP MISC 100/0.3ML/30G X 5/16" MISC

Nebraska Total Care Formulary September 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-THIN II INSULIN QL(5 ea daily) VALUE HEALTH INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 SYRINGE/U- 1 RX/OTC; MP 100/0.5ML/31GX5/16" 100/0.5ML/29G X 1/2" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); VALUE HEALTH INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 RX/OTC; MP SYRINGE/U-100/1ML/29G 1 RX/OTC; MP 100/1ML/30GX5/16" MISC X 1/2" MISC ULTRA-THIN II INSULIN QL(5 ea daily) VANISHPOINT INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 SYRINGE/0.5ML/30G X 1 MP 100/1ML/31GX5/16" MISC 1/2" MISC ULTRA-THIN II INSULIN QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGE/0.5ML/30G X 1 RX/OTC; MP 100/0.5ML/29GX1/2" MISC 5/16" MISC ULTRA-THIN II INSULIN QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGE/1ML/29G X 1/2" 1 RX/OTC; MP 100/1ML/29GX1/2" MISC MISC ULTRACARE INSULIN QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGE/1ML/30G X 1 RX/OTC; MP 100/0.3ML/30G X 5/16" 5/16" MISC MISC VP INSULIN SYRINGE/U- QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) 100/0.3ML/29G X 1/2" 1 RX/OTC; MP SYRINGE/U- 1 MISC 100/0.3ML/31G X 5/16" ZEVRX INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 MP ULTRACARE INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- 1 MP ZEVRX INSULIN QL(5 ea daily); 100/0.5ML/30G X 1/2" SYRINGE/0.5ML/30G X 1 RX/OTC; MP MISC 5/16" MISC ULTRACARE INSULIN QL(5 ea daily); ZEVRX INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC; MP SYRINGE/1ML/30G X 1/2" 1 MP 100/0.5ML/30G X 5/16" MISC MISC ZEVRX INSULIN QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1 RX/OTC; MP SYRINGE/U- 1 5/16" MISC 100/0.5ML/31G X 5/16" MISC Respiratory Therapy Supplies ULTRACARE INSULIN QL(5 ea daily); ACE AEROSOL CLOUD 1 RX/OTC SYRINGE/U-100/1ML/30G 1 MP ENHANCER MISC X 1/2" MISC ACTIVITY POUCH MISC 1 RX/OTC ULTRACARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC; MP ADULT AEROSOL MASK 1 RX/OTC X 5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) QL(2 ea per SYRINGE/U-100/1ML/31G 1 ADULT MASK DEVI 1 350 days X 5/16" MISC retail); RX/OTC ADULT MASK LARGE 1 RX/OTC MISC

Nebraska Total Care Formulary September 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADULT MASK MISC 1 RX/OTC AEROTRACH PLUS MISC 1 RX/OTC QL(2 ea per AEROVENT PLUS QL(2 ea per 1 AEROBIKA DEVI 350 days HOLDING 1 360 days retail); RX/OTC CHAMBER/COLLAPSIBLE retail); RX/OTC AEROCHAMBER MINI QL(2 ea per DEVI 1 AEROSOLCHAMBER 360 days AIRS PEDIATRIC 1 RX/OTC DEVI retail); RX/OTC AEROSOL MASK MISC AEROCHAMBER MV QL(2 ea per QL(2 ea per 1 360 days ALL FLOW 1000 PFT 1 350 days MISC FILTER DEVI retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per ALL FLOW 1000 RX/OTC 1 360 days PULMONARY FUNCTION 1 FLOW VU MISC retail); RX/OTC FILTER MISC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per 1 360 days ALL FLOW 2000 PFT 1 350 days FLOW-VU MISC FILTER DEVI retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per FLOW-VU/LARGE MASK 1 360 days ALL FLOW 3000 PFT 1 FILTER DEVI 350 days MISC retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per 1 360 days ALL FLOW 4000 PFT 1 350 days FLOW-VU/MASK MISC FILTER DEVI retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per FLOW-VU/MEDIUM MASK 1 360 days ALL FLOW 5000 PFT 1 FILTER DEVI 350 days MISC retail); RX/OTC retail); RX/OTC AEROCHAMBER PLUS QL(2 ea per QL(2 ea per FLOW-VU/SMALL MASK 1 360 days ALL FLOW 6000 PFT 1 FILTER DEVI 350 days MISC retail); RX/OTC retail); RX/OTC AEROCHAMBER Z-STAT QL(2 ea per QL(2 ea per PLUS VALVED HOLDING 360 days ALL FLOW 7000 PFT 1 1 FILTER DEVI 350 days CHAMBER W/FLOW VU retail); RX/OTC retail); RX/OTC MISC QL(2 ea per 1 AEROCHAMBER Z-STAT QL(2 ea per ARIAL CHAMBER DEVI 360 days 1 360 days retail); RX/OTC PLUS/FLOWSIGNAL MISC retail); RX/OTC BREATHE EASE RX/OTC 1 AEROCHAMBER Z-STAT QL(2 ea per NEBULIZER MASK/CHILD 1 360 days MISC PLUS/LARGE MASK MISC retail); RX/OTC BREATHE EASE RX/OTC AEROCHAMBER Z-STAT QL(2 ea per NEBULIZER 1 PLUS/MEDIUM MASK 1 360 days MASK/INFANT MISC MISC retail); RX/OTC QL(2 ea per BREATHE EASE/LARGE 1 AEROCHAMBER Z-STAT QL(2 ea per 360 days 1 360 days MASK DEVI retail); RX/OTC PLUS/SMALL MASK MISC retail); RX/OTC QL(2 ea per QL(2 ea per BREATHE EASE/MEDIUM 1 360 days AEROCHAMBER/FLOWSI 1 MASK DEVI GNAL MISC 360 days retail); RX/OTC retail); RX/OTC Nebraska Total Care Formulary September 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREATHE EASE/SMALL QL(2 ea per CARETOUCH CPAP 1 RX/OTC 1 360 days MASK WIPES MISC MASK DEVI retail); RX/OTC CARETOUCH CPAP RX/OTC BREATHERITE QL(2 ea per NEUTRALIZING PRE- 1 COLLAPSIBLEADULT 1 360 days WASH MISC SPACER W/MASK MISC retail); RX/OTC CARETOUCH CPAP TUBE 1 RX/OTC BREATHERITE QL(2 ea per CLEANING BRUSH MISC COLLAPSIBLECHILD 1 360 days CARETOUCH UNIVERSAL 1 RX/OTC SPACER W/MASK MISC retail); RX/OTC CPAPFILTERS MISC BREATHERITE QL(2 ea per CLEVER CHOICE ANTI- QL(2 ea per COLLAPSIBLEINFANT 1 360 days STATICVALVED 360 days SPACER W/MASK MISC retail); RX/OTC HOLDING 1 retail); RX/OTC BREATHERITE QL(2 ea per CHAMBER/ADULT LARGE COLLAPSIBLESMALL 1 360 days DEVI CHILD SPACER W/MASK retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per MISC STATICVALVED 1 360 days BREATHERITE QL(2 ea per HOLDING retail); RX/OTC COLLAPSIBLESPACER 1 360 days CHAMBER/MEDIUM DEVI W/ NEONATE MASK MISC retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per QL(2 ea per STATICVALVED 360 days BREATHERITE MISC 1 360 days HOLDING 1 retail); RX/OTC retail); RX/OTC CHAMBER/MEDIUM/3 YEA DEVI BREATHERITE RIGID QL(2 ea per 1 360 days CLEVER CHOICE ANTI- QL(2 ea per SPACERW/MASK MISC retail); RX/OTC STATICVALVED 1 360 days BREATHERITE VALVED QL(2 ea per HOLDING retail); RX/OTC CHAMBER/SMALL DEVI MDI 1 350 days CHAMBER/COLLAPSIBLE retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per DEVI STATICVALVED 360 days BREATHERITE VALVED QL(2 ea per HOLDING 1 retail); RX/OTC MDI CHAMBER/RIGID 1 350 days CHAMBER/SMALL DEVI retail); RX/OTC INFANT DEVI QL(2 ea per QL(2 ea per BREATHERITE W/LARGE 1 CO MONITOR DEVI 1 350 days MASK MISC 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per CO MONITOR RX/OTC BREATHERITE 1 REPLACEMENT TPIECES 1 W/MEDIUM MASK MISC 360 days retail); RX/OTC MISC QL(2 ea per COMPACT SPACE QL(2 ea per BREATHERITE W/SMALL 1 CHAMBER/ANTI-STATIC 1 360 days MASK MISC 360 days retail); RX/OTC DEVI retail); RX/OTC BUBBLES THE FISH II RX/OTC COMPACT SPACE QL(2 ea per PEDIATRIC MASK/PVC 1 CHAMBER/ANTI- 1 360 days MISC STATIC/LARGE MASK retail); RX/OTC DEVI CARETOUCH 2 CPAP 1 RX/OTC HOSE HANGER MISC CARETOUCH CPAP & 1 RX/OTC BIPAP HOSE/6FT MISC Nebraska Total Care Formulary September 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMPACT SPACE QL(2 ea per QL(2 ea per CHAMBER/ANTI- 360 days EASY FLOW 1 1 WHITE/GREEN DEVI 350 days STATIC/MEDIUM MASK retail); RX/OTC retail); RX/OTC DEVI EASY FLOW WHITE/PINK QL(2 ea per COMPACT SPACE QL(2 ea per 1 350 days DEVI CHAMBER/ANTI- 1 360 days retail); RX/OTC STATIC/SMALL MASK retail); RX/OTC QL(2 ea per DEVI EASY FLOW 1 WHITE/WHITE DEVI 350 days QL(2 ea per retail); RX/OTC EASIVENT MISC 1 360 days QL(2 ea per retail); RX/OTC EASY FLOW 1 WHITE/YELLOW DEVI 350 days QL(2 ea per retail); RX/OTC EASIVENT/MASK-LARGE 1 360 days MISC EBASE CONTROLLER KIT 1 RX/OTC retail); RX/OTC MISC QL(2 ea per EFLOW SCF AEROSOL RX/OTC EASIVENT/MASK- 1 1 MEDIUM MISC 360 days HEAD MISC retail); RX/OTC ELITE DC AUTO 1 RX/OTC QL(2 ea per ADAPTER MISC EASIVENT/MASK-SMALL 1 MISC 360 days retail); RX/OTC QL(2 ea per EQ SPACE CHAMBER 1 360 days ANTI-STATIC DEVI EASY FLOW 300 MM 1 RX/OTC retail); RX/OTC HOSE MISC EQ SPACE CHAMBER QL(2 ea per EASY FLOW 400 MM 1 RX/OTC ANTI-STATIC/LARGE 1 360 days HOSE MISC MASK DEVI retail); RX/OTC EASY FLOW AIR NOZZLE 1 RX/OTC EQ SPACE CHAMBER QL(2 ea per MISC ANTI-STATIC/MEDIUM 1 360 days QL(2 ea per MASK DEVI retail); RX/OTC EASY FLOW BLACK/BLUE 1 350 days DEVI EQ SPACE CHAMBER QL(2 ea per retail); RX/OTC ANTI-STATIC/SMALL 1 360 days QL(2 ea per MASK DEVI retail); RX/OTC EASY FLOW 1 BLACK/ORANGE DEVI 350 days RX/OTC retail); RX/OTC FILTER AIR PP MISC 1 QL(2 ea per QL(2 ea per EASY FLOW BLACK/RED 1 350 days DEVI FLEXICHAMBER DEVI 1 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per FLYP HYPERSONIQ RX/OTC EASY FLOW 1 1 BLACK/WHITE DEVI 350 days CARTRIDGE MISC retail); RX/OTC FULL KIT NEBULIZER 1 RX/OTC QL(2 ea per SET MISC EASY FLOW 1 BLACK/YELLOW DEVI 350 days HUDSON RCI SEE-THRU RX/OTC retail); RX/OTC AEROSOL MASK 1 EASY FLOW HEPA 1 RX/OTC ELONGATED/ADULT FILTER MISC MISC QL(2 ea per IN-CHECK DIAL QL(2 ea per EASY FLOW WHITE/BLUE 1 350 days DEVI INSPIRATORYFLOW 1 350 days retail); RX/OTC TRAINER DEVI retail); RX/OTC

Nebraska Total Care Formulary September 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IN-CHECK INSPIRATORY QL(2 ea per QL(2 ea per FLOWMETER/NASAL 1 350 days MICROSPACER MISC 1 360 days WITH MASK DEVI retail); RX/OTC retail); RX/OTC IN-CHECK INSPIRATORY QL(2 ea per MINIELITE FILTER 1 RX/OTC 1 350 days REPLACEMENTS MISC FLOWMETER/ORAL DEVI retail); RX/OTC MINIELITE RX/OTC INNOSPIRE RX/OTC RECHARGEABLE 1 REPLACEMENT FILTER 1 BATTERY MISC MISC QL(2 ea per INSPIRACHAMBER/ANTI- QL(2 ea per MISTASSIST DEVI 1 350 days STATIC 1 360 days retail); RX/OTC VALVED/MOUTHPIECE retail); RX/OTC NEBULIZER AIR 1 RX/OTC DEVI TUBE/PLUGS MISC INSPIRACHAMBER/LARG QL(2 ea per QL(2 ea per 1 360 days NEBULIZER CUP/TUBING 1 E DEVI DEVI 350 days retail); RX/OTC retail); RX/OTC INSPIRACHAMBER/SOOT QL(2 ea per NEBULIZER PEDIATRIC 1 RX/OTC HERMASK/INSPIRAMASK 1 360 days MASK MISC /MEDIUM DEVI retail); RX/OTC RX/OTC INSPIRACHAMBER/SOOT QL(2 ea per NOSE CLIP MISC 1 HERMASK/INSPIRAMASK 1 360 days QL(2 ea per /SMALL DEVI retail); RX/OTC OMBRA TABLE TOP 1 COMPRESSOR DEVI 350 days QL(2 ea per retail); RX/OTC INSPIREASE DRUG 1 360 days DELIVERYSYSTEM MISC ONE FLOW FVC QL(2 ea per retail); RX/OTC MONITORING 1 350 days QL(2 ea per SPIROMETER DEVI retail); RX/OTC LITEAIRE DEVI 1 360 days OPTICHAMBER QL(2 ea per retail); RX/OTC ADVANTAGE/LARGE 1 360 days LITETOUCH MASK 1 RX/OTC MASK MISC retail); RX/OTC LARGE MISC OPTICHAMBER QL(2 ea per LITETOUCH MASK 1 RX/OTC ADVANTAGE/MEDIUM 1 360 days MEDIUM MISC FACE MASK MISC retail); RX/OTC LITETOUCH MASK 1 RX/OTC OPTICHAMBER QL(2 ea per SMALL MISC ADVANTAGE/SMALL 1 360 days QL(2 ea per FACE MASK MISC retail); RX/OTC MICROCHAMBER DEVI 1 360 days QL(2 ea per retail); RX/OTC OPTICHAMBER 1 360 days DIAMOND MISC QL(2 ea per retail); RX/OTC MICROCHAMBER MISC 1 360 days OPTICHAMBER QL(2 ea per retail); RX/OTC DIAMOND/LARGEFACE 1 360 days MASK DEVI retail); RX/OTC MICROELITE FILTER 1 RX/OTC REPLACEMENTS MISC OPTICHAMBER QL(2 ea per MICROELITE RX/OTC DIAMOND/MEDIUM FACE 1 360 days RECHARGEABLE 1 MASK MISC retail); RX/OTC BATTERY MISC OPTICHAMBER QL(2 ea per DIAMOND/SMALLFACE 1 360 days MASK MISC retail); RX/OTC

Nebraska Total Care Formulary September 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTICHAMBER FACE QL(2 ea per PHARMACIST CHOICE RX/OTC 1 360 days NEBULIZER/CPAP/INHAL MASK/LARGE MISC 1 retail); RX/OTC ER CHAMBER MASK WIPES MISC OPTICHAMBER FACE QL(2 ea per 1 360 days PILLOW MASK/ADULT RX/OTC MASK/MEDIUM MISC 1 retail); RX/OTC MISC QL(2 ea per PILLOW MASK/CHILD RX/OTC OPTICHAMBER FACE 1 1 MASK/SMALL MISC 360 days MISC retail); RX/OTC PILLOW 1 RX/OTC QL(2 ea per MASK/PEDIATRIC MISC OPTIHALER MDI DRUG 1 360 days DELIVERY SYSTEM DEVI QL(2 ea per retail); RX/OTC POCKET CHAMBER DEVI 1 360 days QL(2 ea per retail); RX/OTC OPTIHALER MISC 1 360 days QL(2 ea per retail); RX/OTC POCKET SPACER DEVI 1 360 days PARI ALTERA RX/OTC retail); RX/OTC NEBULIZER HANDSET 1 PRIMEAIRE DUAL- QL(2 ea per MISC VALVED HOLDING 1 350 days PARI BABY CONVERSION 1 RX/OTC CHAMBER DEVI retail); RX/OTC KITSIZE 1 MISC PRO COMFORT INHALER QL(2 ea per PARI BABY CONVERSION 1 RX/OTC SPACER CHAMBER 1 360 days KITSIZE 2 MISC ADULT MISC retail); RX/OTC PARI BABY CONVERSION 1 RX/OTC PRO COMFORT INHALER QL(2 ea per KITSIZE 3 MISC SPACER CHAMBER 1 360 days CHILD MISC retail); RX/OTC PARI ERAPID NEBULIZER 1 RX/OTC HANDSET MISC PRO COMFORT INHALER QL(2 ea per SPACER CHAMBER 1 360 days PARI EXPIRATORY 1 RX/OTC FILTER VALVE SET DEVI INFANT DEVI retail); RX/OTC QL(2 ea per PROCARE SPACER QL(2 ea per PARI MANUAL 1 CHAMBER W/ADULT 1 360 days INTERRUPTER DEVI 350 days retail); RX/OTC MASK DEVI retail); RX/OTC RX/OTC PROCARE SPACER QL(2 ea per PARI MASK SET MISC 1 CHAMBER W/CHILD 1 360 days MASK DEVI retail); RX/OTC PARI SOFT PLASTIC 1 RX/OTC ADULT MASK MISC PRONEB ULTRA FILTER 1 RX/OTC SET MISC PARI SOFT PLASTIC 1 RX/OTC PEDIATRIC MASK MISC QL(2 ea per QL(2 ea per QUAKE DEVI 1 350 days PARI TREK S COMBO 1 350 days retail); RX/OTC PACK DEVI retail); RX/OTC REPLACEMENT AIR 1 RX/OTC FILTER MISC PARI VORTEX ADULT 1 RX/OTC MASK MISC REPLACEMENT FILTERS 1 RX/OTC PEDIATRIC RX/OTC MISC MOUTHPIECE/DISPOSAB 1 QL(2 ea per LE MISC RITEFLO DEVI 1 360 days retail); RX/OTC PFLEX MISC 1 RX/OTC

Nebraska Total Care Formulary September 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAMI THE SEAL RX/OTC QL(2 ea per REPLACEMENTFILTERS 1 VALVED HOLDING 1 CHAMBER DEVI 360 days MISC retail); RX/OTC SIDESTREAM ADULT 1 RX/OTC VORTEX HOLDING QL(2 ea per FACE MASK MISC CHAMBER/MASK/CHILDS 1 350 days DEVI retail); RX/OTC SIDESTREAM PEDIATRIC 1 RX/OTC FACEMASK MISC VORTEX HOLDING QL(2 ea per SIDESTREAM PEDIATRIC RX/OTC CHAMBER/MASK/CHILDS 1 350 days FACEMASK/SAMI THE 1 /FROG DEVI retail); RX/OTC SEAL MISC VORTEX HOLDING QL(2 ea per SIDESTREAM PEDIATRIC RX/OTC CHAMBER/MASK/TODDL 1 350 days FACEMASK/TUCKER THE 1 ER DEVI retail); RX/OTC TURTLE MISC VORTEX HOLDING QL(2 ea per CHAMBER/MASK/TODDL 1 350 days SIDESTREAM PLUS 1 RX/OTC ADULT FACE MASK MISC ER/LADY BUG DEVI retail); RX/OTC SILICONE MASK FOR RX/OTC VORTEX VALVED QL(2 ea per BREATHERITE 1 HOLDING CHAMBER 1 360 days CHAMBER/ADULT MISC DEVI retail); RX/OTC SILICONE MASK FOR RX/OTC QL(2 ea per BREATHERITE 1 WATCHHALER DEVI 1 360 days CHAMBER/INFANT MISC retail); RX/OTC SILICONE MASK FOR RX/OTC WINDMILL TRAINER 1 RX/OTC MISC BREATHERITE 1 CHAMBER/PEDIATRIC MISC MINERALS & ELECTROLYTES SILICONE MASK FOR RX/OTC Calcium BREATHRITE 1 CHAMBER/ADULT MISC CALCET PETITES TABS 1 SOOTHENEB NBL 100 RX/OTC 1 CALCIUM CARBONATE 1 CHILD MASK MISC CHEW 500 MG SOOTHENEB NBL 100 RX/OTC 1 calcium carbonate tabs 600 1 MEDICATION CUP MISC mg, 1500 mg SOOTHENEB NBL 100 RX/OTC 1 calcium carbonate- 1 MESH CAP MISC cholecalciferol chew SOOTHENEB NBL100 RX/OTC 1 calcium carbonate- 1 ADULT MASK MISC cholecalciferol tabs QL(2 ea per calcium carbonate-vitamin 1 SPIRO PD DEVI 1 350 days d tabs retail); RX/OTC calcium carbonate-vitamin 1 THRESHOLD IMT MISC 1 RX/OTC d w/ minerals tabs QL(2 ea per CALCIUM CHEW 1 THRESHOLD PEP DEVI 1 350 days retail); RX/OTC calcium citrate tabs 1 RX/OTC TUBING/WING TIP MISC 1 calcium citrate-vitamin d 1 tabs

Nebraska Total Care Formulary September 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium-magnesium-zinc 1 SLOW-MAG TBEC 1 tabs SLOWMAG MG 1 oyster shell tabs 1 MUSCLE/HEART TBEC RISACAL-D TABS 1 Mineral Combinations ADVANCED Electrolyte Mixtures CALCIUM/VITAMIND/MAG 1 NESIUM TABS BIOLYTE SOLN 1 QL(6084 ml per fill retail) BONE DENSITY BUILDER 1 TABS CERALYTE 70 SOLN 1 QL(6084 ml per fill retail) CAL MAG ZINC +D3 TABS 1 QL(6084 ml per CERASPORT EX1 SOLN 1 fill retail) CAL-MAG-ZINC-D TABS 1 QL(6084 ml per CERASPORT SOLN 1 fill retail) CAL-MAG-ZINC-D3 TABS 1 ENFAMIL ENFALYTE 1 QL(6084 ml per SOLN fill retail) CALCIUM/MAGNESIUM/ZI 1 NC TABS HYDRALYTE FREEZER 1 QL(6084 ml per POPS SOLN fill retail) CALCIUM/MAGNESIUM/ZI 1 NC/VITAMIN D3 TABS QL(6084 ml per HYDRALYTE SOLN 1 fill retail) CITRACAL MAXIMUM 1 PLUS TABS KINDERLYTE PREMAX 1 QL(6084 ml per SOLN fill retail) CITRACAL PLUS TABS 1 QL(6084 ml per KINDERLYTE SOLN 1 CVS CALCIUM fill retail) CITRATE+D/MAGNESIUM 1 QL(6084 ml per oral electrolytes soln 1 TABS fill retail) CVS CALCIUM Fluoride CITRATE+D3 1 W/MAGNESIUM TABS sodium fluoride chew 0.25 1 MP mg, 0.5 mg, 1 mg, 2.2 mg FEM-CAL CITRATE TABS 1 QL(50 ml per sodium fluoride soln 0.5 1 fill retail); MULTI MEGA MINERALS mg/ml 1 RX/OTC TABS multiple minerals w/ sodium fluoride tabs 0.5 1 1 mg vitamins tabs MULTISOURCE CALCIUM Magnesium MAGNESIUM & D 1 magnesium chloride tbec 1 FORMULA TABS PROSTEON TABS 1 MAGNESIUM OXIDE 1 TABS 420 MG THERACAL D2000 TABS 1 magnesium tabs 1 THERACAL D4000 TABS 1 MAGONATE LIQD 1 THERACAL RAPID 1 NU-MAG TBEC 1 REPLETION TABS

Nebraska Total Care Formulary September 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Phosphate Systemic Lupus Erythematosus Agents pot phosphate monobasic BENLYSTA SOAJ 1 PA; SP w/ sod phosphate dibasic & 1 monobasic tabs BENLYSTA SOSY 1 PA; SP potassium & sodium 1 phosphates pack MOUTH/THROAT/DENTAL AGENTS Potassium Anesthetics Topical Oral potassium chloride cpcr 1 MP benzocaine-menthol 1 potassium chloride MP (mouth-throat) lozg microencapsulated crystals 1 lidocaine hcl (mouth-throat) 1 er tbcr soln potassium chloride soln 1 MP Antiseptics - Mouth/Throat chlorhexidine gluconate 1 potassium chloride tbcr 1 MP (mouth-throat) soln Sodium phenol (antiseptic) liqd 1 sodium chloride flush soln 1 Dental Products sodium fluoride (dental) 1 sodium chloride soln 1 crea sodium chloride tabs 1 sodium fluoride (dental) gel 1 Trace Minerals Lozenges selenium tabs 1 DENTIVA LOZG 1 dextromethorphan- 1 Zinc benzocaine lozg zinc gluconate tabs 1 DIABETIC TUSSIN 1 COUGH DROPS LOZG zinc sulfate caps 220 mg 1 menthol (mouth-throat) lozg 1 ZINC SULFATE CAPS 50 1 MG SALESE LOZG 1 zinc tabs 50 mg 1 throat lozenges lozg 1

MISCELLANEOUS THERAPEUTIC CLASSES ZINC W/A&C LOZG 1 Irrigation Solutions Steroids - Mouth/Throat/Dental water for irrigation, sterile 1 triamcinolone acetonide 1 soln (mouth) pste Potassium Removing Agents Throat Products - Misc. sodium polystyrene 1 RX/OTC sulfonate powd AQUORAL SOLN 1 sodium polystyrene 1 sulfonate susp

Nebraska Total Care Formulary September 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BIOTENE DRY MOUTH RX/OTC b-complex w/ c & folic acid RX/OTC MOISTURIZING SPRAY 1 tabs 0.01 mcg-1 mg-1.5 SOLN mg-1.7 mg-10 mg-10 mg- RX/OTC 20 mg-60 mg-300 mcg, 1 CAPHOSOL SOLN 1 mg-1 mg-1.5 mg-1.5 mg- 1.7 mg-1.7 mg-6 mcg-6 CVS DRY MOUTH SPRAY 1 RX/OTC SOLN mcg-10 mg-10 mg-10 mg- 10 mg-20 mg-20 mg-100 EQL DRY MOUTH ORAL 1 RX/OTC mg-100 mg-300 mcg-300 RINSE SOLN mcg, 1 mg-1 mg-1.5 mg- MOI-STIR SOLN 1 RX/OTC 1.7 mg-8 mg-20 mg-30 mcg-200 mg-300 mcg, 1 MOUTH KOTE REMINT 1 RX/OTC mg-1.5 mg-1.7 mg-6 mcg- SOLN 10 mg-10 mg-20 mg-100 RX/OTC mg-300 mcg, 1 mg-1.5 mg- MOUTH KOTE SOLN 1 1.7 mg-6 mcg-10 mg-10 RX/OTC mg-20 mg-60 mg-300 mcg, NUMOISYN LIQD 1 1 mg-6 mcg-10 mg-20 mg- ORAL RELIEF SPRAY RX/OTC 1.5 mg-1.7 mg-10 mg-100 FOR DRYMOUTH & 1 mg-300 mcg, 1.5 mg-0.006 DISCOMFORT SOLN mg-0.3 mg-1 mg-1.7 mg-10 mg-10 mg-20 mg-100 mg, pilocarpine hcl (oral) tabs 1 1.5 mg-1.7 mg-5 mg-6 mcg-10 mg-20 mg-100 mg- RA DRY MOUTH SOLN 1 RX/OTC 150 mcg-1000 mcg, 1.5 mg-1.7 mg-6 mcg-10 mg- 1 XEROSTOMIA RELIEF 1 RX/OTC 10 mg-20 mg-100 mg-300 SPRAY SOLN mcg-1000 mcg, 0.5 mg-4 mg-5 mcg-15 mg-15 mg-18 MULTIVITAMINS mg-100 mg-500 mg, 1 mg- B-Complex Vitamins 1 mg-1 mg-5 mg-10 mg-10 mg-12 mcg-20 mg-30 unit- b-complex vitamins caps 1 45 mcg-100 mg-400 mcg- 500 mg, 15 mcg-5 mg-5 b-complex vitamins tabs 1 mg-5 mg-25 mg-37.5 mcg- 50 mg-150 mg-200 mcg, 2 B-Complex w/ C mg-5 mg-15 mcg-20 mg-25 mg-30 mcg-100 mg-150 b complex w/ c caps 1 mg-400 mcg, 2 mg-5.5 mg- 15 mcg-20 mg-25 mg-30 B-Complex w/ Folic Acid mcg-100 mg-150 mg-400 mcg, 2 mg-5.5 mg-15 mcg- 25 mg-30 mcg-150 mg-400 mcg-100 mg-20 mg, 5 mg- 10 mg-10.2 mg-15 mg-50 mg-300 mcg-300 mg-400 mcg, 5 mg-15 mcg-25 mg- 30 mcg-150 mg-400 mcg- 100 mg-2 mg-20 mg, 5 mg- 5 mg-10 mcg-10 mg-18 mg-45 mg-250 mg-400 mcg, 5 mg-5 mg-5 mg-10 Nebraska Total Care Formulary September 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-25 mg-120 mg-250 ADRENAL C FORMULA 1 RX/OTC mcg-300 mcg-400 mcg, 5 TABS mg-5 mg-5 mg-15 mcg-25 ADVANCED C PLUS 1 RX/OTC mg-37.5 mcg-50 mg-150 TABS mg-200 mcg, 5 mg-5.5 mg- 20 mg-25 mg-25 mg-60 bioflavonoid products tabs 1 RX/OTC mg-100 mcg-100 mg-400 mcg-1000 mcg, 5 mg-5.5 Multiple Vitamins w/ Calcium mg-20 mg-25 mg-25 mg-60 HM ONE DAILY 1 mg-100 mcg-400 mcg- ESSENTIAL TABS 1000 mcg, 5 mg-6 mcg-10 multiple vitamins w/ 1 mg-10.2 mg-15 mg-50 mg- calcium tabs 300 mg-400 mcg, 50 mcg- 50 mcg-50 mg-50 mg-50 SM ONE DAILY 1 mg-50 mg-50 mg-400 mcg- ESSENTIAL TABS 500 mg, 50 mg-50 mcg-50 Multiple Vitamins w/ Iron mcg-50 mg-50 mg-50 mg- multiple vitamins w/ iron 1 50 mg-400 mcg-500 mg tabs b-complex w/ c & folic acid TAB-A-VITE tabs 1.5 mg-0.006 mg-0.3 MULTIVITAMIN/IRON AND 1 mg-0.8 mg-1.7 mg-10 mg- BETA-CAROTENE TABS 10 mg-20 mg-60 mg, 1.5 Multiple Vitamins w/ Minerals mg-1.7 mg-6 mcg-10 mg- 1 10 mg-20 mg-60 mg-300 QL(2 ea daily); mcg-800 mcg, 10 mg-1.5 ABC COMPLETE SENIOR 1 AL(At least 12 mg-1.7 mg-6 mcg-10 mg- WOMENS 50+ TABS yrs old); 20 mg-60 mg-300 mcg-800 RX/OTC mcg ACTIVNUTRIENTS CAPS 1 RX/OTC b-complex w/ folic acid tabs 1 ADULT ONE DAILY 1 b-complex w/biotin & folic 1 GUMMIES CHEW acid tabs QL(2 ea daily); B-COMPLEX/VITAMIN ADVANCED DIABETIC AL(At least 12 C/FOLIC ACID/ BIOTIN 1 MULTIVITAMIN FORMULA 1 TABS yrs old); TABS RX/OTC FULL SPECTRUM 1 B/VITAMIN C TABS AIRBORNE CHEW 1 SM B-COMPLEX/VITAMIN 1 RX/OTC AIRBORNE KIDS CHEW 1 C TABS VITALINE BIOTIN FORTE 1 AIRBORNE LOZG 1 TABS AIRBORNE+GOOD REST WEST-VITE W/FOLIC 1 1 ACID TABS CHEW AIRBORNE+NATURAL 1 RX/OTC B-Complex w/ Minerals ENERGY LIQD b-complex w/ minerals liqd 1 AIRBORNE+PROBIOTIC 1 CHEW Bioflavonoid Products

Nebraska Total Care Formulary September 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); ALIVE WOMENS 50+ ALGAE BASED CALCIUM 1 AL(At least 12 CHEW 0.65 MG-0.85 MG- TABS yrs old); 1.35 MG-2 MG-2.4 MCG- RX/OTC 7.5 MG-7.5 MG-15 MCG- 1 QL(2 ea daily); 15 MG-20 MCG-25 MG-50 MG-75 MCG-75 MCG-120 1 AL(At least 12 ALIVE ENERGY 50+ TABS yrs old); MCG-150 MCG-150 MCG- RX/OTC 165 MCG-225 MCG QL(2 ea daily); ALIVE WOMENS 50+ QL(2 ea daily); TABS 2 MG-4 MG-4.5 MG- AL(At least 12 ALIVE MENS ENERGY 1 AL(At least 12 TABS yrs old); 5 MG-5.1 MG-6 MG-15 yrs old); RX/OTC MG-20 MG-22.5 MG-30 RX/OTC UNIT-50 MG-60 MCG-70 ALIVE MULTI-VITAMIN MCG-75 MCG-90 MG-100 1 CHEW 0.85 MG-1.8 MG-2 MCG-150 MCG-180 MCG- MG-2.4 MCG-2.5 MG-5 300 MCG-300 MCG-400 MG-7.5 MG-10 MCG-15 1 MCG-500 MG-900 MCG- MCG-20 MG-45 MG-75 1000 UNIT-3500 UNIT-150 MCG-120 MCG-150 MCG- MCG 162.5 MCG-450 MCG QL(2 ea daily); ALIVE MULTI-VITAMIN RX/OTC ALIVE WOMENS ENERGY 1 AL(At least 12 LIQD 1 MG/30ML-2 TABS yrs old); MG/30ML-4 MG/30ML-5 RX/OTC MG/30ML-10 MCG/30ML- 15 MG/30ML-20 MG/30ML- ALIVE WOMENS GUMMY 1 25 MG/30ML-25 MG/30ML- VITAMINS CHEW 25 MG/30ML-25 MG/30ML- QL(2 ea daily); 25 MG/30ML-30 MG/30ML- ANTIOXIDANT FORMULA 1 AL(At least 12 40 MG/30ML-40 MG/30ML- TABS yrs old); 50 MG/30ML-50 MG/30ML- RX/OTC 50 MG/30ML-60 MG/30ML- 1 70 MCG/30ML-75 AQUADEKS CHEW 1 MCG/30ML-80 QL(2 ea daily); MCG/30ML-118.6 AZO HORMONAL AL(At least 12 MG/30ML-125 MG/30ML- HEALTH CYCLE CARE & 1 COMFORT TABS yrs old); 133 MG/30ML-150 RX/OTC MCG/30ML-200 QL(2 ea daily); MCG/30ML-200 AZO HORMONAL MCG/30ML-300 HEALTH HAPPY CYCLE 1 AL(At least 12 yrs old); MCG/30ML-400 TABS MCG/30ML-500 MG/30ML- RX/OTC 3000 MCG/30ML QL(2 ea daily); QL(2 ea daily); 1 AL(At least 12 ALIVE ONCE DAILY BACMIN TABS yrs old); 1 AL(At least 12 WOMENS 50+ ULTRA yrs old); RX/OTC POTENCY TABS RX/OTC BARIATRIC FUSION 1 QL(2 ea daily); CHEW ALIVE ONCE DAILY AL(At least 12 BARIATRIC RX/OTC WOMENS ULTRA 1 MULTIVITAMINS/IRON 1 POTENCY TABS yrs old); RX/OTC CAPS

Nebraska Total Care Formulary September 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); CELEBRATE MULTI- RX/OTC 1 AL(At least 12 COMPLETE36 CAPS BASIC AM TABS yrs old); 0.666 MG-1 MG-1.333 MG- RX/OTC 4 MG-4 MG-6.666 MG-10 QL(2 ea daily); MG-12 MG-13.333 MG-20 UNIT-25 MCG-33.333 MG- 1 1 AL(At least 12 BASIC PM TABS yrs old); 40 MCG-46.666 MCG-50 RX/OTC MCG-60 MG-66.666 MCG- 166.666 MCG-200 MCG- BIO-35 GLUTEN-FREE 1 RX/OTC 200 MCG-1000 UNIT- CAPS 3333.333 UNIT BIO-35 IRON FREE CAPS 1 RX/OTC CELEBRATE MULTI- COMPLETE36 CHEW 1 BIOCAL CAPS 1 RX/OTC MG-1.5 MG-2 MG-6 MG-6 MG-10 MG-15 MG-18 BIOSUPP LIQD 1 RX/OTC MCG-20 MG-30 UNIT-37.5 MCG-50 MG-60 MCG-70 BIOTECT PLUS LIQD 1 RX/OTC MCG-75 MCG-90 MG-100 MCG-250 MCG-300 MCG- BURIED TREASURE RX/OTC 400 MCG-1500 UNIT-5000 ACTIVE 55PLUS SENIOR 1 UNIT, 1 MG-1.5 MG-2 MG- COMPLEX LIQD 6 MG-6 MG-10 MG-15 MG- QL(2 ea daily); 18 MG-20 MG-30 UNIT- 1 37.5 MCG-50 MG-60 MCG- 1 AL(At least 12 CAL-DAY 1000 TABS yrs old); 70 MCG-75 MCG-90 MG- RX/OTC 100 MCG-250 MCG-300 CELEBRATE MULTI- RX/OTC MCG-400 MCG-1500 COMPLETE18 CAPS UNIT-5000 UNIT, 6 MG-1 0.666 MG-0.666 MG-1.133 MG-1.5 MG-2 MG-6 MG-10 MG-1.333 MG-2 MG-5 MG- MG-15 MG-18 MCG-20 6 MG-6.666 MG-10 UNIT- MG-30 UNIT-37.5 MCG-50 MG-60 MCG-70 MCG-75 13.333 MCG-13.333 MG- 1 25 MCG-30 MG-33.333 MCG-90 MG-100 MCG-250 MG-46.666 MCG-50 MCG- MCG-300 MCG-400 MCG- 66.666 MCG-166.666 1500 UNIT-5000 UNIT MCG-200 MCG-266.666 CELEBRATE MULTI- RX/OTC MCG-1000 UNIT-1666.666 COMPLETE45 CAPS 4 UNIT MG-0.666 MG-1 MG-1.33 CELEBRATE MULTI- MG-4 MG-6.666 MG-10 COMPLETE18 CHEW 2 MG-13.333 MG-15 MG-20 MG-2 MG-3.4 MG-4 MG-6 UNIT-25 MCG-33.333 MG- 1 MG-15 MG-18 MG-20 MG- 40 MCG-46.666 MCG-50 MCG-60 MG-66.666 MCG- 30 UNIT-40 MCG-40 MG- 1 75 MCG-90 MG-100 MG- 200 MCG-266.666 MCG- 140 MCG-150 MCG-200 333.333 MCG-1000 UNIT- MCG-500 MCG-600 MCG- 3333.333 UNIT 800 MCG-3000 UNIT-5000 UNIT

Nebraska Total Care Formulary September 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEBRATE MULTI- CENTRUM CHEW 1 MG- COMPLETE45 CHEW 1 1.5 MG-1.7 MG-2 MG-2 MG-1.5 MG-2 MG-6 MG-6 MG-6 MCG-10 MCG-10 MG-10 MG-15 MG-20 MG- MG-15 MG-18 MG-20 22.5 MG-30 UNIT-37.5 1 MCG-20 MCG-20 MG-30 1 MCG-50 MG-60 MCG-70 UNIT-40 MG-45 MCG-50 MCG-75 MCG-90 MG-100 MG-60 MG-108 MG-150 MCG-300 MCG-400 MCG- MCG-400 MCG-400 UNIT- 500 MCG-1500 UNIT-5000 3500 UNIT UNIT CENTRUM FLAVOR 1 CELEBRATE MULTI- RX/OTC BURST ADULT CHEW COMPLETE60 CAPS 1 CENTRUM FLAVOR 1 MG-4 MG-0.666 MG-1.333 BURST CHEW MG-4 MG-6.666 MG-10 MG-13.333 MG-20 MG-20 CENTRUM UNIT-25 MCG-33.333 MG- 1 FRESH/FRUITY ADULTS 1 40 MCG-46.666 MCG-50 50+ CHEW MCG-60 MG-66.666 MCG- CENTRUM MEN TABS 2.3 QL(2 ea daily); 200 MCG-266.666 MCG- MG-0.9 MG-1.2 MG-1.3 AL(At least 12 333.333 MCG-1000 UNIT- MG-2 MG-2 MG-5 MCG-6 yrs old); 3333.333 UNIT MCG-8 MG-10 MCG-10 RX/OTC CELEBRATE MULTI- MCG-11 MG-15 MG-16 COMPLETE60 CHEW 1 MG-20 MG-35 MCG-40 1 MG-1.5 MG-2 MG-6 MG-6 MCG-45 UNIT-50 MCG-60 MG-10 MG-15 MG-20 MG- MCG-72 MG-80 MG-90 MG-100 MCG-100 MG-150 30 MG-30 UNIT-37.5 1 MCG-60 MCG-70 MCG-75 MCG-200 MCG-210 MG- MCG-90 MG-100 MCG- 600 MCG-1000 UNIT-3500 300 MCG-400 MCG-500 UNIT MCG-500 MG-1500 UNIT- CENTRUM 5000 UNIT MULTIGUMMIES ADULTS 1 CHEW CELLULAR SECURITY 1 RX/OTC CAPS CENTRUM QL(2 ea daily); MULTIGUMMIES MEN 1 CHEW CENTRAVITES 50 PLUS 1 AL(At least 12 TABS yrs old); CENTRUM RX/OTC MULTIGUMMIES MULTI 1 QL(2 ea daily); +OMEGA 3 CHEW CENTRUM CENTRAVITES ADULTS 1 AL(At least 12 TABS yrs old); MULTIGUMMIES WOMEN 1 RX/OTC CHEW QL(2 ea daily); 1 AL(At least 12 CENTRUM CARDIO TABS yrs old); RX/OTC

Nebraska Total Care Formulary September 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM SILVER CHEW CHOICEFUL RX/OTC 2 MG-4.5 MG-2.2 MG-2.7 MULTIVITAMIN CAPS 1 MG-4 MG-5 MCG-7 MG-10 MG-1.5 MG-1.9 MG-5 MCG-10 MCG-10 MG-12 MCG-8 MG-15 MG-18 MG- 1 MG-15 MG-22.5 MCG-25 1 30 MG-80 MCG-170 UNIT- MCG-25 MCG-45 MCG-50 180 MCG-700 MCG-1000 MG-70 UNIT-75 MG-100 UNIT-14000 UNIT MCG-100 MCG-125 MG- CHOICEFUL 200 MG-250 MCG-400 MULTIVITAMIN CHEW 1.2 UNIT-500 MCG-4000 UNIT MG-1.4 MG-1.5 MG-6 QL(2 ea daily); MCG-8 MG-10 MG-15 MG- 1 CENTRUM SILVER 1 AL(At least 12 60 MG-80 MCG-180 MCG- ULTRA WOMENS TABS yrs old); 180 UNIT-600 MCG-800 RX/OTC UNIT-13000 UNIT QL(2 ea daily); QL(2 ea daily); CENTRUM SPECIALIST 1 AL(At least 12 CLINICAL NUTRIENTS 45- 1 AL(At least 12 HEART TABS yrs old); PLUS WOMEN TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); CENTRUM SPECIALIST 1 AL(At least 12 CLINICAL NUTRIENTS 50- 1 AL(At least 12 IMMUNE SUPPORT TABS yrs old); PLUS MEN TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); CLINICAL NUTRIENTS 1 RX/OTC CENTRUM SPECIALIST 1 AL(At least 12 ANTIOXIDANT CAPS VISION TABS yrs old); QL(2 ea daily); RX/OTC CLINICAL NUTRIENTS FOR FEMALE TEENS 1 AL(At least 12 QL(2 ea daily); yrs old); TABS CENTRUM ULTRA 1 AL(At least 12 RX/OTC WOMENS TABS yrs old); QL(2 ea daily); RX/OTC CLINICAL NUTRIENTS 1 AL(At least 12 CENTRUM VITAMINTS 1 FOR MALE TEENS TABS yrs old); CHEW RX/OTC QL(2 ea daily); QL(2 ea daily); CERTAVITE SENIOR 1 AL(At least 12 CLINICAL NUTRIENTS 1 AL(At least 12 TABS yrs old); FOR MEN TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); CERTAVITE SENIOR/ANTIOXIDANT 1 AL(At least 12 CLINICAL NUTRIENTS 1 AL(At least 12 yrs old); FOR WOMEN TABS yrs old); NUTRIENTS TABS RX/OTC RX/OTC QL(2 ea daily); CULTURELLE CERTAVITE/ANTIOXIDAN 1 AL(At least 12 PROBIOTICS + 1 TS TABS yrs old); MULTIVITAMIN CHEW RX/OTC CVS ADULT 50+ EYE 1 RX/OTC HEALTH CAPS CVS AIRSHIELD IMMUNITY SUPPORT 1 CHEW

Nebraska Total Care Formulary September 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS EYE HEALTH ADULT 1 RX/OTC QL(2 ea daily); 50+ CAPS CVS SPECTRAVITE 1 AL(At least 12 QL(2 ea daily); ULTRA MEN50+ TABS yrs old); RX/OTC CVS ONE DAILY MENS 1 AL(At least 12 50+ ADVANCED TABS yrs old); CVS SPECTRAVITE QL(2 ea daily); RX/OTC AL(At least 12 ULTRA MENS HEALTH 1 QL(2 ea daily); SENIOR TABS yrs old); CVS ONE DAILY RX/OTC WOMENS 50+ADVANCED 1 AL(At least 12 yrs old); QL(2 ea daily); TABS CVS SPECTRAVITE RX/OTC 1 AL(At least 12 ULTRA MENS HEALTH yrs old); CVS SPECTRAVITE TABS ADULT 50+ CHEW 2 MG- RX/OTC 2.2 MG-2.7 MG-4 MG-4.5 QL(2 ea daily); MG-5 MCG-7 MG-10 CVS SPECTRAVITE 1 AL(At least 12 MCG-10 MCG-10 MG-12 ULTRA WOMEN TABS yrs old); MG-15 MG-25 MCG-25 1 RX/OTC MCG-25 MCG-45 MCG-50 QL(2 ea daily); MG-70 UNIT-75 MG-100 CVS SPECTRAVITE AL(At least 12 MCG-100 MCG-125 MG- ULTRA WOMENS 1 HEALTH SENIOR TABS yrs old); 150 MCG-200 MG-250 RX/OTC MCG-400 UNIT-500 MCG- 4000 UNIT QL(2 ea daily); CVS SPECTRAVITE AL(At least 12 CVS SPECTRAVITE QL(2 ea daily); ULTRA WOMENS 1 HEALTH TABS yrs old); ADULT 50+ TABS 0.5 MG- AL(At least 12 RX/OTC 1.5 MG-1.7 MG-2 MG-2.3 yrs old); MG-3 MG-5 MCG-10 RX/OTC CVS SPECTRAVITE 1 MCG-10 MG-11 MG-19 WOMEN CHEW MCG-20 MG-20 MG-22.5 CVS VISION HEALTH 1 RX/OTC MG-25 MCG-25 MCG-30 CAPS MCG-30 MCG-45 MCG-50 QL(2 ea daily); MCG-50 MG-60 MG-72 1 AL(At least 12 MG-80 MG-150 MCG-220 DAYAVITE TABS yrs old); MG-250 MCG-300 MCG- 1 RX/OTC 400 MCG-750 MCG, 0.5 RX/OTC MG-1.5 MG-3 MG-1.7 MG- DECUBI-VITE CAPS 1 2 MG-2.3 MG-5 MCG-10 DEKAS BARIATRIC 1 MCG-10 MG-11 MG-19 CHEW MCG-20 MG-20 MG-25 MCG-30 MCG-30 MCG-45 DEKAS PLUS CAPS 1.5 RX/OTC MCG-50 MCG-50 MG-50 MG-1.7 MG-1.9 MG-10 UNIT-60 MG-72 MG-80 MG-10 MG-10 MG-12 MG-150 MCG-220 MG-250 MCG-12 MG-75 MCG-75 MCG-300 MCG-400 MCG- MCG-75 MG-100 MCG-101 1000 UNIT-2500 UNIT MG-200 MCG-1000 MCG- 5450 MCG, 1.5 MG-1.7 1 QL(2 ea daily); MG-1.9 MG-10 MG-10 MG- CVS SPECTRAVITE 1 AL(At least 12 10 MG-12 MCG-12 MG-75 ADULTS TABS yrs old); MCG-75 MG-100 MCG-150 RX/OTC UNIT-200 MCG-1000 MCG-3000 UNIT-18167 UNIT

Nebraska Total Care Formulary September 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEKAS PLUS CHEW 1.5 QL(2 ea daily); MG-1.7 MG-1.9 MG-10 EQL CENTURY MATURE 1 AL(At least 12 MG-10 MG-10 MG-12 ADULTS50+ TABS yrs old); MCG-12 MG-70 MG-75 1 RX/OTC MCG-100 MCG-100 UNIT- QL(2 ea daily); 200 MCG-1000 MCG-2000 EQL CENTURY MENS 1 AL(At least 12 UNIT-18167 UNIT TABS yrs old); QL(2 ea daily); RX/OTC DERMACINRX RIBOTIN-E 1 AL(At least 12 QL(2 ea daily); TABS yrs old); EQL CENTURY WOMENS 1 AL(At least 12 RX/OTC TABS yrs old); QL(2 ea daily); RX/OTC DERMACINRX AL(At least 12 1 EQL ONE DAILY ADULT 1 ZINTREXYL-C TABS yrs old); GUMMIES CHEW RX/OTC QL(2 ea daily); QL(2 ea daily); EQL ONE DAILY MENS AL(At least 12 AL(At least 12 1 DERMAVITE TABS 1 TABS yrs old); yrs old); RX/OTC RX/OTC QL(2 ea daily); EMERGEN-C IMMUNE 1 ESTROVEN MENOPAUSE 1 AL(At least 12 PLUS/VITAMIN D CHEW SUPPLEMENT TABS yrs old); EMERGEN-C VITAMIN C 1 RX/OTC CHEW EYE HEALTH CAPS 1 RX/OTC QL(2 ea daily); EQ COMPLETE 1 AL(At least 12 QL(2 ea daily); MULTIVITAMINADULTS yrs old); UNDER 50 TABS EYE HEALTH/LUTEIN 1 AL(At least 12 RX/OTC TABS yrs old); RX/OTC EQ MULTIVITAMINS 1 ADULT GUMMY CHEW QL(2 ea daily); EYE QL(2 ea daily); 1 AL(At least 12 MULTIVITAMIN/LUTEIN yrs old); EQ ONE DAILY MENS 50+ 1 AL(At least 12 TABS TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); EYE QL(2 ea daily); 1 AL(At least 12 MULTIVITAMIN/SODIUM yrs old); EQ ONE DAILY MENS 1 AL(At least 12 TABS HEALTH TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); FITNESS TABS FOR MEN 1 AL(At least 12 AM/PM/LYCOPENE TABS yrs old); EQ ONE DAILY WOMENS 1 AL(At least 12 50+ TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); FITNESS TABS FOR QL(2 ea daily); 1 AL(At least 12 WOMEN yrs old); EQ ONE DAILY WOMENS 1 AL(At least 12 AM/PM/LYCOPENE TABS HEALTH TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); 1 AL(At least 12 FOLIKA-CI TABS yrs old); RX/OTC

Nebraska Total Care Formulary September 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); QL(2 ea daily); HM COMPLETE MEN AL(At least 12 FOLIKA-MG TABS 1 AL(At least 12 1 yrs old); TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); 1 AL(At least 12 HM COMPLETE TABS 1 AL(At least 12 FOLITIN-Z TABS yrs old); yrs old); RX/OTC RX/OTC FORTAVIT CAPS 1 RX/OTC QL(2 ea daily); HM HAIR/SKIN/NAILS 1 AL(At least 12 FORTAVIT LIQD 1 RX/OTC TABS yrs old); RX/OTC QL(2 ea daily); QL(2 ea daily); AL(At least 12 FREEDAVITE TABS 1 HM ONE DAILY MENS 1 AL(At least 12 yrs old); TABS yrs old); RX/OTC RX/OTC GENADEK STEP 1 CAPS 1 RX/OTC QL(2 ea daily); HM ONE DAILY WOMENS 1 AL(At least 12 GENADEK STEP 2 CAPS 1 RX/OTC TABS yrs old); RX/OTC QL(2 ea daily); QL(2 ea daily); GERI-FREEDA SENIOR AL(At least 12 1 1 AL(At least 12 FORMULA TABS yrs old); HYLAZINC TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); HAIR SKIN & NAILS QL(2 ea daily); 1 AL(At least 12 ICAPS AREDS FORMULA AL(At least 12 ADVANCED FORMULA yrs old); 1 TABS TABS yrs old); RX/OTC RX/OTC RX/OTC HAIR/SKIN/NAILS CAPS 1 ICAPS LUTEIN & 1 ZEAXANTHIN TBEC QL(2 ea daily); HIGH POTENCY IMMUNE SUPPORT 1 MULTIVITAMIN/BETA- 1 AL(At least 12 CHEW CAROTENE TABS yrs old); RX/OTC K-PAX IMMUNE RX/OTC SUPPORT FORMULA QL(2 ea daily); 1 HIGH POTENCY DOUBLE STRENGTH MULTIVITAMIN/FOLIC 1 AL(At least 12 CAPS ACID TABS yrs old); RX/OTC K-PAX IMMUNE QL(2 ea daily); SUPPORT FORMULA 1 AL(At least 12 QL(2 ea daily); PROFESSIONAL yrs old); HM COMPLETE 50+ 1 AL(At least 12 STRENGTH TABS RX/OTC MENS ULTIMATE TABS yrs old); RX/OTC K-PAX IMMUNE RX/OTC SUPPORT FORMULA 1 QL(2 ea daily); SINGLE STRENGTH HM COMPLETE 50+ AL(At least 12 WOMENS ULTIMATE 1 CAPS TABS yrs old); RX/OTC QL(2 ea daily); LUTEIN 1 AL(At least 12 PLUS/ZEAXANTHIN TABS yrs old); RX/OTC

Nebraska Total Care Formulary September 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); MENS MULTIVITAMIN QL(2 ea daily); MACULAR VITAMIN 1 AL(At least 12 TABS 2 MG-1.35 MG-1.7 AL(At least 12 BENEFIT TABS yrs old); MG-2 MG-3 MG-15 MG-16 yrs old); RX/OTC MG-18 MCG-18 MG-20 RX/OTC QL(2 ea daily); MCG-22.5 UNIT-60 MG-75 1 MCG-110 MCG-120 MCG- MEGA MULTI FOR MEN 1 AL(At least 12 TABS yrs old); 140 MG-210 MG-300 RX/OTC MCG-400 MCG-700 UNIT- 3500 UNIT QL(2 ea daily); QL(2 ea daily); MEGA MULTI FOR 1 AL(At least 12 WOMEN TABS yrs old); MULTI-BETIC DIABETES 1 AL(At least 12 RX/OTC TABS yrs old); RX/OTC QL(2 ea daily); QL(2 ea daily); MEGA MULTIVITAMIN 1 AL(At least 12 FOR MEN TABS yrs old); MULTI-VITAMIN 1 AL(At least 12 RX/OTC MONOCAPS TABS yrs old); RX/OTC QL(2 ea daily); RX/OTC MEGA MULTIVITAMIN 1 AL(At least 12 MULTI-VITE LIQD 1 FOR WOMEN TABS yrs old); RX/OTC QL(2 ea daily); QL(2 ea daily); 1 AL(At least 12 MULTILEX T&M TABS yrs old); MEGAVITE FRUITS & 1 AL(At least 12 VEGGIES TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); 1 AL(At least 12 MULTILEX TABS yrs old); MEGAVITE GOLDEN 1 AL(At least 12 YEARS 55+ TABS yrs old); RX/OTC RX/OTC MENS 50+ ADVANCED 1 RX/OTC CAPS QL(2 ea daily); MENS 50+ MULTI AL(At least 12 VITAMIN &MINERAL 1 FORMULA TABS yrs old); RX/OTC QL(2 ea daily); MENS MULTI VITAMIN & AL(At least 12 MINERAL FORMULA 1 TABS yrs old); RX/OTC MENS MULTIVITAMIN CHEW 2 MG-2.5 MG-5 MG-7.5 MCG-7.5 MG-8.75 1 MCG-10 MCG-27.5 MCG- 37.5 MG-50 MCG-75 MCG-200 MCG-300 MCG

Nebraska Total Care Formulary September 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits multiple vitamins w/ RX/OTC 600 mcg, 1 mg-1 mg-1.7 minerals caps 0.33 mg- mg-2.7 mg-3.3 mcg-4.3 0.33 mg-0.5 mg-0.83 mg- mcg-4.3 mg-5.7 mg-8.3 1.67 mg-3.3 mg-3.3 mg- unit-11.3 mg-14 mcg-14 0.67 mg-1.67 mcg-1.67 mcg-42.3 mcg-42.3 mcg- mg-4 mg-6.7 mg-6.7 mg- 42.3 mg-56.7 mg-56.7 mg- 8.3 mg-16.5 mg-16.7 mcg- 85 mg-106.3 unit-255 mcg- 16.7 mcg-16.7 mg-20 mg- 2973 unit, 1 mg-1 mg-5 20 mg-20.8 mcg-25 mg- mg-10 mg-200 unit-250 33.3 mcg-33.3 mcg-33.3 mg, 1 mg-1 mg-5 mg-10 mcg-33.3 mg-33.3 mg-33.3 mg-90 mg-250 mg, 1 mg-1 mg-33.3 mg-41.7 mg-50 mg-5 mg-12.5 mg-200 unit- mcg-66.7 unit-66.7 unit- 250 mg, 1 mg-1 mg-5 mg- 83.3 mg-83.3 mg-83.3 mg- 40 mg-200 unit-250 mg, 1 133.3 mcg-166.7 mcg- mg-1 mg-5 mg-5 mg-7.5 833.3 unit, 0.333 mg-1 mg- mg-10 mg-10 mg-10 mg-20 1.667 mg-1.667 mg-1.667 mg-25 mcg-100 mcg-200 mg-2.5 mg-2.667 mcg- unit-250 mg-500 unit, 1 mg- 3.333 mg-4.167 mcg-5 mg- 1 mg-5 mg-9 mg-30 unit-90 8.333 mg-8.333 mg-10 mg- mg-150 mg-160 mg-250 10 mg-10 unit-20 mg-30 mg, 1 mg-1.5 mg-7.5 mg- mg-133.333 mcg-666.667 15 mcg-200 unit-250 mg- unit-1666.667 mcg- 10000 unit, 1 mg-2 mg-2 1666.667 unit, 0.4 mg-1.5 mg-1.5 mg-1.7 mg-2 mg-6 mg-1.7 mg-2 mg-2 mg-2.6 mcg-10 mg-15 mg-20 mg- mg-6 mcg-10 mcg-10 mcg- 1 30 mcg-30 mg-30 unit-40 10 mcg-10 mg-15 mg-20 mg-70 mcg-75 mcg-100 mg-27 mg-30 mcg-30 unit- mcg-120 mcg-120 mg-150 37.5 mg-60 mg-100 mg- mcg-200 mcg-500 mcg- 100 mg-130 mg-150 mcg- 2000 unit-5000 unit, 1 mg-2 400 unit-1500 unit-5000 mg-2 mg-3 mg-5 mg-6 mg- unit, 0.5 mg-0.567 mg- 7 mg-10 mcg-10 mcg-25 0.667 mg-0.667 mg-1.667 mg-30 mg-30 mg-32 mg- mg-2 mcg-3 mg-3.333 mg- 300 mcg-315 mg-1000 5 mg-6.667 mg-10 unit-20 mcg, 1 mg-2 mg-4 mg-5 mg-20 mg-33.333 mg- mg-10 mcg-10 mg-10 mg- 33.333 mg-50 mcg-66.667 25 mg-50 unit-70 mg-80 mg-83.333 mg-133.333 mg-150 mg-8000 unit, 1 mcg-133.333 mg-166.667 mg-5 mg-20 unit-26.667 mg-200 mcg-2000 unit, 0.5 mg-88.333 mg-273.333 mg-0.75 mg-0.85 mg-30 unit-491.667 mg-1000 unit, mg-135 mg-150 mcg-175 1.2 mg-1.7 mg-2 mg-2 mg- mg-200 unit-215 mg-250 3 mg-5 mg-15 mg-16 mg- mg-613.5 mg-1500 mcg, 18 mcg-20 mcg-30 mcg-45 0.8 mg-34.8 mg-200 unit- unit-90 mg-100 mg-105 226 mg-14320 unit, 0.8 mcg-120 mcg-120 mg-210 mg-5 mg-34.8 mg-200 unit- mg-400 mcg-400 unit-600 226 mg, 0.9 mg-1 mg-1.2 mcg-3500 unit, 1.333 mg- mg-1.3 mg-1.3 mg-2 mg- 0.667 mg-1 mg-1.133 mg- 2.3 mg-2.4 mcg-7 mg-10 3.333 mg-3.333 mg-4 mg-5 mg-10 unit-16 mg-34 mcg- mg-6.667 mg-10 mg-10 45 mg-240 mcg-280 mg- mg-10 mg-10 mg-10 unit- Nebraska Total Care Formulary September 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 15 mg-16.667 mg-23.333 70 mcg-90 mg-300 mcg- mcg-25 mcg-33.333 mcg- 400 unit, 10000 unit-25 33.333 mg-40 mcg-40 mg- mcg-125 unit-200 mg, 15 50 mcg-133.333 mg-200 mg-30 unit-2 mg-6 mg-22 mcg-266.667 mcg-1000 mg-60 mg, 2 mg-0.4 mg- unit-3333.333 unit, 1.5 mg- 1.5 mg-1.7 mg-2 mg-2.6 1.7 mg-2 mg-2 mg-4 mg-6 mg-6 mcg-10 mcg-10 mcg- mcg-10 mg-15 mg-18 mg- 10 mcg-10 mg-15 mg-20 20 mcg-20 mg-30 mcg-40 mg-27 mg-30 unit-37.5 mg- mcg-40 mg-45 mcg-50 100 mg-100 mg-150 mcg- unit-60 mg-100 mg-120 400 unit-1500 unit-5000 mcg-150 mcg-400 mcg- unit-30 mcg-130 mg-60 mg, 1000 unit-2500 unit, 1.5 2 mg-15 mg-30 unit-60 mg, mg-1.7 mg-2 mg-2 mg-4 2 mg-3 mg-3 mg-6 mg-12 mg-6 mcg-10 mg-15 mg-18 mcg-15 unit-25 mcg-25 mg-20 mcg-20 mg-30 mcg- mcg-25 mg-25 mg-50 mg- 40 mcg-40 mg-45 mcg-50 50 mg-250 mg-500 unit- unit-60 mg-100 mg-120 800 mcg-2500 unit, 2 mg-4 mcg-150 mcg-600 mcg- mg-2 mg-3.4 mg-4 mg-4.5 1000 unit-2500 unit, 1.5 mg-5 mcg-6 mg-6 mg-9.5 mg-1.7 mg-2 mg-4 mg-4 mg-10 mcg-10 mcg-10 mg- mg-10 mg-15 mg-18 mcg- 16 mg-20 mcg-20 mg-20 20 mg-22.5 mg-25 mcg-30 mg-21 mg-22.5 mg-25 mcg-40 mcg-40 mcg-40 mcg-30 mcg-33 unit-72 mg- mg-45 mcg-60 mg-100 mg- 90 mcg-100 mcg-105 mcg- 120 mcg-150 mcg-400 150 mcg-150 mcg-180 mcg-750 mcg, 1.5 mg-1.7 mcg-234 mcg-400 mcg-552 mg-2 mg-4 mg-6 mg-10 mcg-1000 unit-2500 unit, 2 mg-15 mg-20 mg-25 mcg- mg-5 mg-5 mg-7.2 mg-15 30 mcg-60 mg-60 unit-70 mg-25 mg-25 mg-25 mg-25 mcg-75 mcg-80 mcg-100 mg-25 mg-25 mg-25 mg-50 mg-120 mcg-150 mcg-200 mg-100 mcg-100 mg-100 mg-400 mcg-1000 unit- unit-150 mcg-150 mcg-150 2500 unit, 1.5 mg-1.7 mg-2 mg-200 mcg-200 mcg-300 mg-4 mg-6 mg-10 mg-15 mcg-400 mcg-400 unit- mg-20 mg-25 mcg-30 mcg- 5000 unit, 2 mg-6 mg-15 60 unit-70 mcg-75 mcg-80 mg-22 mg-30 unit-60 mg, mcg-100 mg-120 mcg-150 226 mg-0.8 mg-34.8 mg- mcg-200 mg-400 mcg- 200 mg-14320 unit, 226 1000 unit-2500 unit-60 mg, mg-0.8 mg-34.8 mg-200 1.7 mg-2 mg-2 mg-2 mg-3 unit-14320 unit, 25 mcg- mg-4 mg-4 mg-5 mcg-6 100 unit-200 mg-5000 unit, mg-9.5 mg-10 mcg-10 25 mg-45 mg-100 unit-500 mcg-10 mg-15 mcg-15 mg- mg, 3.333 mg-6.667 mg- 16 mg-18 mg-20 mcg-20 16.667 unit-33.333 mg- mg-20 mg-21 mg-30 mcg- 133.333 mg-166.667 mg, 4 33 unit-70 mcg-72 mg-75 mg-1.5 mg-1.7 mg-2 mg-4 mcg-100 mcg-120 mcg-150 mg-10 mg-15 mg-18 mcg- mcg-150 mcg-234 mcg-552 20 mg-30 mcg-40 mcg-40 mcg-600 mcg-1000 unit- mcg-40 mg-45 mcg-50 unit- 2500 unit, 10 mg-15 mg-18 60 mg-100 mg-120 mcg- mg-20 mg-25 mg-30 mcg- 150 mcg-400 mcg-1000 Nebraska Total Care Formulary September 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits unit-2500 unit, 4 mg-1.5 multiple vitamins w/ mg-1.7 mg-2 mg-6 mg-10 minerals chew 0.033 mg- mg-15 mg-20 mg-25 mcg- 0.333 mg-1.667 mg-2.233 30 mcg-60 mg-60 unit-70 mg-3.333 mg-5 mcg-20 mcg-75 mcg-80 mcg-100 mcg-250 mg, 0.5 mg-1.25 mg-120 mcg-150 mcg-200 mg-2.5 mcg-10 mcg-10 mg-400 mcg-1000 unit- unit-15 mcg-15 mg-20 mcg- 2500 unit, 5 mcg-0.5 mg- 37.5 mcg-100 unit-1000 0.5 mg-3.75 mg-25 mg- unit, 0.5 mg-2.5 mg-4.5 68.75 unit-100 mcg-300 mg-15 unit-50 mg, 0.75 mg-375 mg, 5 mg-1 mg-1 mg-2 mg-3.75 mcg-7.5 mg-5 mg-5 mg-7.5 mg-10 unit-10 mg-11.25 mg-250 mg-15 mg-25 mcg-25 mg- mg-500 unit, 0.75 mg-2 25 mg-25 mg-25 mg-25 mg-3.75 mcg-7.5 unit-10 mg-25 mg-25 unit-30 mcg- mg-250 mg-500 unit, 0.75 35 mg-50 mg-50 mg-70 mg-3.75 mcg-0.7 mg-2 mg- mcg-75 mcg-100 mcg-100 3.38 mg-5 mg-150 mcg- mcg-100 mg-150 mcg-150 250 mg, 0.9 mg-1.9 mg-3 mcg-150 mg-250 mcg-400 mcg-5 mg-5 mg-10 mg-10 mcg-400 unit-10000 unit, 5 unit-25 mg-25 mg-113.5 mg-1 mg-2 mg-4 mg-10 mg-200 mcg-1000 unit- mcg-10 mg-10 mg-25 mg- 1250 unit, 1 mg-1 mg-1 50 unit-70 mg-80 mg-150 mg-1.7 mg-2 mg-5 mg-6.25 mg-8000 unit, 50 mcg-400 mg-7.5 mg-7.5 mg-10 mg- unit-500 mg-25000 unit, 6 10 mg-10 mg-15 mg-22.5 mg-13.5 mg-15 mg-60 mg, mg-25 mcg-25 mg-35 mcg- 1 7.5 mg-50 mcg-400 unit- 45 mg-60 mcg-75 mcg-75 500 mg, 9 mg-1 mg-1 mg-5 mg-75 unit-300 mcg-400 mg-30 unit-90 mg-150 mg- mcg-500 mcg-500 mcg- 160 mg-250 mg 1500 unit-5000 unit, 1 mg-1 mg-2.5 mg-2.5 mg-3 mcg-5 mg-7.5 unit-20 mcg-30 mcg-30 mg-140 mg-150 mcg-200 mcg-400 unit- 1250 unit, 1 mg-1.25 mg- 4.5 mcg-15 mg-15 unit-20 mcg-50 mg-75 mcg-200 mcg-400 unit-1250 unit, 1 mg-1.5 mg-1.7 mg-2 mg-2 mg-6 mcg-10 mg-10 unit- 15 mg-18 mg-20 mcg-20 mg-20 mg-40 mg-45 mcg- 50 mg-60 mg-60 unit-108 mg-150 mcg-400 mcg-400 unit-3500 unit, 1 mg-1.9 mg-2 mg-3 mcg-5 mg-9 mcg-9.4 mcg-10 mg-15 mcg-15 mg-15 unit-19 mcg- 20 mcg-60 mcg-75 mcg- 150 mcg-200 unit-1250 unit, 1 mg-2.5 mg-4 mcg-5 mcg-5 mg-9 mg-17.5 mg- Nebraska Total Care Formulary September 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 30 mg-40 mcg-75 mcg-200 multiple vitamins w/ RX/OTC mcg-600 mcg, 1 mg-2.5 minerals liqd 1.5 mg/15ml- mg-4 mcg-5 mg-20 unit-30 1.7 mg/15ml-2 mg/15ml-2 mg-40 mcg-75 mcg-200 mg/15ml-3 mg/15ml-6 mcg-400 unit-2000 unit, 1 mcg/15ml-9 mg/15ml-10 mg-2.5 mg-5 mcg-5 mg-20 mg/15ml-20 mg/15ml-25 mcg-20 unit-30 mcg-30 mcg/15ml-25 mcg/15ml-30 mg-40 mcg-75 mcg-200 unit/15ml-60 mg/15ml-150 mcg-200 unit-2000 unit, 1 mcg/15ml-300 mcg/15ml, mg-3 mcg-3.75 mg-5 mg- 1.5 mg/15ml-1.7 mg/15ml-2 10 mg-15 unit-30 mg-37.5 mg/15ml-2 mg/15ml-3 mcg-75 mcg-200 mcg-500 mg/15ml-6 mcg/15ml-9 unit-1250 unit, 1.5 mg-2 mg/15ml-10 mg/15ml-20 mg-5 mg-5 mg-6 mcg-7.5 mg/15ml-25 mcg/15ml-25 mcg-7.5 unit-15 mg-18.75 mcg/15ml-30 unit/15ml-60 mcg-20 mcg-60 mcg-75 mg/15ml-150 mcg/15ml- mcg-137.5 mcg-200 mcg- 300 mcg/15ml-1000 400 unit-1250 unit, 15 mg-1 unit/15ml-1300 unit/15ml, mg-1.25 mg-4.5 mcg-15 1.5 mg/15ml-1.7 mg/15ml-2 unit-20 mcg-50 mg-75 mg/15ml-2 mg/15ml-3 mcg-200 mcg-400 unit- mg/15ml-6 mcg/15ml-9 1250 unit, 2 mg-2.2 mg-2.7 mg/15ml-10 mg/15ml-20 mg-4 mg-4.5 mg-5 mcg-7 mg/15ml-25 mcg/15ml-25 mg-10 mcg-10 mcg-10 mg- mcg/15ml-30 unit/15ml-60 12 mg-15 mg-22.5 mcg-25 mg/15ml-150 mcg/15ml- mcg-25 mcg-45 mcg-50 300 mcg/15ml-400 1 mg-70 unit-75 mg-100 unit/15ml-1300 unit/15ml, mcg-100 mcg-125 mg-200 1.5 mg/15ml-1.7 mg/15ml-2 mg-250 mcg-400 unit-500 mg/15ml-2 mg/15ml-3 mcg-4000 unit, 2.233 mg- mg/15ml-6 mcg/15ml-9 0.033 mg-0.333 mg-1.667 mg/15ml-10 mg/15ml-20 mg-3.333 mg-5 mcg-20 mg/15ml-25 mcg/15ml-30 mcg-250 mg, 2.5 mg-2.5 unit/15ml-60 mg/15ml-150 mg-3 mg-7.5 mcg-15 unit- mcg/15ml-250 mcg/15ml- 22.5 mg-37.5 mcg-55 mcg- 300 mcg/15ml-400 75 mcg-80 mcg-500 unit- unit/15ml, 2 mg/15ml-10 1250 unit, 2.5 mg-2.5 mg-5 mg/15ml-15 mcg/15ml-15 mg-7.5 mcg-15 unit-20 mg/15ml-15 mg/15ml-50 mcg-30 mcg-37.5 mg-55 mcg/15ml-50 mg/15ml-50 mcg-75 mcg-200 mcg-200 mg/15ml-50 mg/15ml-50 unit-300 mcg-2000 unit, mg/15ml-150 mcg/15ml- 3.333 unit-0.033 mg-0.333 800 mcg/15ml-1000 mg-3.333 mg-5 mcg- mg/15ml-5000 unit/15ml, 66.666 unit-333.333 mg, 2.25 mg/15ml-2.55 7.5 unit-0.75 mg-2 mg-3.75 mg/15ml-3 mg/15ml-15 mcg-10 mg-250 mg-500 mg/15ml-15 mg/15ml-18 unit mcg/15ml-37 mg/15ml-45 mg/15ml-45 unit/15ml-75 mg/15ml-90 mg/15ml-112.5 mcg/15ml-150 mcg/15ml- 300 mcg/15ml-600 unit/15ml-5250 unit/15ml, Nebraska Total Care Formulary September 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2.5 unit/5ml-5 mcg/5ml-5 multiple vitamins w/ QL(2 ea daily); mg/5ml-7.5 mg/5ml-7.5 minerals tabs 0.05 mg-1.1 AL(At least 12 mg/5ml-10 mg/5ml-12.5 mg-1.1 mg-2 mg-2.3 mg-5 yrs old); mg/5ml-25 mcg/5ml-75 mcg-5 mg-5 mg-8 mg-10 RX/OTC mg/5ml-100 unit/5ml-200 mcg-14 mg-15 mg-20 mg- mcg/5ml-225 mg/5ml-750 30 mcg-35 unit-50 mcg-50 mcg/5ml-2500 unit/5ml-250 mcg-50 mcg-50 mcg-50 mg/5ml-25 mcg/5ml mg-55 mcg-72 mg-80 mg- 100 mg-150 mcg-150 mcg- 300 mcg-400 mcg-500 mg- 800 unit-3500 unit, 0.075 mg-0.38 mg-0.5 mg-0.5 mg-0.83 mg-0.9 mg-1.5 mcg-1.67 mg-2.5 mg-2.5 mg-2.5 mg-6.25 mcg-7.5 mcg-10 mcg-18.75 mcg- 21.15 mg-25 mg-30 mcg- 35 mg-37.5 mcg-83.25 mg- 100 mcg-100 unit-107.5 unit-128 mg, 0.08 mg-1.67 mg-2.5 mg-4.16 mg-4.16 mg-4.16 mg-4.16 mg-4.16 mg-4.16 mg-7.9 mg-10.4 mcg-12.5 mcg-16.7 mcg- 16.7 mcg-16.7 unit-16.7 unit-33.3 mcg-41.7 mg- 1 52.08 mg-250 mg-2083.3 unit, 0.1 mg-0.15 mg-0.8 mg-3 mg-5 mg-20 mg-20 mg-22.5 mg-25 mg-25 mg- 27 mg-30 unit-50 mcg-50 mg-100 mg-500 mg-5000 unit, 0.1 mg-0.25 mg-0.4 mg-1 mcg-2.2 mg-5 mg- 6.15 mg-7.2 mg-12.5 mg- 12.5 unit-15 mg-15 mg-15 mg-24.3 mg-25 mg-25 mg- 25 mg-50 mcg-50 mg-50 mg-50 mg-53.5 mg-150 mg-150 mg-162 mg-250 mg-400 unit-25000 unit, 0.125 mg-0.161 mg-0.4 mg-1.25 mg-2 mg-5 mg-6 mcg-10 mg-10 mg-15 mg- 20 mg-24 mg-30 unit-100 mg-100 mg-150 mcg-250 mg-400 unit-10000 unit, 0.15 mg-0.5 mg-5 mg-6 mg-7 mg-10 mg-10 mg-25 mg-30 mg-30 mg-30 mg-30 mg-50 mg-80 mcg-80 mcg- 80 mg-80 mg-80 mg-80 Nebraska Total Care Formulary September 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-80 mg-80 mg-80 mg-80 mg-27 mg-30 unit-60 mg- mg-100 unit-250 mg-400 400 unit-450 mg-5000 unit, mcg-1000 unit-25000 unit, 0.4 mg-1.5 mg-1.7 mg-2 0.15 mg-1 mg-1 mg-1.5 mg-6 mcg-10 mg-20 mg-30 mg-1.7 mg-3 mcg-5 mg-5 unit-45 mg-60 mg-400 unit- mg-5.5 unit-10 mg-10 mg- 3000 unit, 0.4 mg-1.5 mg- 15 mg-30 mg-100 mg-400 1.7 mg-2 mg-6 mcg-10 mg- unit-10000 unit, 0.2 mg-2 20 mg-30 unit-60 mg-400 mg-7.5 mg-10 mg-15 mg- unit-5000 unit, 0.4 mg-17.4 30 mcg-30 mcg-30 mg-30 mg-100 unit-113 mg-7160 mg-30 mg-30 mg-30 mg-35 unit, 0.4 mg-2 mg-2.6 mg-9 mcg-50 unit-100 mg-150 mcg-20.6 mg-22.5 mg-27 mcg-300 mg-400 mcg-400 mg-30 mg-45 unit-400 unit- unit-5000 unit, 0.33 mg- 5000 unit-90 mg, 0.4 mg-2 0.67 mg-3.3 mg-3.3 mg-3.3 mg-3 mg-3 mg-3.4 mg-5 mg-5 unit-11.7 mg-33.3 mg-7.5 mg-7.5 mg-9 mcg- mg-41.7 mg-50 mcg-66.7 10 mcg-10 mg-15 mcg-15 mg-100 mg-140 unit-1400 mcg-15 mcg-15 mg-27 mg- unit, 0.35 mg-0.75 mg-0.85 30 mg-30 unit-41 mg-100 mg-1 mg-1 mg-2.5 mcg-2.5 mg-120 mg-150 mcg-400 mg-3 mg-3.75 mg-5 mcg-5 unit-5500 unit, 0.4 mg-2 mcg-5 mg-10 mcg-10 mg- mg-3 mg-3 mg-3.4 mg-5 12.5 mcg-15 mcg-15 unit- mg-7.5 mg-7.5 mg-9 mcg- 16 mcg-20 mg-29 mg-30 10 mcg-10 mg-15 mcg-15 mg-32 mg-37.5 mcg-40 mcg-15 mg-27 mg-30 mg- mg-54 mg-60 mcg-75 mcg- 30 unit-31 mg-35 mcg-40 100 mcg-200 mcg-200 unit- mg-90 mg-100 mg-150 400 mg-1750 unit, 0.37 mcg-400 unit-1250 unit- mg-0.5 mg-1 mcg-1 mg-1.5 5000 unit, 0.4 mg-5 mg-12 mg-2.5 mg-2.5 mg-2.5 mg- mcg-15 mg-15 mg-20 mg- 5 mg-15 mg-15 unit-60 mg- 27 mg-30 unit-45 mcg-100 75 mcg-80 mg-100 mg-400 mg-500 mg, 0.5 mg-0.5 mcg-400 unit-5000 unit, mg-1 mg-1 mg-1 mg-1 mg- 0.375 mg-0.5 mg-1 mcg-1 1 mg-2 mg-2 mg-2 mg-3.5 mg-1.5 mg-2.5 mg-2.5 mg- mg-4.5 mg-5 mg-5.1 mg-6 5 mg-7.5 mg-15 mg-15 mg-6.5 mcg-7.5 mg-10 mg- unit-60 mg-75 mcg-80 mg- 10 mg-10 mg-13 mcg-13 100 mg-400 mcg-400 unit- mcg-15 mg-18 mg-24 mcg- 5000 unit, 0.4 mg-0.8 mg- 25 mg-25 mg-40 mg-60 1.3 mg-7 mg-10 mg-10 mg- mcg-60 unit-80 mcg-80 mg- 18 mg-25 mcg-25 mg-25 90 mg-100 mg-100 mg-120 mg-50 unit-100 mg-300 mg-150 mcg-165 mg-200 mg, 0.4 mg-1.2 mg-1.7 mg- mcg-200 mcg-200 mcg-275 2 mg-6 mcg-15 mg-18 mg- mcg-300 mcg-400 mcg-400 20 mg-60 mg-100 mg-125 unit-5000 unit, 0.5 mg-0.75 mg-150 mcg-160 mg-400 mg-1.25 mg-1.5 mg-1.75 unit-5000 unit, 0.4 mg-1.5 mg-3.75 mg-5 mg-5 mg-5 mg-1.7 mg-2 mg-6 mcg-10 mg-5 mg-5 mg-6.25 mg- mcg-20 mg-30 unit-45 mg- 11.25 mcg-12.5 mcg-12.5 60 mg-400 unit-3000 unit, mcg-12.5 mg-25 mcg-30 0.4 mg-1.5 mg-1.7 mg-2 mg-32 mg-50 mcg-75 mcg- mg-6 mcg-10 mg-15 mg-20 75 mg-200 mcg-200 mg- Nebraska Total Care Formulary September 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 200 unit, 0.5 mg-1 mg-7.5 mg-1.1 mg-2 mg-2.3 mg-5 mg-9 mg-10 mcg-10 mg-10 mcg-5 mg-5 mg-8 mg-10 mg-10 mg-10 mg-10 mg-10 mcg-14 mg-15 mg-20 mg- mg-10 mg-17.5 mcg-30 30 mcg-35 unit-50 mcg-50 mcg-30 unit-35 mg-60 mg- mcg-50 mcg-50 mcg-50 75 mcg-100 mg-120 mg- mg-55 mcg-72 mg-80 mg- 200 mg-400 mcg-400 unit- 100 mg-150 mcg-150 mg- 5000 unit, 0.5 mg-1.1 mg- 300 mcg-400 mcg-500 mg- 1.1 mg-1.8 mg-2 mg-6 800 unit-3500 unit, 0.5 mg- mcg-8 mg-14 mg-15 mg-18 1.1 mg-1.1 mg-2 mg-2.3 mcg-18 mg-20 mg-32 mcg- mg-5 mg-5 mg-8 mg-10 35 unit-40 mcg-50 mcg-50 mcg-14 mg-15 mg-15.7 mcg-72 mg-75 mg-80 mg- mg-20 mg-22 mcg-25 mcg- 100 mg-150 mcg-200 mg- 30 mcg-50 mcg-50 mcg-50 400 mcg-800 unit-3500 mcg-52 mcg-72 mg-80 mg- unit, 0.5 mg-1.1 mg-1.1 100 mg-100 mg-150 mcg- mg-2 mg-2.3 mg-5 mcg-5 300 mcg-300 mg-400 mcg- mg-5 mg-8 mg-10 mcg-14 1050 mcg, 0.5 mg-1.1 mg-2 mg-15 mg-15.8 mg-20 mg- mg-2.3 mg-5 mcg-5 mg-5 22 mcg-25 mcg-30 mcg-50 mg-8 mg-10 mcg-14 mg-20 mcg-50 mcg-50 mcg-52 mg-30 mcg-50 mcg-50 mcg-72 mg-80 mg-100 mg- mcg-50 mcg-50 mcg-1.1 100 mg-150 mcg-300 mcg- mg-15 mg-35 unit-50 mg- 300 mg-400 mcg-1050 55 mcg-72 mg-80 mg-100 mcg, 0.5 mg-1.1 mg-1.1 mg-150 mcg-150 mcg-300 mg-2 mg-2.3 mg-5 mcg-5 mcg-400 mcg-500 mg-800 mg-5 mg-8 mg-10 mcg-14 unit-3500 unit, 0.5 mg-1.5 mg-15 mg-17.5 mg-20 mg- mg-1.7 mg-2 mg-2 mg-2.3 22 mcg-25 mcg-30 mcg-50 mg-5 mcg-10 mcg-10 mcg- mcg-50 mcg-50 mcg-52 10 mg-11 mg-18 mg-20 mcg-72 mg-80 mg-100 mg- mg-20 mg-25 mcg-30 mcg- 100 mg-150 mcg-300 mcg- 30 unit-35 mg-45 mcg-50 300 mg-400 mcg-1052 mg-55 mcg-60 mg-72 mg- mcg, 0.5 mg-1.1 mg-1.1 75 mcg-80 mg-150 mcg- mg-2 mg-2.3 mg-5 mcg-5 200 mg-400 unit-3500 unit, mg-5 mg-8 mg-10 mcg-14 0.5 mg-1.5 mg-1.7 mg-2 mg-15 mg-20 mg-22 mcg- mg-2 mg-2.3 mg-5 mcg-6 30 mcg-35 unit-50 mcg-50 mcg-10 mcg-10 mcg-10 mcg-50 mcg-52 mcg-72 mcg-10 mg-11 mg-13.5 mg-80 mg-100 mg-100 mg- mg-18 mg-20 mg-20 mg-25 150 mcg-300 mcg-300 mg- mcg-30 mcg-35 mcg-45 400 mcg-800 unit-3500 mcg-50 mg-55 mcg-60 mg- unit, 0.5 mg-1.1 mg-1.1 72 mg-75 mcg-80 mg-150 mg-2 mg-2.3 mg-5 mcg-5 mcg-200 mg-400 mcg-1050 mg-5 mg-8 mg-10 mcg-14 mcg, 0.5 mg-1.5 mg-1.7 mg-15 mg-20 mg-30 mcg- mg-2 mg-2 mg-2.3 mg-5 35 unit-50 mcg-50 mcg-50 mcg-6 mcg-10 mcg-10 mcg-50 mcg-50 mg-55 mcg-10 mg-11 mg-18 mg- mcg-72 mg-80 mg-100 mg- 20 mg-20 mg-25 mcg-30 150 mcg-150 mcg-300 mcg-30 unit-35 mcg-45 mcg-400 mcg-500 mg-800 mcg-50 mg-55 mcg-60 mg- unit-3500 unit, 0.5 mg-1.1 72 mg-75 mcg-80 mg-150 Nebraska Total Care Formulary September 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-200 mg-400 mcg-400 72 mg-80 mg-150 mcg-150 unit-3500 unit, 0.5 mg-1.5 mcg-220 mg-250 mcg-300 mg-1.7 mg-2 mg-2 mg-2.3 mcg-400 mcg-500 unit- mg-6 mcg-10 mcg-10 mcg- 2500 unit-50 unit-11 mg, 10 mg-11 mg-13.5 mg-18 0.5 mg-1.5 mg-1.7 mg-2 mg-20 mg-20 mg-25 mcg- mg-4 mg-5 mcg-6 mg-10 25 mcg-30 mcg-35 mcg-45 mcg-10 mg-15 mg-20 mg- mcg-50 mg-55 mcg-60 mg- 20 mg-21 mcg-25 mcg-27 72 mg-80 mg-150 mcg-200 mg-30 mcg-50 mcg-60 mg-400 mcg-1050 mcg, 0.5 mcg-60 mcg-72 mg-75 mg- mg-1.5 mg-1.7 mg-2 mg- 80 mg-100 mcg-120 mg- 2.3 mg-3 mg-5 mcg-10 150 mcg-210 mg-300 mcg- mcg-10 mg-11 mg-19 mcg- 300 mcg-600 mcg-1050 20 mg-20 mg-25 mcg-30 mcg, 0.5 mg-1.5 mg-1.7 mcg-30 mcg-45 mcg-50 mg-4 mg-6 mg-10 mg-15 mcg-50 mg-50 unit-60 mg- mg-20 mg-20 mg-21 mcg- 72 mg-80 mg-150 mcg-220 25 mcg-27 mg-30 mcg-50 mg-250 mcg-300 mcg-400 mcg-60 mcg-60 mcg-72 mcg-500 unit-2500 unit, 0.5 mg-75 mg-80 mg-100 mcg- mg-1.5 mg-1.7 mg-2 mg- 120 mg-150 mcg-210 mg- 2.3 mg-3 mg-5 mcg-10 300 mcg-300 mcg-600 mcg-10 mg-11 mg-19 mcg- mcg-1050 mcg, 0.5 mg-1.5 20 mg-20 mg-25 mcg-30 mg-1.7 mg-4 mg-6 mg-10 mcg-30 mcg-45 mcg-50 mg-15 mg-20 mg-20 mg-21 mcg-50 mg-50 unit-60 mg- mcg-30 mcg-50 mcg-60 72 mg-80 mg-150 mg-220 mcg-60 mcg-60 unit-72 mg- mg-250 mcg-300 mcg-400 75 mg-80 mg-100 mcg-120 mcg-1000 unit-2500 unit, mg-150 mcg-210 mg-300 0.5 mg-1.5 mg-1.7 mg-2 mcg-300 mcg-600 mcg-600 mg-2.3 mg-3 mg-5 mcg-10 unit-3500 unit, 0.5 mg-1.7 mcg-10 mg-11 mg-20 mg- mg-2 mg-2.3 mg-3 mg-5 20 mg-25 mcg-30 mcg-30 mcg-10 mg-11 mg-20 mg- mcg-45 mcg-45 mcg-50 20 mg-25 mcg-30 mcg-30 mg-50 unit-55 mcg-60 mg- mcg-45 mcg-50 mg-50 unit- 72 mg-80 mg-150 mcg-150 55 mcg-1.5 mg-10 mcg-45 mcg-220 mg-250 mcg-300 mcg-60 mg-72 mg-80 mg- mcg-400 mcg-500 unit- 150 mcg-150 mcg-220 mg- 2500 unit, 0.5 mg-1.5 mg- 250 mcg-300 mcg-400 1.7 mg-2 mg-2.3 mg-3 mg- mcg-500 unit-2500 unit, 0.5 5 mcg-10 mcg-10 mg-20 mg-2 mg-1.1 mg-1.1 mg- mg-20 mg-25 mcg-30 mcg- 1.8 mg-2 mg-5 mcg-6 mcg- 30 mcg-45 mcg-45 mcg-50 8 mg-10 mcg-10 mcg-14 mg-50 unit-55 mcg-60 mg- mg-15 mg-18 mcg-18 mg- 72 mg-80 mg-150 mcg-150 20 mg-32 mcg-35 unit-40 mcg-220 mg-250 mcg-300 mcg-50 mcg-50 mcg-72 mcg-400 mcg-500 unit- mg-75 mg-80 mg-100 mg- 2500 unit-11 mg, 0.5 mg- 150 mcg-200 mg-400 mcg- 1.5 mg-1.7 mg-2 mg-2.3 800 unit-3500 unit, 0.5 mg- mg-3 mg-5 mcg-10 mcg-10 2 mg-1.5 mg-1.7 mg-2 mg- mg-20 mg-20 mg-25 mcg- 2.3 mg-5 mcg-6 mcg-10 30 mcg-30 mcg-45 mcg-45 mcg-10 mcg-10 mg-11 mg- mcg-50 mg-55 mcg-60 mg- 18 mg-20 mg-20 mg-25 Nebraska Total Care Formulary September 1, 2021

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-30 mcg-30 unit-35 1.1 mg-1.1 mg-2.3 mg-5 mcg-45 mcg-50 mg-55 mg-5 mg-8 mg-10 mcg-14 mcg-60 mg-72 mg-75 mcg- mg-15 mg-15 mg-20 mg-30 80 mg-150 mcg-200 mg- mcg-35 unit-50 mcg-50 400 mcg-400 unit-3500 mcg-50 mcg-50 mcg-50 unit, 0.5 mg-2.3 mg-1.1 mg-55 mcg-72 mg-80 mg- mg-1.1 mg-2 mg-5 mcg-5 100 mg-150 mcg-150 mcg- mg-5 mg-8 mg-10 mcg-14 300 mcg-400 mcg-500 mg- mg-15 mg-15.8 mg-20 mg- 800 unit-3500 unit, 0.6 mg- 22 mcg-25 mcg-30 mcg-50 0.6 mg-3.3 mg-3.5 mg-5 mcg-50 mcg-50 mcg-52 mg-5 mg-6.5 mg-7.2 mg- mcg-72 mg-80 mg-100 mg- 7.5 mg-10 mg-10 mg-10 100 mg-150 mcg-300 mcg- mg-10 mg-10 mg-15 mg-20 300 mg-400 mcg-1050 mg-25 mcg-25 mcg-25 mcg, 0.5 mg-2.3 mg-1.5 mcg-25 mg-25 unit-50 mg- mg-1.7 mg-2 mg-3 mg-5 50 unit-58 mg-125 mg-150 mcg-10 mcg-10 mg-11 mg- mcg-897 mcg-2500 unit, 19 mcg-20 mg-20 mg-25 0.6 mg-0.6 mg-3.3 mg-3.5 mcg-30 mcg-30 mcg-45 mg-5 mg-5 mg-6.5 mg-7.2 mcg-50 mcg-50 mg-50 mg-7.5 mg-10 mg-10 mg- unit-60 mg-72 mg-80 mg- 10 mg-15 mg-20 mg-25 150 mcg-220 mg-250 mcg- mcg-25 mcg-25 mcg-25 300 mcg-400 mcg-500 unit- mg-25 unit-50 mg-50 mg- 2500 unit, 0.5 mg-2.3 mg- 50 unit-54 mg-70 mg-150 1.5 mg-1.7 mg-2 mg-3 mg- mcg-897 mcg-2500 unit, 5 mcg-10 mcg-10 mg-11 0.6 mg-1.2 mg-1.7 mg-2 mg-20 mg-20 mg-25 mcg- mg-2 mg-3 mg-5 mg-15 30 mcg-30 mcg-45 mcg-45 mg-16 mg-18 mcg-20 mcg- mcg-50 mg-50 unit-55 30 mcg-45 unit-90 mg-99 mcg-60 mg-72 mg-80 mg- mg-105 mcg-120 mcg-120 150 mcg-150 mcg-220 mg- mg-210 mg-400 mcg-400 250 mcg-300 mcg-400 unit-3500 unit, 0.667 mg- mcg-500 unit-2500 unit, 0.5 0.5 mg-0.667 mg-0.667 mg-2.3 mg-3 mg-1.5 mg- mg-0.667 mg-3.333 mg-5 1.7 mg-2 mg-5 mcg-10 mg-5 mg-5.333 mg-8.333 mcg-10 mg-11 mg-19 mcg- mg-10 mg-10 mg-15 mg-20 20 mg-20 mg-25 mcg-30 mg-20 mg-20 mg-22.333 mcg-30 mcg-45 mcg-50 unit-25 mcg-25 mcg-26.667 mcg-50 mg-50 unit-60 mg- mcg-30 mg-33.333 mg-50 72 mg-80 mg-150 mcg-220 mcg-50 mg-50 mg-66.667 mg-250 mcg-300 mcg-400 mcg-66.667 mcg-71.667 mcg-500 unit-2500 unit, 0.5 mg-100 mcg-100 mg-100 mg-2.3 mg-3 mg-1.5 mg- mg-166.667 mcg-200 mcg- 1.7 mg-2 mg-5 mcg-10 266.667 mcg-266.667 unit- mcg-10 mg-11 mg-20 mg- 1666.667 unit, 0.667 mg- 20 mg-25 mcg-30 mcg-30 0.667 mg-1 mg-1 mg-1.667 mcg-45 mcg-45 mcg-50 mg-1.667 mg-1.667 mg-2.5 mg-50 unit-55 mcg-60 mg- mg-2.5 mg-2.667 mcg- 72 mg-80 mg-150 mcg-150 3.333 mg-3.333 mg-4.167 mcg-220 mg-250 mcg-300 mcg-4.167 mg-5 mg-5 unit- mcg-400 mcg-500 unit- 5 unit-8.333 mg-10 mg- 2500 unit, 0.5 mg-5 mcg- 12.667 mg-16.667 mg- Nebraska Total Care Formulary September 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 16.667 mg-20 mg-30 mg- mg-10 mg-10 mg-18 mg-20 66.667 mcg-66.667 mg- mcg-25 mcg-30 mg-30 unit- 333.333 unit-1666.667 unit- 72 mg-80 mg-109 mg-120 1666.667 unit, 0.667 mg- mcg-150 mcg-150 mcg-250 0.667 mg-1 mg-1 mg-1.667 mcg-300 mcg-400 mcg-400 mg-1.667 mg-2.5 mg-2.667 unit-3500 unit, 0.75 mg- mcg-3.333 mg-3.333 mg-5 0.85 mg-1 mg-1 mg-1 mg-1 mg-5 unit-8.333 mg-10 mg- mg-3 mcg-5 mg-5 mg-7 12.667 mg-16.667 mg- mg-10 mg-11.5 mg-15 16.667 mg-20 mg-30 mg- mcg-15 mcg-25 unit-35 66.667 mcg-66.667 mg- mcg-37.5 mcg-50 mg-60 333.333 unit-1666.667 unit, mcg-75 mcg-75 mg-100 0.667 mg-0.667 mg-1 mg- mg-150 mcg-200 mcg-200 1.667 mg-1.667 mg-2.5 unit-500 unit, 0.75 mg-0.85 mg-2.667 mcg-3.333 mg- mg-1 mg-1 mg-1 mg-1 mg- 3.333 mg-5 mg-5 unit- 3 mcg-5 mg-7.5 mg-10 mg- 8.333 mg-10 mg-12.667 15 unit-25 mcg-25 mg-30 mg-16.667 mg-16.667 mg- mg-35 mcg-37.5 mcg-40 20 mg-30 mg-66.667 mcg- mg-45 mg-75 mcg-100 66.667 mg-333.333 unit- mcg-125 mg-150 mcg-200 1000 mcg-1666.667 unit, mcg-200 mg-200 unit-2500 0.7 mg-1.5 mg-1.7 mg-2 unit, 0.9 mg-0.9 mg-1.5 mg-4 mg-5 mcg-6 mg-10 mg-1.5 mg-1.7 mg-1.7 mg- mcg-10 mg-15 mg-20 mg- 2 mg-2 mg-2 mg-2 mg-2.3 20 mg-30 mcg-50 mcg-50 mg-2.3 mg-5 mcg-5 mcg-6 mg-60 mcg-60 mcg-60 mcg-6 mcg-10 mcg-10 unit-72 mg-80 mg-100 mcg-10 mcg-10 mcg-10 mcg-100 mcg-120 mg-150 mg-10 mg-11 mg-11 mg-18 mcg-150 mcg-250 mg-300 mg-18 mg-20 mg-20 mg-25 mcg-300 mcg-600 mcg-600 mcg-25 mcg-30 mcg-30 unit-3500 unit, 0.7 mg-1.5 mcg-30 unit-30 unit-35 mg-1.7 mg-4 mg-5 mcg-6 mcg-35 mcg-45 mcg-45 mg-10 mcg-10 mg-15 mg- mcg-55 mcg-55 mcg-72 15 mg-20 mg-20 mg-30 mg-72 mg-80 mg-80 mg-90 mcg-50 mcg-50 mg-60 mg-90 mg-100 mg-100 mg- mcg-60 mcg-60 unit-72 109 mg-109 mg-150 mcg- mg-80 mg-100 mcg-100 150 mcg-150 mcg-150 mcg-120 mg-150 mcg-150 mcg-200 mg-200 mg-250 mcg-250 mg-300 mcg-300 mcg-250 mcg-300 mcg-300 mcg-600 mcg-600 unit- mcg-400 unit-400 unit-500 3500 unit, 0.7 mg-5 mcg- mcg-500 mcg-3500 unit- 1.5 mg-1.7 mg-4 mg-6 mg- 3500 unit, 0.9 mg-0.9 mg- 10 mcg-10 mcg-10 mg-15 1.5 mg-1.5 mg-1.7 mg-1.7 mg-20 mg-20 mg-30 mcg- mg-2 mg-2 mg-2.3 mg-2.3 50 mcg-50 mg-60 mcg-60 mg-3 mg-3 mg-5 mcg-5 mcg-60 unit-72 mg-80 mg- mcg-10 mcg-10 mcg-10 100 mcg-100 mcg-120 mg- mg-10 mg-11 mg-11 mg-20 150 mcg-150 mcg-250 mg- mg-20 mg-25 mcg-25 mcg- 300 mcg-300 mcg-600 30 mcg-30 mcg-30 mcg-30 mcg-600 unit-3500 unit, mcg-45 mcg-45 mcg-45 0.75 mcg-2 mg-2 mg-2 mg- mcg-45 mcg-50 mg-50 mg- 5 mcg-10 mcg-10 mcg-10 50 unit-50 unit-55 mcg-55 Nebraska Total Care Formulary September 1, 2021

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-72 mg-72 mg-80 mg- mcg-10 mcg-10 mcg-10 80 mg-90 mg-90 mg-110 mg-10 mg-0.9 mg-2.3 mg-5 mg-110 mg-150 mcg-150 mcg-11 mg-11 mg-20 mg- mcg-150 mcg-150 mcg-220 20 mg-25 mcg-25 mcg-30 mg-220 mg-250 mcg-250 mcg-30 mcg-30 mcg-30 mcg-300 mcg-300 mcg-500 mcg-45 mcg-45 mcg-45 mcg-500 mcg-500 unit-500 mcg-45 mcg-50 mg-50 mg- unit-2500 unit-2500 unit, 50 unit-50 unit-55 mcg-55 0.9 mg-1.1 mg-1.1 mg-1.8 mcg-72 mg-72 mg-80 mg- mg-2 mg-2 mg-5 mcg-6 80 mg-90 mg-90 mg-110 mcg-8 mg-10 mcg-10 mcg- mg-110 mg-150 mcg-150 14 mg-15 mg-18 mg-20 mcg-150 mcg-150 mcg-220 mg-25 mcg-35 unit-40 mg-220 mg-250 mcg-250 mcg-50 mcg-50 mcg-55 mcg-300 mcg-300 mcg-500 mcg-72 mg-75 mg-80 mg- mcg-500 mcg-500 unit-500 100 mg-150 mcg-150 mcg- unit-2500 unit-2500 unit, 400 mcg-500 mg-800 unit- 0.9 mg-1.5 mg-1.7 mg-2 3500 unit, 0.9 mg-1.2 mg- mg-2 mg-2.3 mg-5 mcg-10 1.3 mg-1.7 mg-1.8 mg-3.4 mcg-10 mcg-10 mg-11 mg- mg-5 mg-6 mcg-8 mg-16 20 mg-25 mcg-30 mcg-30 mg-18 mg-25 mcg-25 mcg- unit-35 mcg-45 mcg-55 25 mcg-27.5 mcg-75 mg- mcg-72 mg-80 mg-90 mg- 150 mcg-380 mg-400 mcg- 109 mg-150 mcg-150 mcg- 665 mcg-1000 mcg, 0.9 200 mg-250 mcg-6 mcg-18 mg-1.2 mg-1.3 mg-1.7 mg- mg-100 mg-300 mcg-400 1.8 mg-5 mg-6 mcg-7.5 unit-500 mcg-3500 unit, 0.9 mg-8 mg-16 mg-18 mg-25 mg-1.5 mg-1.7 mg-2 mg-2 mcg-25 mcg-25 mcg-27.5 mg-2.3 mg-5 mcg-6 mcg- mcg-75 mg-150 mcg-380 10 mcg-10 mcg-10 mg-11 mg-400 mcg-700 mcg- mg-18 mg-20 mg-25 mcg- 1000 mcg, 0.9 mg-1.2 mg- 30 mcg-30 unit-35 mcg-45 1.3 mg-2 mg-2 mg-2.3 mg- mcg-55 mcg-72 mg-80 mg- 5 mcg-6 mcg-8 mg-10 90 mg-100 mg-109 mg-150 mcg-10 mcg-11 mg-15 mg- mcg-150 mcg-200 mg-250 16 mg-20 mg-25 mcg-35 mcg-300 mcg-400 unit-500 mcg-40 mcg-45 mg-50 mcg-3500 unit, 0.9 mg-1.5 mcg-60 mcg-72 mg-80 mg- mg-1.7 mg-2 mg-2.3 mg-3 90 mg-100 mcg-100 mg- mg-5 mcg-10 mcg-10 mg- 150 mcg-200 mcg-210 mg- 11 mg-20 mg-25 mcg-30 600 mcg-900 mcg, 0.9 mg- mcg-30 mcg-45 mcg-45 1.2 mg-1.3 mg-2 mg-2 mg- mcg-50 mg-50 unit-55 mcg- 2.3 mg-5 mcg-6 mcg-8 mg- 72 mg-80 mg-90 mg-110 10 mcg-10 mcg-11 mg-15 mg-150 mcg-150 mcg-220 mg-16 mg-20 mg-35 mcg- mg-250 mcg-300 mcg-500 40 mcg-45 unit-50 mcg-60 mcg-500 unit-2500 unit, 0.9 mcg-72 mg-80 mg-90 mg- mg-1.5 mg-1.7 mg-2 mg- 100 mcg-100 mg-150 mcg- 2.3 mg-3 mg-5 mcg-10 150 mcg-200 mcg-210 mg- mcg-10 mg-11 mg-20 mg- 600 mcg-600 unit-3500 25 mcg-30 mcg-30 mcg-45 unit, 0.9 mg-1.5 mg-1.5 mcg-45 mcg-50 mg-50 unit- mg-1.7 mg-1.7 mg-2 mg-2 55 mcg-72 mg-80 mg-90 mg-2.3 mg-3 mg-3 mg-5 mg-150 mcg-150 mcg-220 Nebraska Total Care Formulary September 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-250 mcg-300 mcg-500 40 mg-40 mg-40 mg-50 mcg-500 unit-2500 unit, 0.9 mcg-50 mcg-50 unit-75 mg-1.7 mg-2 mg-2 mg-2.3 mcg-100 mg-100 mg-200 mg-5 mcg-6 mcg-10 mcg- mcg-200 unit-250 mcg-250 10 mg-18 mg-20 mg-25 mg-5000 unit, 1 mg-1 mg- mcg-1.5 mg-10 mcg-11 1.5 mg-1.7 mg-3 mcg-5 mg-30 mcg-30 unit-35 mg-10 unit-20 mg-50 mg- mcg-45 mcg-55 mcg-72 100 mcg-125 mg-150 mcg- mg-80 mg-90 mg-100 mg- 400 unit-5000 unit, 1 mg-1 109 mg-150 mcg-150 mcg- mg-2 mg-2.5 mg-2.5 mg-5 200 mg-250 mcg-300 mcg- mcg-5 mg-5 mg-7.5 mg-10 400 unit-500 mcg-3500 mcg-12.5 mg-12.5 mg-13.5 unit, 0.9 mg-2 mg-1.5 mg- mcg-25 mcg-25 mcg-37.5 1.7 mg-2 mg-2.3 mg-5 mcg-40 mg-40 mg-40 mg- mcg-6 mcg-10 mcg-10 40 mg-40 mg-40 mg-40 mcg-10 mg-11 mg-18 mg- mg-50 mcg-50 mcg-50 mg- 20 mg-25 mcg-30 mcg-30 50 unit-75 mcg-100 mg-200 unit-35 mcg-45 mcg-55 mg-200 unit-250 mcg-250 mcg-72 mg-80 mg-90 mg- mg-5000 unit, 1 mg-1 mg-5 100 mg-109 mg-150 mcg- mg-5 mg-6 mg-7.5 mg-10 150 mcg-200 mg-250 mcg- mg-15 mg-18 mg-25 mcg- 300 mcg-400 unit-500 mcg- 25 mg-25 mg-25 mg-25 3500 unit, 1 mcg-1 mg-1 mg-25 mg-25 mg-25 unit- mg-1 mg-2 mg-2.5 mg-3.75 30 mcg-35 mg-50 mcg-50 mg-4.5 mg-5 mcg-5 mcg- mg-50 mg-75 mcg-100 10 mg-10 mg-19 mg-20 mcg-100 mcg-100 mg-150 mg-50 mg-150 mcg-400 mcg-150 mcg-150 mg-250 unit-5000 unit, 1 mcg-1 mg- mcg-400 mcg-400 unit- 1 mg-1 mg-2 mg-2.5 mg- 10000 unit, 1 mg-1.5 mg- 3.75 mg-4.5 mg-5 mcg-5 1.7 mg-2 mg-5 mg-5 mg-6 mcg-10 mg-11.6 mg-15.8 mcg-10 mg-15 mg-30 unit- mg-20 mg-50 mg-150 mcg- 50 mg-60 mg-200 mcg-200 400 unit-5000 unit, 1 mg- mg-300 mcg-400 mcg-1000 0.5 mg-0.5 mg-1 mg-1 mg- unit-2500 unit, 1 mg-1.5 1 mg-1 mg-2 mg-2 mg-2 mg-2.5 mg-2.5 mg-2.5 mg- mg-3.5 mg-4.5 mg-5 mg- 3.75 mg-4 mcg-4 mg-5 mg- 5.1 mg-6 mg-6.5 mcg-7.5 5 mg-5 mg-5 mg-7.5 mg- mg-10 mg-10 mg-10 mg-13 7.5 unit-12.5 mg-15 mg-15 mcg-13 mcg-15 mg-18 mg- mg-25 mg-25 mg-30 mg-50 24 mcg-25 mg-25 mg-40 mg-64 mg-100 mcg-130 mg-60 mcg-60 unit-80 mg-500 unit-2500 mcg- mcg-80 mg-90 mg-100 mg- 2500 unit, 1 mg-1.67 mg- 100 mg-120 mg-150 mcg- 1.67 mg-1.67 mg-1.67 mg- 165 mg-200 mcg-200 mcg- 2.5 mg-2.67 mcg-4.17 mcg- 200 mcg-275 mcg-300 4.17 mg-5 mg-5 unit-8.33 mcg-400 mcg-400 unit- mg-8.33 mg-8.33 mg-8.33 5000 unit, 1 mg-1 mg-1 mg-10 mg-10 mg-20 mg-25 mg-1 mg-2.5 mg-5 mg-5 mg-33.33 mg-33.33 unit- mg-7.5 mg-10 mcg-12.5 37.5 mcg-50 mg-66.67 mg-12.5 mg-13.5 mg-25 mcg-66.67 mcg-100 mg- mcg-25 mg-37.5 mcg-40 1666.67 unit, 1 mg-10 mg- mcg-40 mcg-40 mg-40 mg- 25 mg-25 mg-25 mg-25 Nebraska Total Care Formulary September 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-33 mg-50 mcg-50 mg- mg-5 mg-8 mg-0.5 mg-2.3 60 mg-100 unit-125 mg- mg-5 mg-14 mg-15 mg- 200 unit-300 mcg-500 mg- 15.8 mg-20 mg-22 mcg-25 5000 unit, 1 mg-2 mg-3.5 mcg-30 mcg-50 mcg-50 mg-4.5 mg-5 mg-5 mg-5 mcg-50 mcg-52 mcg-72 mg-5.1 mg-6 mg-6.5 mcg- mg-80 mg-100 mg-100 mg- 7.5 mg-10 mg-10 mg-10 150 mcg-300 mcg-300 mg- mg-10 mg-13 mcg-13 mcg- 400 mcg-1050 mcg, 1.1 15 mg-18 mcg-18 mg-25 mg-1.35 mg-2 mg-5 mg-5 mg-25 mg-40 mg-60 mcg- mg-6.5 mg-10 mg-10 mg- 60 unit-72 mg-80 mcg-80 12 mcg-15 mg-20 mg-30 mg-80 mg-100 mg-120 mg- mg-30 unit-50 mg-75 mg- 150 mcg-165 mg-200 mcg- 100 mg-100 mg-150 mcg- 200 mcg-200 mcg-200 150 mg-400 mcg-400 unit- mcg-275 mcg-300 mcg-400 5000 unit, 1.2 mg-1.7 mg-2 mcg-400 unit-5000 unit, 1 mg-2 mg-3 mg-5 mg-15 mg-2 mg-3.5 mg-4.5 mg-5 mg-16 mg-18 mcg-20 mcg- mg-5 mg-5 mg-5.1 mg-6 22.5 unit-30 mcg-60 mg- mg-6.5 mcg-7.5 mg-10 mg- 100 mg-110 mcg-120 mcg- 10 mg-10 mg-10 mg-13 120 mg-210 mg-300 mcg- mcg-13 mcg-18 mcg-18 400 mcg-700 unit-3500 mg-25 mg-25 mg-40 mg-60 unit, 1.2 mg-1.7 mg-2 mg-2 mcg-60 unit-72 mg-80 mg- mg-3 mg-5 mg-15 mg-16 80 mg-100 mg-120 mg-150 mg-18 mcg-20 mcg-22.5 mcg-165 mg-200 mcg-200 unit-30 mcg-60 mg-110 mcg-200 mcg-200 mcg-275 mcg-120 mcg-120 mg-210 mcg-300 mcg-400 mcg-400 mg-300 mcg-400 mcg-700 unit-5000 unit-80 mcg-15 unit-3500 unit, 1.2 mg-1.7 mg, 1 mg-2.5 mg-2.5 mg-5 mg-2 mg-2 mg-3 mg-5 mg- mcg-5 mg-5 mg-5 mg-5 15 mg-16 mg-18 mcg-20 mg-12.5 mg-15 mcg-15 mcg-30 mcg-45 unit-90 mg- mg-15 mg-15 mg-15 mg-15 100 mg-105 mcg-120 mcg- mg-15 mg-15 mg-25 mcg- 120 mg-210 mg-400 mcg- 25 mg-25 mg-25 mg-25 400 unit-600 mcg-3500 mg-35 mg-35 mg-37.5 unit, 1.2 mg-1.7 mg-2 mg-2 mcg-50 mcg-50 mg-50 mg-3 mg-5 mg-15 mg-16 unit-75 mcg-100 mg-100 mg-18 mcg-20 mcg-30 unit-125 mcg-150 mg-175 mcg-45 unit-90 mg-99 mg- mcg-200 mcg-250 mcg- 105 mcg-120 mcg-120 mg- 5000 unit-35 mg-12.5 mg, 210 mg-400 mcg-400 unit- 1 mg-2.5 mg-5 mg-5 mg- 600 mcg-3500 unit, 1.2 mg- 12.5 mg-15 mcg-15 mg-15 1.7 mg-2 mg-2 mg-3 mg-5 mg-15 mg-2.5 mg-5 mg-5 mg-15 mg-18 mcg-18 mg- mg-5 mcg-12.5 mg-15 mg- 20 mcg-30 mcg-45 unit-90 15 mg-15 mg-15 mg-25 mg-100 mg-105 mcg-120 mcg-25 mg-25 mg-25 mg- mcg-120 mg-210 mg-400 25 mg-35 mg-35 mg-35 mcg-400 unit-600 mcg- mg-37.5 mcg-50 mcg-50 1500 unit, 1.2 mg-1.7 mg-5 mg-50 unit-75 mcg-100 mg-2 mg-2 mg-3 mg-15 mg-100 unit-125 mcg-150 mg-16 mg-18 mcg-20 mcg- mg-175 mcg-200 mcg-250 30 mcg-45 unit-90 mg-100 mcg-5000 unit, 1.1 mg-1.1 mg-105 mcg-120 mcg-120 Nebraska Total Care Formulary September 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-210 mg-400 mcg-400 mcg-200 mg-200 mg-250 unit-600 mcg-3500 unit, mcg-250 mcg-300 mcg-300 1.333 mg-0.333 mg-0.333 mcg-400 mcg-400 mcg-400 mg-0.833 mg-1.333 mg- unit-400 unit-3500 unit- 1.666 mg-1.666 mg-1.666 3500 unit, 1.5 mg-1.5 mg- mg-3.333 mg-3.333 mg- 1.7 mg-1.7 mg-2 mg-2 mg- 3.333 mg-3.333 mg-3.333 2 mg-2 mg-2 mg-6 mcg-6 mg-3.333 mg-3.333 mg- mcg-10 mcg-10 mcg-10 3.333 mg-5 mg-5 mg-6.666 mcg-10 mcg-10 mg-10 mg- mg-6.666 mg-6.666 mg- 15 mg-15 mg-20 mcg-20 8.333 mcg-8.333 mg-8.333 mcg-20 mg-20 mg-25 mcg- mg-8.333 mg-8.333 mg- 25 mcg-30 mcg-30 mcg-30 8.333 mg-8.333 mg-8.333 unit-30 unit-60 mg-60 mg- mg-8.333 mg-8.333 mg- 72 mg-72 mg-75 mcg-75 8.333 mg-8.333 mg-8.333 mcg-80 mg-80 mg-100 mg- mg-8.333 mg-10 mg- 100 mg-120 mcg-120 mcg- 11.666 mg-16.666 mcg- 150 mcg-150 mcg-150 16.666 mcg-16.666 mg-20 mcg-150 mcg-162 mg-162 mg-25 mcg-33.333 mcg- mg-250 mcg-250 mcg-300 33.333 mg-33.333 mg- mcg-300 mcg-400 mcg-400 33.333 mg-33.333 mg- mcg-400 unit-400 unit-3500 33.333 mg-33.333 mg-50 unit-3500 unit, 1.5 mg-1.5 mcg-83.333 mg-83.333 mg-1.7 mg-1.7 mg-2 mg-2 unit-133.333 mcg-133.333 mg-6 mcg-6 mcg-10 mg-10 unit-333.333 mg-333.333 mg-15 mg-15 mg-20 mg-20 mg-5000 unit, 1.35 mg-1.7 mg-27 mg-27 mg-30 unit- mg-2 mg-2 mg-3 mg-15 30 unit-60 mg-60 mg-400 mg-16 mg-18 mcg-18 mg- mcg-400 mcg-400 unit-400 20 mcg-22.5 unit-60 mg-75 unit-450 mg-450 mg-5000 mcg-110 mcg-120 mcg-140 unit-5000 unit, 1.5 mg-1.5 mg-210 mg-300 mcg-400 mg-1.7 mg-2 mg-2.3 mg-3 mcg-700 unit-3500 unit, mg-5 mcg-10 mcg-10 mg- 1.35 mg-1.7 mg-2 mg-2 12 mg-20 mg-30 mcg-30 mg-3 mg-15 mg-18 mcg-18 mcg-35 mcg-45 mcg-50 mg-20 mcg-22.5 unit-110 mg-50 unit-72 mg-80 mg- mcg-120 mcg-140 mg-210 90 mg-110 mg-150 mcg- mg-16 mg-60 mg-75 mcg- 150 mcg-220 mg-250 mcg- 300 mcg-400 mcg-700 unit- 300 mcg-500 mcg-600 3500 unit, 1.5 mg-1.5 mg- mcg-600 unit-2500 unit, 1.5 1.7 mg-1.7 mg-2 mg-2 mg- mg-1.5 mg-5 mg-15 unit-20 2 mg-2 mg-2 mg-3 mg-3 mg-20 mg-30 mg-50 mcg- mg-5 mcg-5 mcg-10 mcg- 400 mcg-400 unit-2500 10 mcg-10 mcg-10 mcg-10 unit-30 mg, 1.5 mg-1.7 mg- mg-10 mg-15 mg-15 mg-20 2 mcg-2 mg-2 mg-2.5 mg-5 mcg-20 mcg-20 mg-20 mg- mcg-6 mcg-10 mcg-10 25 mcg-25 mcg-30 mcg-30 mcg-10 mg-15 mg-18 mg- mcg-45 unit-45 unit-48 mg- 20 mcg-20 mg-25 mcg-25 48 mg-60 mg-60 mg-72 mcg-25 mcg-30 mcg-30 mg-72 mg-75 mcg-75 mcg- unit-36.3 mg-40 mg-60 mg- 80 mg-80 mg-100 mg-100 100 mg-109 mg-150 mcg- mg-150 mcg-150 mcg-150 150 mcg-162 mg-400 mcg- mcg-150 mcg-150 mcg-150 400 unit-5000 unit, 1.5 mg- Nebraska Total Care Formulary September 1, 2021

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1.7 mg-2 mg-2 mg-10 mg- 77 mg-100 mg-100 mg-120 15 mg-20 mg-25 mg-2 mg- mcg-120 mg-150 mcg-150 9 mg-12 mcg-25 mg-30 mcg-250 mcg-400 mcg-400 mcg-50 unit-70 mcg-75 unit-3000 unit, 1.5 mg-1.7 mcg-80 mcg-100 mg-120 mg-2 mg-2 mg-2 mg-3 mg- mcg-120 mg-150 mcg-275 5 mcg-10 mcg-10 mcg-10 mcg-400 mcg-400 unit- mg-15 mg-20 mcg-20 mg- 5000 unit-225 mg-150 mcg, 25 mcg-30 mcg-45 unit-48 1.5 mg-1.7 mg-2 mg-2 mg- mg-60 mg-72 mg-75 mcg- 2 mg-2 mg-5 mcg-6 mcg- 80 mg-100 mg-150 mcg- 10 mcg-10 mcg-10 mg-15 150 mcg-150 mcg-200 mg- mg-18 mg-20 mcg-20 mg- 250 mcg-300 mcg-400 25 mcg-30 mcg-30 unit-60 mcg-400 unit-3500 unit, 1.5 mg-72 mg-75 mcg-80 mg- mg-1.7 mg-2 mg-2 mg-2 100 mg-108 mg-120 mcg- mg-3 mg-5 mcg-10 mcg-10 150 mcg-150 mcg-162 mg- mcg-10 mg-15 mg-20 mcg- 250 mcg-400 mcg-400 unit- 20 mg-25 mcg-30 mcg-45 5000 unit, 1.5 mg-1.7 mg-2 unit-48 mg-60 mg-72 mg- mg-2 mg-2 mg-2 mg-5 75 mcg-80 mg-100 mg-150 mcg-6 mcg-10 mcg-10 mcg-150 mcg-150 mcg-200 mcg-10 mg-15 mg-18 mg- mg-250 mcg-400 mcg-400 20 mcg-20 mg-25 mcg-30 unit-5000 unit, 1.5 mg-1.7 mcg-30 unit-60 mg-72 mg- mg-2 mg-2 mg-2 mg-3.5 75 mcg-80 mg-100 mg-109 mg-5 mcg-6 mcg-10 mcg- mg-120 mcg-150 mcg-150 10 mcg-10 mcg-15 mg-18 mcg-162 mg-250 mcg-300 mg-20 mcg-20 mg-25 mcg- mcg-400 mcg-400 unit- 30 mcg-30 unit-60 mg-65 3500 unit, 1.5 mg-1.7 mg-2 mcg-72 mg-80 mg-100 mg- mg-2 mg-2 mg-2 mg-5 109 mg-150 mcg-150 mcg- mcg-6 mcg-10 mcg-10 160 mcg-162 mg-400 mcg- mcg-10 mg-15 mg-20 mcg- 400 unit-2500 unit, 1.5 mg- 20 mg-30 mcg-30 unit-60 1.7 mg-2 mg-2 mg-2 mg- mg-72 mg-75 mcg-80 mg- 3.5 mg-5 mcg-6 mcg-10 100 mg-109 mg-120 mg- mcg-10 mcg-10 mg-15 mg- 150 mcg-150 mcg-162 mg- 18 mg-20 mcg-20 mg-25 250 mcg-300 mcg-400 mcg-30 mcg-30 unit-50 mg- mcg-400 unit-3500 unit, 1.5 65 mcg-72 mg-80 mg-100 mg-1.7 mg-2 mg-2 mg-2 mg-109 mg-150 mcg-150 mg-2 mg-5 mcg-6 mcg-10 mcg-160 mcg-162 mg-400 mcg-10 mcg-10 mg-18 mg- mcg-400 unit-2500 unit, 1.5 20 mcg-20 mg-25 mcg-30 mg-1.7 mg-2 mg-2 mg-2 mcg-30 unit-60 mg-72 mg- mg-3.5 mg-5 mcg-6 mcg- 75 mcg-80 mg-100 mg-108 10 mcg-10 mcg-10 mg-15 mg-120 mcg-150 mcg-150 mg-18 mg-20 mcg-20 mg- mcg-162 mg-250 mcg-400 25 mcg-30 mcg-30 unit-60 mcg-400 unit-5000 unit-15 mg-65 mcg-72 mg-80 mg- mg, 1.5 mg-1.7 mg-2 mg-2 100 mg-109 mg-150 mcg- mg-2 mg-2 mg-5 mcg-6 150 mcg-160 mcg-162 mg- mcg-9 mg-10 mcg-10 mcg- 400 mcg-400 unit-2500 10 mg-15 mg-20 mg-25 unit, 1.5 mg-1.7 mg-2 mg-2 mcg-25 mcg-25 mcg-30 mg-2 mg-3.5 mg-5 mcg-6 mcg-36 mg-40 mg-50 unit- mcg-10 mcg-10 mcg-10 Nebraska Total Care Formulary September 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-15 mg-18 mg-20 mcg- unit, 1.5 mg-1.7 mg-2 mg-2 20 mg-25 mcg-30 mcg-30 mg-2 mg-6 mcg-8 mg-8 unit-60 mg-65 mcg-72 mg- mg-9 mg-10 mcg-10 mg-15 80 mg-100 mg-109 mg-150 mcg-15 mcg-15 mg-20 mg- mcg-150 mcg-160 mcg-162 30 mcg-30 unit-40 mg-60 mg-400 mcg-400 unit-5000 mg-90 mg-150 mcg-400 unit, 1.5 mg-1.7 mg-2 mg-2 mcg-400 unit-5000 unit, 1.5 mg-2 mg-3.5 mg-5 mcg-6 mg-1.7 mg-2 mg-2 mg-2.5 mcg-10 mcg-10 mcg-10 mg-3 mg-4 mg-5 mcg-10 mg-15 mg-18 mg-20 mcg- mcg-10 mcg-10 mg-15 mg- 20 mg-25 mcg-30 mcg-30 20 mcg-20 mg-25 mcg-30 unit-60 mg-65 mcg-72 mg- mcg-45 unit-48 mg-60 mg- 80 mg-100 mg-109 mg-150 72 mg-80 mg-100 mg-130 mcg-150 mcg-160 mg-162 mcg-150 mcg-150 mcg-160 mg-400 mcg-400 unit-5000 mcg-200 mg-400 mcg-400 unit, 1.5 mg-1.7 mg-2 mg-2 unit-5000 unit, 1.5 mg-1.7 mg-2 mg-5 mg-6 mcg-10 mg-2 mg-2 mg-2.5 mg-5 mg-15 mg-18 mg-20 mcg- mcg-6 mcg-10 mcg-10 22.5 unit-25 mcg-30 mcg- mcg-10 mg-15 mcg-15 50 mg-60 mg-120 mcg-400 mcg-15 mcg-15 mg-18 mg- mcg-500 mg-1000 unit- 20 mg-25 mcg-30 unit-34 2500 unit, 1.5 mg-1.7 mg-2 mg-37.5 mg-45 mcg-60 mg-2 mg-2 mg-5 mg-6 mg-80 mcg-100 mg-125 mcg-10 mg-15 mg-18 mg- mg-150 mcg-162 mg-400 20 mcg-25 mcg-30 mcg-30 mcg-400 unit-6000 unit, 1.5 unit-50 mg-60 mg-120 mg-1.7 mg-2 mg-2 mg-2.5 mcg-400 mcg-400 unit-450 mg-5 mg-6 mcg-10 mcg-10 mg-2500 unit, 1.5 mg-1.7 mcg-10 mcg-10 mg-15 mg- mg-2 mg-2 mg-2 mg-5 mg- 18 mg-20 mg-25 mcg-25 6 mcg-10 mg-15 mg-18 mcg-25 mcg-25 mcg-30 mg-20 mcg-25 mcg-30 mcg-30 unit-36.3 mg-40 mcg-30 unit-50 mg-60 mg- mg-60 mg-100 mg-125 mg- 120 mcg-400 mcg-450 mg- 150 mcg-162 mg-400 mcg- 1000 unit-2500 unit, 1.5 400 unit-5000 unit, 1.5 mg- mg-1.7 mg-2 mg-2 mg-2 1.7 mg-2 mg-2 mg-2.5 mg- mg-5 mg-6 mcg-10 mg-15 6 mcg-10 mcg-10 mcg-10 mg-18 mg-20 mcg-25 mcg- mcg-10 mg-15 mg-20 mg- 30 mcg-30 unit-50 mg-60 30 mcg-30 unit-40 mg-60 mg-120 mcg-400 mcg-450 mg-100 mg-100 mg-130 mg-800 unit-2500 unit, 1.5 mg-150 mcg-400 mcg-400 mg-1.7 mg-2 mg-2 mg-2 unit-5000 unit, 1.5 mg-1.7 mg-6 mcg-10 mg-15 mg-18 mg-2 mg-2 mg-2.5 mg-6 mg-20 mcg-20 mg-22.5 mcg-10 mcg-10 mcg-10 unit-25 mcg-60 mg-120 mcg-10 mg-18 mg-20 mg- mcg-150 mcg-300 mcg-400 30 mcg-34 mg-37.5 mg-60 mcg-500 mg-1000 unit- mg-100 mg-100 mg-130 2500 unit, 1.5 mg-1.7 mg-2 mg-150 mcg-400 mcg-5000 mg-2 mg-2 mg-6 mcg-10 unit-400 unit-15 mg-30 unit, mg-20 mcg-20 mg-25 mcg- 1.5 mg-1.7 mg-2 mg-2 mg- 27 mg-30 mcg-60 mg-120 3 mg-3.5 mg-4 mg-5 mcg- mcg-400 mcg-400 unit-450 10 mcg-10 mcg-10 mg-15 mg-5250 unit-15 mg-30 mg-20 mcg-20 mg-25 mcg- Nebraska Total Care Formulary September 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 30 mcg-45 unit-48 mg-60 mg-0.5 mg-2.3 mg-5 mcg- mg-72 mg-80 mg-100 mg- 11 mg-20 mg-20 mg-25 130 mcg-150 mcg-150 mcg-30 mcg-30 mcg-45 mcg-160 mcg-200 mg-400 mcg-45 mcg-50 mg-50 unit- mcg-400 unit-5000 unit, 1.5 55 mcg-60 mg-80 mg-150 mg-1.7 mg-2 mg-2 mg-3 mcg-150 mcg-220 mg-250 mg-3.5 mg-4 mg-5 mcg-10 mcg-300 mcg-400 mcg-500 mcg-10 mcg-10 mg-15 mg- unit-2500 unit, 1.5 mg-1.7 20 mcg-20 mg-25 mcg-30 mg-2 mg-4 mg-4 mg-10 mcg-45 unit-48 mg-60 mg- mg-15 mg-18 mcg-20 mg- 72 mg-80 mg-100 mg-130 30 mcg-50 unit-70 mcg-75 mcg-150 mcg-150 mcg-160 mcg-80 mcg-100 mg-120 mg-200 mg-400 mcg-400 mcg-150 mcg-162 mg-180 unit-5000 unit, 1.5 mg-1.7 mg-400 mcg-1000 unit- mg-2 mg-2 mg-3 mg-4 mg- 2500 unit, 1.5 mg-1.7 mg-2 7.5 mcg-10 mg-10 mg-10 mg-4 mg-6 mg-10 mg-15 mg-10 mg-15 mcg-15 mcg- mg-20 mg-25 mcg-30 mcg- 15 mg-20 mg-22.5 mg-25 60 unit-70 mcg-75 mcg-80 mg-30 mcg-30 mcg-48 mg- mcg-100 mg-120 mcg-150 60 unit-75 mg-80 mg-100 mcg-180 mg-200 mg-400 mg-105 mcg-112.5 mcg- mcg-1000 unit-2500 unit, 120 mg-150 mcg-180 mg- 1.5 mg-1.7 mg-2 mg-4 mg- 200 mg-225 mcg-300 mcg- 6 mg-10 mg-15 mg-20 mg- 350 mcg-400 mcg-400 unit- 25 mcg-30 mcg-60 unit-75 3000 unit-3000 unit, 1.5 mcg-80 mcg-100 mg-105 mg-1.7 mg-2 mg-2 mg-4 mcg-120 mcg-150 mcg-162 mg-6 mcg-10 mg-15 mg-18 mg-180 mg-400 mcg-1000 mg-20 mg-30 mg-50 unit- unit-2500 unit, 1.5 mg-1.7 70 mcg-75 mcg-80 mcg- mg-2 mg-5 mcg-0.9 mg-2 100 mg-120 mcg-150 mcg- mg-2.3 mg-6 mcg-10 mcg- 162 mg-180 mg-400 mcg- 10 mcg-10 mg-11 mg-18 1000 unit-2500 unit, 1.5 mg-20 mg-25 mcg-30 mcg- mg-1.7 mg-2 mg-2 mg-6 30 unit-35 mcg-45 mcg-55 mcg-0.5 mg-2.3 mg-5 mcg- mcg-72 mg-80 mg-90 mg- 10 mcg-10 mcg-10 mg-11 100 mg-109 mg-150 mcg- mg-18 mg-20 mg-20 mg-25 150 mcg-200 mg-250 mcg- mcg-30 mcg-30 unit-35 300 mcg-400 unit-500 mcg- mcg-45 mcg-50 mg-55 3500 unit, 1.5 mg-1.7 mg-2 mcg-60 mg-72 mg-75 mcg- mg-5 mg-6 mcg-10 mg-15 80 mg-150 mcg-200 mg- mg-18 mg-30 unit-50 mg- 400 mcg-400 unit-3500 60 mg-400 mcg-400 unit- unit, 1.5 mg-1.7 mg-2 mg- 450 mg-2500 unit, 1.5 mg- 2.3 mg-3 mg-5 mcg-10 1.7 mg-2 mg-6 mcg-10 mg- mcg-11 mg-20 mg-30 mcg- 15 mg-20 mg-27 mg-30 30 mcg-45 mcg-45 mcg-0.9 unit-60 mg-400 mcg-400 mg-10 mg-25 mcg-50 mg- unit-450 mg-2500 unit-2500 50 unit-55 mcg-72 mg-80 unit, 1.5 mg-1.7 mg-2 mg-6 mg-90 mg-110 mg-150 mcg-10 mg-15 mg-20 mg- mcg-150 mcg-220 mg-250 27 mg-30 unit-60 mg-400 mcg-300 mcg-500 mcg-500 mcg-400 unit-450 mg-5000 unit-2500 unit, 1.5 mg-1.7 unit, 1.5 mg-1.7 mg-2 mg-6 mg-2 mg-3 mg-10 mcg-10 mcg-10 mg-18 mg-20 mg- Nebraska Total Care Formulary September 1, 2021

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 30 unit-60 mg-75 mg-400 mg-2.5 mg-9 mg-10 mcg- mcg-400 unit-5000 unit, 1.5 1.7 mg-3 mg-5 mcg-10 mg-1.7 mg-2 mg-6 mcg-10 mcg-10 mcg-10 mg-15 mg- mg-20 mg-30 unit-45 mg- 20 mg-25 mcg-25 mcg-25 60 mg-400 mcg-400 unit- mcg-30 mcg-45 unit-48 mg- 3000 unit, 1.5 mg-1.7 mg-2 60 mg-72 mg-80 mg-100 mg-6 mg-10 mcg-10 mg- mcg-100 mg-150 mcg-200 0.7 mg-4 mg-5 mcg-15 mg- mcg-200 mg-400 unit-6000 20 mg-20 mg-30 mcg-50 unit, 1.5 mg-2.3 mg-1.5 mcg-50 mg-60 mcg-60 mg-1.7 mg-2 mg-3 mg-5 mcg-60 unit-72 mg-80 mg- mcg-10 mcg-10 mg-12 mg- 100 mcg-100 mcg-120 mg- 20 mg-30 mcg-30 mcg-35 150 mcg-150 mcg-250 mg- mcg-45 mcg-50 mg-50 unit- 300 mcg-300 mcg-600 72 mg-80 mg-90 mg-110 mcg-600 unit-3500 unit, 1.5 mg-150 mcg-150 mcg-200 mg-1.7 mg-2.5 mg-2.5 mg- mcg-220 mg-250 mcg-300 5 mcg-7.5 mg-10 mg-20 mcg-500 mcg-600 unit- mg-25 mcg-30 unit-50 2500 unit, 1.6 mg-1.7 mg-2 mcg-50 mg-50 mg-60 mg- mg-2 mg-2 mg-5 mg-6 75 mcg-75 mcg-100 mcg- mcg-10 mg-15 mg-18 mg- 100 mg-100 mg-200 mcg- 20 mcg-22.5 unit-25 mcg- 200 unit-250 mcg-2500 30 mcg-50 mg-60 mg-120 unit, 1.5 mg-1.7 mg-6 mcg- mcg-400 mcg-500 mg-1000 10 mg-10 mg-12.5 mg-20 unit-2500 unit, 1.666 mg- mg-60 mg-300 mcg-800 0.666 mg-1 mg-1.666 mg- mcg, 1.5 mg-2 mg-0.5 mg- 1.666 mg-2.5 mg-2.666 1.7 mg-2 mg-2.3 mg-5 mcg-3.333 mg-3.333 mg- mcg-6 mcg-10 mcg-10 3.333 mg-3.333 mg-5 mg-5 mcg-10 mg-11 mg-18 mg- unit-8.333 mg-10 mg- 20 mg-20 mg-25 mcg-30 16.666 mg-16.666 mg-20 mcg-30 unit-35 mcg-45 mg-42.666 mg-66.666 mcg-50 mg-55 mcg-60 mg- mcg-86.666 mg-333.333 72 mg-75 mcg-80 mg-150 unit-1666.666 mcg- mcg-200 mg-400 mcg-400 1666.666 unit, 1.667 mg-1 unit-3500 unit, 1.5 mg-2 mg-1 mg-1.667 mg-1.667 mg-1.7 mg-2 mcg-2 mg-2.5 mg-1.667 mg-2.5 mg-2.667 mg-5 mcg-6 mcg-10 mcg- mcg-3.333 mg-4.167 mcg- 10 mg-18 mg-20 mcg-20 4.167 mg-5 mg-5 unit- mg-25 mcg-25 mcg-30 8.333 mg-8.333 mg-8.333 mcg-30 unit-10 mcg-15 mg-8.333 mg-10 mg-10 mg-25 mcg-36.3 mg-40 mg-25 mg-33.333 mg- mg-60 mg-100 mg-109 mg- 33.333 unit-37.5 mcg-40 150 mcg-150 mcg-162 mg- mg-50 mg-66.667 mcg- 400 mcg-400 unit-5000 244.333 mg-1000 mcg- unit, 1.5 mg-2 mg-2 mg-2.5 1666.667 unit, 1.67 mg-1 mg-6 mcg-10 mcg-10 mcg- mg-1.67 mg-1.67 mg-1.67 10 mcg-10 mg-15 mg-18 mg-2.5 mg-2.67 mcg-4.17 mg-20 mg-30 mcg-30 unit- mcg-4.17 mg-5 mg-5 unit- 34 mg-37.5 mg-60 mg-100 8.33 mg-8.33 mg-8.33 mg- mg-100 mg-130 mg-150 8.33 mg-10 mg-10 mg-20 mcg-400 mcg-400 unit- mg-25 mg-33.33 mg-33.33 5000 unit-1.7 mg, 1.5 mg-2 unit-37.5 mcg-50 mg-66.67 Nebraska Total Care Formulary September 1, 2021

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-66.67 mcg-100 mg- mcg-150 mcg-300 mg-400 1666.67 unit, 1.7 mg-0.9 mcg-400 unit-2500 unit, 1.9 mg-1.2 mg-1.3 mg-1.8 mg- mg-2 mg-2 mg-2.125 mg- 5 mg-6 mcg-7.5 mg-8 mg- 2.5 mg-7.5 mcg-12.5 mg- 16 mg-18 mg-25 mcg-25 15 mg-18 mg-25 mg-30 mcg-25 mcg-27.5 mcg-75 unit-32 mg-50 mg-60 mg- mg-150 mcg-380 mg-400 70 mcg-80 mcg-200 mcg- mcg-700 mcg-1000 mcg, 300 mg-400 mcg-400 unit- 1.7 mg-2 mg-2 mg-2 mg-5 2500 unit, 10 mcg-2 mg-2 mcg-5 mg-5 mg-10 mg-15 mg-6 mg-10 mg-10 mg-10 mg-15 mg-20 mcg-25 mcg- mg-15 mg-18 mg-25 mcg- 30 mcg-30 unit-50 mg-60 25 mg-30 mcg-60 unit-70 mg-120 mcg-400 mcg-450 mcg-75 mcg-100 mcg-100 mg-500 unit-2500 unit, 1.7 mcg-100 mg-100 mg-100 mg-2 mg-2 mg-2.5 mg-3 mg-100 mg-150 mcg-250 mg-5 mcg-6 mcg-10 mcg- mcg-400 mcg-2000 unit- 10 mcg-10 mcg-10 mg-15 3000 unit, 10 mg-1.5 mg- mg-18 mg-20 mg-25 mcg- 1.7 mg-6 mcg-10 mg-15 25 mcg-25 mcg-25 mcg-30 mg-20 mg-30 unit-70 mcg- mcg-30 unit-36.3 mg-40 80 mg-300 mcg-800 mcg- mg-60 mg-100 mg-125 mg- 2000 unit, 100 mcg-200 150 mcg-150 mcg-162 mg- unit-250 mg-5000 unit, 113 400 mcg-400 unit-5000 mg-0.4 mg-17.4 mg-100 unit, 1.7 mg-2 mg-2 mg-3 unit-7160 unit, 12 mg-1.25 mg-3.5 mg-4 mg-5 mcg-10 mg-1.3 mg-1.5 mg-13.5 mcg-10 mcg-10 mg-15 mg- mg-15 mg-25 mg-30 unit- 15 mg-20 mcg-20 mg-25 50 mcg-60 mg-75 mg-200 mcg-30 mcg-45 unit-46 mg-500 mg-5000 unit, mg-60 mg-60 mg-72 mg- 166.667 mg-16.667 mcg-53 100 mg-130 mcg-150 mcg- mg-133.333 unit-8333.333 150 mcg-160 mcg-200 mg- unit, 166.667 mg-16.667 400 mcg-400 unit-5000 mcg-53.333 mg-133.333 unit, 1.8 mg-0.9 mg-1.1 unit-8333.333 unit, 17 mcg- mg-1.1 mg-2 mg-2 mg-5 53 mg-133 unit-167 mg- mcg-6 mcg-8 mg-10 mcg- 8333 unit, 2 mg-0.5 mg-1.1 10 mcg-14 mg-15 mg-18 mg-1.1 mg-2.3 mg-5 mcg-5 mg-20 mg-25 mcg-35 unit- mg-5 mg-8 mg-10 mcg-14 40 mcg-50 mcg-50 mcg-55 mg-15 mg-20 mg-30 mcg- mcg-72 mg-75 mg-80 mg- 35 unit-50 mcg-50 mcg-50 100 mg-150 mcg-150 mcg- mcg-50 mcg-50 mg-55 400 mcg-500 mg-800 unit- mcg-72 mg-80 mg-100 mg- 3500 unit, 1.9 mg-2 mg-2 150 mcg-150 mcg-300 mg-2.1 mg-2.5 mg-7.5 mcg-400 mcg-500 mg-800 mcg-10 mg-12.5 mg-15 unit-3500 unit, 2 mg-0.5 mg-18 mg-25 mg-30 unit- mg-1.5 mg-1.7 mg-2 mg- 50 mg-60 mg-70 mcg-80 2.3 mg-5 mcg-6 mcg-10 mcg-200 mcg-200 mg-400 mcg-10 mcg-10 mg-11 mg- mcg-400 unit-2500 unit, 1.9 15 mg-18 mg-20 mg-20 mg-2 mg-2 mg-2.1 mg-2.5 mg-25 mcg-30 mcg-30 unit- mg-7.5 mcg-12.5 mg-15 35 mcg-45 mcg-50 mg-55 mg-18 mg-25 mg-30 unit- mcg-72 mg-75 mcg-80 mg- 50 mg-60 mg-70 mcg-80 150 mcg-200 mg-400 mcg- Nebraska Total Care Formulary September 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 400 unit-3500 unit-60 mg, 2 20 mg-25 mcg-30 mcg-30 mg-0.5 mg-1.5 mg-1.7 mg- mcg-45 mcg-45 mg-50 mg- 2 mg-2.3 mg-5 mcg-6 mcg- 50 unit-55 mcg-60 mg-72 10 mcg-10 mcg-10 mg-11 mg-80 mg-150 mcg-150 mg-18 mg-20 mg-20 mg-25 mcg-220 mg-250 mcg-300 mcg-30 mcg-30 unit-35 mcg-400 mcg-500 unit- mcg-45 mcg-50 mg-55 2500 unit, 2 mg-0.6 mg-1.2 mcg-60 mg-72 mg-75 mcg- mg-1.7 mg-2 mg-3 mg-5 80 mg-150 mcg-200 mg- mg-15 mg-16 mg-18 mcg- 400 mcg-400 unit-3500 20 mcg-30 mcg-45 unit-90 unit, 2 mg-0.5 mg-1.5 mg- mg-100 mg-105 mcg-120 1.7 mg-2 mg-2.3 mg-5 mcg-120 mg-210 mg-400 mcg-6 mcg-10 mcg-10 mcg-400 unit-3500 unit, 2 mcg-11 mg-18 mg-20 mg- mg-0.9 mg-1.2 mg-1.3 mg- 20 mg-25 mcg-30 unit-35 2 mg-2.3 mg-5 mcg-6 mcg- mcg-45 mcg-50 mg-55 8 mg-10 mcg-10 mcg-11 mcg-72 mg-10 mg-30 mcg- mg-15 mg-16 mg-20 mg-35 60 mg-75 mcg-80 mg-150 mcg-40 mcg-45 unit-50 mcg-200 mg-400 mcg-400 mcg-60 mcg-72 mg-80 mg- unit-3500 unit, 2 mg-0.5 90 mg-100 mcg-100 mg- mg-1.5 mg-1.7 mg-2.3 mg- 150 mcg-150 mcg-200 3 mg-5 mcg-10 mcg-10 mcg-210 mg-600 mcg-600 mg-11 mg-12.5 mcg-20 unit-3500 unit, 2 mg-0.9 mg-20 mg-22.75 mg-25 mg-1.5 mg-1.7 mg-2 mg- mcg-30 mcg-30 mcg-45 2.3 mg-5 mcg-6 mcg-10 mcg-45 mcg-50 mg-55 mcg-10 mcg-10 mg-11 mg- mcg-60 mg-72 mg-80 mg- 18 mg-20 mg-20 mg-25 150 mcg-150 mcg-220 mg- mcg-30 mcg-30 unit-35 250 mcg-300 mcg-400 mcg-45 mcg-50 mg-55 mcg-750 mcg, 2 mg-0.5 mcg-60 mg-72 mg-75 mcg- mg-1.5 mg-1.7 mg-2.3 mg- 80 mg-150 mcg-200 mg- 3 mg-5 mcg-10 mcg-10 400 mcg-400 unit-3500 mg-11 mg-20 mg-20 mg-25 unit, 2 mg-0.9 mg-1.5 mg- mcg-30 mcg-30 mcg-45 1.7 mg-2 mg-2.3 mg-5 mcg-45 mcg-50 mg-50 mcg-6 mcg-10 mcg-10 unit-55 mcg-60 mg-72 mg- mcg-10 mg-11 mg-18 mg- 80 mg-100 mcg-150 mcg- 20 mg-25 mcg-30 mcg-30 220 mg-250 mcg-300 mcg- unit-35 mcg-45 mcg-55 400 mcg-500 unit-2500 mcg-72 mg-80 mg-90 mg- unit, 2 mg-0.5 mg-1.5 mg- 100 mg-109 mg-150 mcg- 1.7 mg-2.3 mg-3 mg-5 150 mcg-200 mg-250 mcg- mcg-10 mcg-10 mg-11 mg- 300 mcg-400 unit-500 mcg- 20 mg-20 mg-25 mcg-30 3500 unit, 2 mg-0.9 mg-1.5 mcg-30 mcg-45 mcg-45 mg-1.7 mg-2.3 mg-3 mg-5 mcg-50 mg-50 unit-55 mcg-10 mcg-10 mg-11 mg- mcg-60 mg-72 mg-80 mg- 20 mg-25 mcg-30 mcg-30 150 mcg-150 mcg-220 mg- mcg-45 mcg-45 mcg-50 250 mcg-300 mcg-400 mg-50 unit-55 mcg-72 mg- mcg-500 unit-2500 unit, 2 80 mg-90 mg-110 mg-150 mg-0.5 mg-1.5 mg-1.7 mg- mcg-150 mcg-220 mg-250 2.3 mg-3 mg-5 mcg-10 mcg-300 mcg-500 mcg-500 mcg-10 mg-11 mg-20 mg- unit-2500 unit, 2 mg-0.9 Nebraska Total Care Formulary September 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-1.5 mg-1.7 mg-2.3 mg- 250 mcg-300 mcg-400 3 mg-5 mcg-10 mcg-10 mcg-400 unit-3500 unit, 2 mg-20 mg-25 mcg-30 mcg- mg-1.5 mg-1.7 mg-2 mg-2 30 mcg-45 mcg-45 mcg-50 mg-3.5 mg-5 mcg-6 mcg- mg-50 unit-55 mcg-72 mg- 10 mcg-10 mcg-10 mg-15 80 mg-90 mg-110 mg-150 mg-18 mg-20 mcg-20 mg- mcg-150 mcg-220 mg-250 25 mcg-30 mcg-30 unit-60 mcg-300 mcg-500 mcg-500 mg-65 mcg-72 mg-80 mg- unit-2500 unit-11 mg, 2 100 mg-109 mg-150 mcg- mg-1.35 mg-1.7 mg-2 mg-3 150 mcg-160 mcg-162 mg- mg-15 mg-16 mg-18 mcg- 400 mcg-400 unit-2500 18 mg-20 mcg-22.5 unit-60 unit, 2 mg-1.5 mg-1.7 mg-2 mg-75 mcg-110 mcg-120 mg-2 mg-3.5 mg-5 mcg-6 mcg-140 mg-210 mg-300 mcg-10 mcg-10 mcg-10 mcg-400 mcg-700 unit- mg-15 mg-18 mg-20 mcg- 3500 unit, 2 mg-1.5 mg-1.7 20 mg-25 mcg-30 mcg-30 mg-2 mg-2 mg-2 mg-5 unit-60 mg-65 mcg-72 mg- mcg-6 mcg-10 mcg-10 80 mg-100 mg-109 mg-150 mcg-10 mg-15 mg-18 mg- mcg-150 mcg-160 mcg-162 20 mcg-20 mg-25 mcg-30 mg-400 mcg-400 unit-600 mcg-30 unit-60 mg-72 mg- mcg-2500 unit, 2 mg-1.5 75 mcg-80 mg-100 mg-108 mg-1.7 mg-2 mg-2 mg-3.5 mg-120 mcg-150 mcg-150 mg-5 mcg-6 mcg-10 mcg- mcg-162 mg-250 mcg-400 10 mcg-10 mg-15 mg-18 mcg-400 unit-5000 unit, 2 mg-20 mcg-20 mg-25 mcg- mg-1.5 mg-1.7 mg-2 mg-2 30 mcg-30 unit-65 mcg-72 mg-2 mg-5 mcg-6 mcg-10 mg-80 mg-90 mg-100 mg- mcg-10 mcg-10 mg-15 mg- 125 mg-150 mcg-150 mcg- 18 mg-20 mcg-20 mg-25 160 mcg-162 mg-400 mcg- mcg-30 mcg-30 unit-60 400 unit-5000 unit, 2 mg- mg-72 mg-75 mcg-80 mg- 1.5 mg-1.7 mg-2 mg-2 mg- 100 mg-109 mg-120 mcg- 5 mg-6 mcg-10 mg-15 mg- 150 mcg-150 mcg-162 mg- 18 mg-20 mcg-22.5 unit-25 250 mcg-300 mcg-400 mcg-30 mcg-50 mg-60 mg- mcg-400 unit-3500 unit, 2 120 mcg-400 mcg-500 mg- mg-1.5 mg-1.7 mg-2 mg-2 1000 unit-2500 unit, 2 mg- mg-2 mg-5 mcg-6 mcg-10 1.5 mg-1.7 mg-2 mg-2 mg- mcg-10 mcg-10 mg-18 mg- 5 mg-6 mcg-10 mg-15 mg- 20 mg-25 mcg-25 mcg-30 18 mg-20 mcg-25 mcg-30 mcg-36 mg-40 mg-50 unit- mcg-30 unit-50 mg-60 mg- 77 mg-100 mcg-100 mg- 120 mcg-400 mcg-450 mg- 120 mcg-120 mg-150 mcg- 1000 unit-2500 unit, 2 mg-2 150 mcg-250 mcg-250 mg- mg-1.5 mg-1.7 mg-2 mg-9 400 mcg-3000 unit-400 mg-10 mg-12 mcg-15 mg- unit-15 mg, 2 mg-1.5 mg- 20 mg-25 mg-25 mg-30 1.7 mg-2 mg-2 mg-3 mg-5 mcg-50 unit-70 mcg-75 mcg-10 mcg-10 mcg-10 mcg-80 mcg-100 mg-120 mg-15 mg-20 mcg-20 mg- mcg-120 mg-150 mcg-150 25 mcg-30 mcg-45 unit-48 mcg-225 mg-275 mcg-400 mg-60 mg-72 mg-75 mcg- mcg-400 unit-5000 unit, 2 80 mg-100 mg-150 mcg- mg-2 mg-10 mcg-5 mg-5 150 mcg-150 mcg-200 mg- mg-5 mg-10 mg-15 mg-20 Nebraska Total Care Formulary September 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mcg-20 mg-30 mcg-30 mcg-800 unit-2500 unit, 2 mcg-30 unit-75 mcg-100 mg-2 mg-2.4 mg-2.7 mg- mg-100 mg-100 mg-100 3.2 mg-5 mg-9.5 mcg-10 mg-120 mcg-150 mcg-250 mg-15 mg-18 mg-20 mcg- mcg-400 mcg-3500 unit, 2 22.5 unit-25 mcg-30 mcg- mg-2 mg-2 mg-1.5 mg-1.7 50 mg-50 mg-60 mg-120 mg-2 mg-5 mcg-6 mcg-10 mcg-120 mg-300 mg-400 mcg-10 mcg-10 mg-15 mg- mcg-800 unit-2500 unit, 2 18 mg-20 mcg-20 mg-25 mg-2 mg-2.4 mg-2.7 mg- mcg-30 mcg-30 unit-60 3.2 mg-5 mg-9.5 mcg-10 mg-72 mg-75 mcg-80 mg- mg-15 mg-18 mg-20 mcg- 100 mg-109 mg-120 mcg- 25 mcg-30 mcg-30 unit-50 150 mcg-150 mcg-162 mg- mg-60 mg-120 mcg-180 250 mcg-300 mcg-400 mg-300 mg-400 mcg-800 mcg-400 unit-3500 unit, 2 unit-2500 unit, 2 mg-2 mg-3 mg-2 mg-2 mg-3 mg-3.4 mg-3 mg-3.4 mg-3.5 mg-5 mg-5 mcg-6 mg-7.5 mg-7.5 mcg-7.5 mg-7.5 mg-9 mcg- mg-9 mg-10 mcg-10 mcg- 10 mcg-10 mcg-10 mg-15 10 mg-12 mcg-15 mg-20 mg-18 mg-20 mg-21 mcg- mg-28 mcg-30 mcg-31 mg- 26 mcg-28 mcg-30 mcg-30 40 mg-50 mcg-60 unit-70 unit-31 mg-32 mcg-40 mg- mcg-75 mcg-90 mg-100 90 mg-100 mg-150 mcg- mg-150 mcg-150 mcg-400 150 mcg-400 mcg-400 unit- mcg-400 unit-5000 unit, 2 5000 unit, 2 mg-2 mg-3 mg-2 mg-2 mg-3 mg-3.4 mg-3.4 mg-4 mg-5 mcg-5 mg-5 mcg-6 mg-7.5 mg-7.5 mg-9 mg-10 mcg-10 mcg- mg-9 mg-10 mcg-10 mcg- 10 mg-12 mcg-15 mg-25 10 mg-12 mcg-15 mg-20 mcg-25 mcg-30 unit-40 mg- mg-28 mcg-30 mcg-31 mg- 40 mg-45 mcg-60 mg-90 40 mg-60 unit-70 mcg-75 mg-99 mg-100 mcg-150 mcg-100 mg-120 mcg-150 mcg-150 mcg-250 mg-300 mcg-150 mcg-250 mcg-400 mcg-400 mcg-400 unit- mcg-400 unit-5000 unit-90 3500 unit, 2 mg-2 mg-30 mg, 2 mg-2 mg-2 mg-5 unit-30 unit-40 mcg-40 mcg-10 mcg-10 mcg-10 mcg-40 mg-40 mg-60 mg- mg-10 mg-10 mg-18 mg-20 60 mg-5000 unit-5000 unit, mcg-25 mcg-30 unit-75 2 mg-2 mg-30 unit-40 mcg- mcg-109 mg-120 mcg-150 40 mg-60 mg-5000 unit, 2 mcg-150 mcg-250 mcg-300 mg-2 mg-40 mg-55 mcg-60 mcg-400 unit-3500 unit, 2 unit-1000 unit-200 mg, 2 mg-2 mg-2.2 mg-2.5 mg-3 mg-2 mg-40 mg-55 mcg-60 mg-9 mcg-15 mg-22.5 mg- unit-200 mg-1000 unit, 2 25 mcg-25 mg-45 unit-75 mg-2 mg-5 mg-5 mg-5 mg- mcg-90 mg-99 mg-100 mg- 10 mg-10 mg-10 mg-18 105 mcg-154 mg-200 mcg- mg-22.5 mg-25 mcg-30 200 mg-400 mcg-400 unit- mg-30 unit-75 mcg-100 450 mcg-2500 unit, 2 mg-2 mg-150 mg-150 mg-400 mg-2.3 mg-2.6 mg-3 mg-9 unit-5000 unit, 2 mg-2.25 mcg-10 mg-15 mg-18 mg- mg-2.6 mg-3 mg-5 mg-9 20 mcg-25 mcg-30 mg-30 mcg-10 mg-15 mg-20 mg- unit-50 mg-120 mcg-120 25 mcg-25 mcg-25 mcg-25 mg-300 mcg-300 mg-400 mcg-27 mg-27 mg-30 mg- Nebraska Total Care Formulary September 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 34 unit-45 mcg-90 mg-100 mg-50 unit-200 mg-6000 mg-125 mg-150 mcg-162 unit, 2 mg-3.4 mg-2 mg-2 mg-300 mcg-400 mcg-400 mg-3 mg-5 mcg-6 mg-7.5 unit-5000 unit, 2 mg-2.5 mg-7.5 mg-9 mg-10 mcg- mg-5 mcg-1.7 mg-2 mg-3 10 mcg-10 mg-12 mcg-15 mg-6 mcg-10 mcg-10 mcg- mg-20 mg-28 mcg-30 mcg- 10 mcg-10 mg-15 mg-18 31 mg-40 mg-50 mcg-60 mg-20 mg-25 mcg-25 mcg- unit-70 mcg-75 mcg-90 mg- 25 mcg-25 mcg-30 mcg-30 100 mg-150 mcg-150 mcg- unit-36.3 mg-40 mg-60 mg- 400 mcg-400 unit-5000 100 mg-125 mg-150 mcg- unit, 2 mg-3.4 mg-2 mg-3 150 mcg-162 mg-400 mcg- mg-3 mg-3.5 mg-5 mcg-7.5 400 unit-5000 unit, 2 mg-3 mg-7.5 mg-9 mcg-10 mcg- mg-1.1 mg-1.7 mg-2 mg-5 10 mcg-10 mg-15 mg-18 mg-10 mg-14 mg-15 mg-18 mg-20 mg-21 mcg-26 mcg- mcg-20 mcg-30 mcg-33 28 mcg-30 mcg-30 unit-31 unit-70 mcg-75 mg-100 mg-32 mcg-40 mg-90 mg- mg-120 mcg-120 mg-240 100 mg-150 mcg-150 mcg- mg-400 mcg-400 unit-3000 400 mcg-400 unit-5000 unit, 2 mg-3 mg-3 mg-3.4 unit, 2 mg-3.4 mg-4 mg-4.5 mg-5 mg-7.5 mg-7.5 mg-9 mg-6 mg-15 mg-20 mcg-20 mcg-10 mcg-10 mg-15 mcg-20 mg-22.5 mg-22.5 mcg-15 mcg-15 mcg-15 unit-25 mcg-30 mcg-50 mg- mg-18 mg-30 mg-30 unit- 60 mg-90 mcg-120 mg-150 31 mg-44 mg-100 mg-120 mcg-180 mcg-400 mcg-500 mg-150 mcg-400 mcg-400 mg-1000 unit-2500 unit, 2 unit-5500 unit, 2 mg-3 mg- mg-3.4 mg-4 mg-4.5 mg-6 3 mg-3.4 mg-5 mg-7.5 mg- mg-15 mg-20 mcg-20 mcg- 9 mcg-10 mcg-10 mg-15 20 mg-22.5 mg-25 mcg-30 mcg-15 mcg-15 mcg-15 mcg-33 unit-50 mg-60 mg- mg-18 mg-30 mg-30 unit- 90 mcg-100 mcg-120 mg- 31 mg-40 mg-100 mg-120 150 mcg-400 mcg-405 mg- mg-150 mcg-400 mcg-400 800 unit-2500 unit, 2 mg- unit-5500 unit, 2 mg-3 mg- 3.4 mg-4 mg-4.5 mg-6 mg- 3 mg-3.4 mg-5 mg-9 mcg- 15 mg-20 mcg-20 mcg-20 10 mcg-10 mg-10 mg-15 mg-22.5 mg-25 mcg-30 mcg-15 mcg-15 mcg-15 mcg-33 unit-50 mg-60 mg- mg-27 mg-30 mg-30 unit- 90 mcg-120 mg-150 mcg- 40 mg-100 mg-120 mg-150 180 mcg-400 mcg-405 mg- mcg-400 mcg-400 unit- 800 unit-2500 unit, 2 mg- 5500 unit, 2 mg-3 mg-5 3.4 mg-4 mg-4.5 mg-6 mg- mcg-5 mg-5 mg-5 mg-7 15 mg-20 mcg-20 mg-22.5 mg-7.5 mg-7.7 mg-10 mcg- mg-22.5 unit-25 mcg-30 10 mcg-10 mg-12 mcg-15 mcg-60 mg-90 mcg-100 mg-25 mcg-25 mg-30 mg- mg-110 mcg-120 mg-120 30 unit-40 mcg-50 mcg-50 mg-150 mcg-180 mcg-300 mcg-50 mcg-90 mg-100 mg-400 mcg-700 unit-2500 mg-125 mg-150 mcg-150 unit, 2 mg-3.4 mg-4 mg-4.5 mcg-162 mg-275 mcg-300 mg-6 mg-15 mg-20 mcg-20 mcg-400 mcg-400 unit- mg-22.5 mg-25 mcg-30 3500 unit, 2 mg-3 mg-5 mcg-33 unit-34 mg-40 mg- mg-5 mg-40 mcg-40 mg-40 90 mcg-100 mg-105 mcg- Nebraska Total Care Formulary September 1, 2021

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 120 mg-120 mg-150 mcg- unit-2000 unit-3000 unit, 2 180 mcg-400 mcg-400 unit- mg-5 mg-6 mcg-15 mg-18 2500 unit, 2 mg-3.4 mg-4 mg-30 mg-35 mg-65 mg- mg-4.5 mg-6 mg-15 mg-20 100 mg-125 mg-150 mcg- mcg-20 mg-22.5 mg-25 300 mcg-400 mcg, 2 mg-5 mcg-30 mcg-33 unit-40 mg-6 mcg-15 mg-30 mg-35 mg-90 mcg-100 mg-105 mg-100 mcg-100 mg-125 mcg-120 mg-120 mg-120 mg-150 mcg-400 mcg-500 mg-150 mcg-180 mcg-400 mg, 2 mg-6 mg-15 mg-30 mcg-400 unit-600 mcg- unit-60 mg, 2.1 mg-1.875 2500 unit, 2 mg-3.4 mg-4 mg-2 mg-2 mg-2.5 mg-5 mg-4.5 mg-6 mg-15 mg-20 mcg-7.5 mcg-10 mcg-10 mcg-20 mg-22.5 mg-30 mcg-10 mg-10 mg-10 mg- mcg-30 mcg-34 mg-37.5 10 mg-12.5 mg-15 mg-25 mg-60 unit-90 mcg-100 mg-25 mg-27 mg-36 mg- mg-105 mcg-120 mg-120 37.5 mcg-40 mg-45 unit-70 mg-150 mcg-180 mcg-400 mcg-75 mcg-77 mg-80 mcg-400 unit-5000 unit, 2 mcg-100 mg-120 mcg-120 mg-3.4 mg-4.5 mg-6 mg-15 mg-150 mcg-150 mcg-250 mg-20 mcg-22.5 mg-25 mg-300 mcg-400 mcg-400 mcg-4 mg-20 mcg-20 mg- unit-5000 unit, 2.1 mg-1.9 30 mcg-33 unit-50 mg-60 mg-2 mg-2 mg-2.5 mg-2.5 mg-90 mcg-120 mg-150 mg-5 mcg-7.5 mcg-10 mcg- mcg-180 mcg-400 mcg-405 10 mcg-12.5 mg-15 mg-18 mg-800 unit-2500 unit, 2 mg-25 mcg-25 mg-25 mg- mg-30 mg-40 mcg-40 mg- 37.5 mcg-45 unit-70 mcg- 60 mg-5000 unit, 2 mg-30 75 mcg-75 mg-77 mg-80 unit-40 mcg-40 mg-44 mg- mg-100 mg-120 mcg-120 60 mg-5000 unit, 2 mg-30 mg-150 mcg-150 mcg-162 unit-40 mcg-40 mg-60 mg- mg-300 mcg-400 mcg-400 1000 unit, 2 mg-30 unit-40 unit-2000 unit-3000 unit, mcg-40 mg-60 mg-5000 2.2 mg-3.4 mg-4.2 mg-4.5 unit, 2 mg-4 mg-4 mg-4.5 mg-6 mg-10 mg-20 mcg-20 mg-5 mcg-5.1 mg-6 mg-10 mg-24 mg-25 mcg-27 mcg- mcg-10 mcg-10 mg-15 mg- 30 mcg-30 unit-50 mg-90 16 mcg-18 mg-25 mcg-40 mcg-120 mg-150 mcg-180 mcg-40 mg-40 mg-48 mg- mcg-400 mcg-500 mg-1000 50 mg-60 mcg-60 mg-60 unit-3500 unit, 2.2 mg-3.4 unit-70 mcg-72 mg-75 mg-4.2 mg-4.5 mg-6 mg- mcg-80 mg-100 mg-120 11.6 mg-15 mg-17.5 mcg- mcg-120 mg-150 mcg-400 20 mcg-20 mg-24 mg-25 mcg-400 unit-3500 unit, 2 mcg-30 mcg-90 mcg-110 mg-4 mg-4 mg-4.5 mg-5 mg-117 mcg-120 mg-120 mcg-5.1 mg-6 mg-10 mcg- mg-150 mcg-180 mcg-370 10 mcg-10 mg-15 mg-18 mcg-400 mcg-1046 mcg, mg-21 mcg-25 mcg-25 mg- 2.2 mg-3.4 mg-4.2 mg-4.5 35 mg-40 mcg-40 mg-45 mg-6 mg-13.5 mg-15 mg- mg-48 mg-50 mg-60 mg-60 20 mcg-20 mg-24 mg-25 unit-70 mcg-72.5 mg-75 mcg-25 mcg-27 mcg-30 mcg-80 mg-100 mg-120 mcg-50 mg-90 mcg-120 mcg-120 mg-150 mcg-150 mg-150 mcg-180 mcg-400 mcg-250 mcg-400 mcg-400 mcg-500 mg-1050 mcg, 2.2 Nebraska Total Care Formulary September 1, 2021

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-3.4 mg-4.2 mg-4.5 mg- 2500 unit, 2.5 mg-1 mg-1 6 mg-15 mg-20 mcg-20 mg-2.5 mg-2.5 mg-9 mg-10 mg-24 mg-25 mcg-25.5 mg-10 mg-10 mg-11.25 unit-30 mcg-90 mcg-110 mg-12.5 mcg-15 mg-15 mg-117 mcg-120 mg-120 unit-37.5 mcg-50 mg-75 mg-150 mcg-180 mcg-370 mg-200 unit-300 mcg-2500 mcg-400 mcg-700 unit- unit, 2.5 mg-1.7 mcg-1.7 3500 unit, 2.2 mg-3.4 mg- mg-1.7 mg-2.5 mg-5 mg-5 4.2 mg-4.5 mg-6 mg-15 mg-5 unit-8.3 mcg-8.3 mg- mg-20 mcg-20 mg-24 mg- 16.7 mg-16.7 mg-28.3 mg- 25 mcg-27 mcg-30 mcg-30 33 unit-41.7 mg-66.7 mcg- unit-50 mg-90 mcg-120 83 mcg-83 mg-83 mg-250 mg-120 mg-150 mcg-180 mcg-833 unit, 20 mg-20 mcg-400 mcg-500 mg- mg-2.5 mg-5 mg-20 mg-25 1000 unit-3500 unit, 2.2 mg-25 mg-50 mcg-50 mcg- mg-3.4 mg-4.2 mg-4.5 mg- 50 mg-50 unit-66 mg-100 6 mg-15 mg-20 mcg-20 mg-200 mcg-200 mcg-400 mg-24 mg-25 mcg-27 mcg- unit-500 mg-1000 mcg- 30 mcg-30 unit-50 mg-90 5000 unit, 25 mcg-200 mg- mcg-120 mg-150 mcg-180 200 unit-10000 unit, 25 mg- mcg-400 mcg-500 mg- 1 mg-10 mg-25 mg-25 mg- 1000 unit-3500 unit, 2.2 25 mg-33 mg-50 mcg-50 mg-3.4 mg-4.2 mg-4.5 mg- mg-80 mg-100 unit-125 6 mg-15 mg-20 mcg-20 mg-200 unit-300 mcg-500 mg-24 mg-25 mcg-30 mcg- mg-5000 unit, 3 mg-0.05 30 unit-90 mcg-110 mg- mg-0.15 mg-1 mg-10 mg- 117 mcg-120 mg-120 mg- 15 mg-20 mcg-20 mg-20 150 mcg-180 mcg-370 mg-25 mg-25 mg-50 mcg- mcg-400 mcg-700 unit- 50 mcg-50 mg-60 unit-100 3500 unit, 2.2 mg-3.4 mg- mg-400 unit-500 mg, 3 mg- 4.2 mg-6 mg-15 mg-17.5 0.4 mg-2 mg-3 mg-3.4 mg- mcg-20 mcg-20 mg-25 5 mg-7.5 mg-7.5 mg-9 mcg-30 mcg-90 mcg-4.5 mcg-10 mcg-10 mg-15 mg-11.6 mg-24 mg-110 mcg-15 mcg-15 mg-20 mg- mg-117 mcg-120 mg-150 27 mg-30 mcg-30 unit-31 mcg-180 mcg-210 mg-370 mg-40 mg-90 mg-100 mg- mcg-400 mcg-1046 mcg, 150 mcg-400 unit-2500 2.3 mg-0.5 mg-1.7 mg-2 unit-2500 unit, 3 mg-0.5 mg-2 mg-1.5 mg-5 mcg-6 mg-1.5 mg-1.7 mg-2 mg- mcg-10 mcg-10 mcg-10 2.3 mg-5 mcg-10 mcg-10 mg-11 mg-18 mg-20 mg-20 mg-11 mg-20 mg-20 mg-25 mg-25 mcg-30 mcg-30 mcg-30 mcg-30 mcg-45 unit-35 mcg-45 mcg-50 mcg-45 mcg-50 mg-50 unit- mg-55 mcg-60 mg-72 mg- 55 mcg-60 mg-72 mg-80 75 mcg-80 mg-150 mcg- mg-150 mcg-150 mcg-220 200 mg-400 mcg-400 unit- mg-250 mcg-300 mcg-400 3500 unit, 2.5 mg-0.5 mg- mcg-500 unit-2500 unit, 3 0.75 mg-0.85 mg-6.25 mg-0.5 mg-1.7 mg-2 mg- mcg-7.5 mg-10 mg-30 unit- 2.3 mg-1.5 mg-5 mcg-10 50 mg-50 mg-60 mg-72.5 mcg-10 mg-11 mg-20 mg- mg-100 mcg-100 mg-250 20 mg-25 mcg-30 mcg-30 mcg-500 unit-1500 mcg- mcg-45 mcg-45 mcg-50 Nebraska Total Care Formulary September 1, 2021

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mg-50 unit-55 mcg-60 mg- mcg-500 mg, 3.3 mg-3.5 72 mg-80 mg-150 mcg-150 mg-5 mg-0.5 mg-0.6 mg-5 mcg-220 mg-250 mcg-300 mg-6.5 mg-7.2 mg-7.5 mg- mcg-400 mcg-500 unit- 10 mg-10 mg-10 mg-10 2500 unit, 3 mg-0.5 mg-2.3 mg-10 mg-15 mg-20 mg-25 mg-1.5 mg-1.7 mg-2 mg-5 mcg-25 mcg-25 mcg-25 mcg-10 mcg-10 mg-11 mg- mg-25 unit-50 mg-50 mg- 20 mg-20 mg-20 mg-25 50 unit-54 mg-73 mg-150 mcg-30 mcg-30 mcg-45 mcg-897 mcg-2500 unit, mcg-45 mcg-50 mg-50 3.333 mg-4.167 mcg-6 mg- unit-55 mcg-60 mg-72 mg- 7.5 mg-11.667 mg-16.667 80 mg-150 mcg-150 mcg- mg-16.667 mg-16.667 mg- 220 mg-250 mcg-300 mcg- 33.333 mcg-33.333 mcg- 400 mcg-500 unit-2500 33.333 mg-33.333 mg- unit, 3 mg-1.5 mg-1.7 mg-2 33.333 mg-33.333 mg-50 mg-2 mg-2 mg-10 mcg-10 mcg-66.667 mcg-66.667 mcg-15 mg-20 mcg-25 unit-83.333 mg-100 mcg- mcg-45 unit-60 mg-5 mcg- 133.333 unit-266.667 mcg- 20 mg-48 mg-10 mg-30 333.333 mg-1666.667 unit, mcg-72 mg-75 mcg-80 mg- 3.333 mg-4.167 mcg-7.5 100 mg-150 mcg-150 mcg- mg-11.667 mg-16.667 mg- 150 mcg-200 mg-250 mcg- 16.667 mg-16.667 mg- 400 mcg-400 unit-5000 33.333 mcg-33.333 mcg- unit, 3 mg-1.5 mg-1.7 mg-2 33.333 mg-33.333 mg- mg-2 mg-2 mg-5 mcg-10 33.333 mg-33.333 mg-50 mcg-10 mcg-10 mg-15 mg- mcg-66.667 mcg-66.667 20 mcg-20 mg-25 mcg-30 unit-83.333 mg-100 mcg- mcg-45 unit-48 mg-60 mg- 133.333 unit-266.667 mcg- 72 mg-75 mcg-80 mg-100 333.333 mg-1666.667 unit, mg-150 mcg-150 mcg-150 3.4 mg-2 mg-3 mg-3 mg-5 mcg-200 mg-250 mcg-300 mg-9 mcg-10 mcg-10 mg- mcg-400 mcg-400 unit- 10 mg-15 mcg-15 mcg-15 3500 unit, 3 mg-2 mg-2 mcg-15 mg-27 mg-30 mg- mg-3 mg-3.4 mg-3.5 mg-5 30 unit-40 mg-100 mg-120 mcg-7.5 mg-7.5 mg-9 mcg- mg-150 mcg-400 mcg-400 10 mcg-10 mcg-10 mg-15 unit-5500 unit, 4.5 mg-2 mg-18 mg-20 mg-21 mcg- mg-3.4 mg-4 mg-6 mg-15 26 mcg-28 mcg-30 mcg-30 mg-20 mcg-20 mcg-20 mg- unit-31 mg-32 mcg-40 mg- 22.5 mg-25 mcg-30 mcg-33 90 mg-100 mg-150 mcg- unit-50 mg-60 mg-90 mcg- 150 mcg-400 mcg-400 unit- 120 mg-150 mcg-180 mcg- 5000 unit, 3 mg-5 mg-10 400 mcg-405 mg-800 unit- mg-10 mg-12 mcg-20 mg- 2500 unit, 4.5 mg-2 mg-3.4 23.9 mg-30 unit-45 mcg- mg-4 mg-6 mg-15 mg-20 100 mg-400 mcg-500 mg, mcg-20 mg-22.5 mg-25 3 mg-5 mg-10 mg-10 mg- mcg-30 mcg-33 unit-40 mg- 12 mcg-20 mg-24 mg-30 90 mcg-100 mg-105 mcg- unit-45 mcg-77 mg-100 120 mg-120 mg-120 mg- mg-400 mcg-500 mg, 3 150 mcg-180 mcg-400 mg-5 mg-20 mcg-20 mg-20 mcg-400 unit-600 mcg- mg-20 mg-24 mg-46 mg-60 2500 unit, 40 mg-2 mg-30 mg-100 mcg-100 mg-400 unit-40 mcg-60 mg-5000 Nebraska Total Care Formulary September 1, 2021

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits unit, 5 mcg-6 mcg-0.5 mg- mcg-400 mcg-500 mg-700 2.3 mg-1.5 mg-1.7 mg-2 mcg-1000 unit-3500 unit, mg-2 mg-10 mcg-10 mcg- 50 mcg-100 unit-400 unit- 10 mg-11 mg-18 mg-20 10000 unit, 55 mcg-2 mg-2 mg-20 mg-25 mcg-30 mcg- mg-40 mg-60 unit-200 mg- 30 unit-35 mcg-45 mcg-50 1000 unit, 60 unit-2 mg-40 mg-55 mcg-60 mg-72 mg- mg-55 mcg-200 mg-1000 75 mcg-80 mg-150 mcg- unit 200 mg-400 mcg-400 unit- MULTIVITAMIN ADULT 1 3500 unit, 5 mg-0.667 mg- CHEW 3.333 mg-1.667 mg-5 mcg- MULTIVITAMIN ADULT 1 5 mg-16.667 mcg-16.667 EXTRAVITAMIN C CHEW mg-16.667 mg-16.667 mg- 16.667 mg-26.667 mg- QL(2 ea daily); 33.333 mcg-50 mcg-66.667 MULTIVITAMIN ADULTS 1 AL(At least 12 mg-66.667 mg-66.667 unit- TABS yrs old); 133.333 mg-133.333 mg- RX/OTC 133.333 unit-166.667 mg- QL(2 ea daily); 333.333 mcg-333.333 mg- MULTIVITAMIN MEN 1 AL(At least 12 1666.667 unit, 5 mg-1 mg- TABS yrs old); 1.25 mg-3.4 mg-25 mg-35 RX/OTC mg-35 mg-35 mg-35 mg-35 MULTIVITAMIN TABS 1 QL(2 ea daily); mg-70 mcg-125 mcg-125 MG-1 MG-1.5 MG-2 MG- AL(At least 12 mcg-125 unit-400 mcg-400 2.5 MG-5 MG-7.5 MCG-10 1 yrs old); unit-10 mg-75 mcg-150 MCG-10 MG-10 MG-15 RX/OTC mcg-500 mg, 5 mg-1 mg- MG-15 MG-100 MG-150 1.5 mg-1.7 mg-2 mg-2 mg- MCG-150 MG-3000 MCG 6 mcg-10 mg-15 mg-16 mg-20 mg-30 unit-45 mg- QL(2 ea daily); 60 mg-60 mg-150 mcg-400 MULTIVITAMIN WOMEN 1 AL(At least 12 mcg-400 unit-5000 unit, 5 TABS yrs old); mg-1 mg-5 mg-1.5 mg-1.7 RX/OTC mg-2 mg-6 mcg-7 mg-10 QL(2 ea daily); mg-15 mg-30 unit-50 mg- MULTIVITAMIN/ZINC 1 AL(At least 12 60 mg-200 mg-300 mcg- STRESSFORMULA TABS yrs old); 400 mcg-1000 unit-2500 RX/OTC unit, 5 mg-1.2 mg-1.7 mg-3 MVW COMPLETE 1 RX/OTC mg-2 mg-2 mg-15 mg-16 FORMULATION CAPS mg-18 mcg-20 mcg-30 MVW COMPLETE RX/OTC mcg-45 unit-90 mg-100 FORMULATIOND3000 1 mg-105 mcg-120 mcg-120 CAPS mg-210 mg-400 mcg-400 unit-600 mcg-3500 unit, 5 MVW COMPLETE RX/OTC mg-10 mg-10 mg-12 mcg- FORMULATIOND500 1 20 mg-30 unit-45 mcg-69 CAPS mg-100 mg-400 mcg-500 MVW COMPLETE RX/OTC mg, 5.1 mg-2 mg-2 mg-4.5 FORMULATIONMINIS 1 mg-6 mg-15 mg-15 mg-18 CAPS mcg-18 mg-20 mg-30 unit- 50 mg-60 mcg-60 mg-70 mcg-75 mcg-100 mcg-120 mcg-150 mcg-150 mcg-300 Nebraska Total Care Formulary September 1, 2021

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); QL(2 ea daily); NAT-RUL THERAVITE- AL(At least 12 1 ONCOVITE TABS 1 AL(At least 12 M/HIGHPOTENCY TABS yrs old); yrs old); RX/OTC RX/OTC QL(2 ea daily); ONE A DAY MENS AL(At least 12 VITACRAVES MULTI 1 NATRUL-VITES TABS 1 yrs old); GUMMIES CHEW RX/OTC QL(2 ea daily); ONE DAILY MENS QL(2 ea daily); 1 AL(At least 12 FORMULA W/O IRON yrs old); NEOVITE TABS 1 AL(At least 12 TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); ONE DAILY WOMENS 1 AL(At least 12 TABS yrs old); NICADAN TABS 1 AL(At least 12 yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); ONE-A-DAY ENERGY 1 AL(At least 12 AL(At least 12 TABS yrs old); NICADAN ZX TABS 1 yrs old); RX/OTC RX/OTC ONE-A-DAY FOR HER QL(2 ea daily); VITACRAVES TEEN 1 AL(At least 12 MULTI GUMMIES CHEW NICAZEL FORTE TABS 1 yrs old); ONE-A-DAY FOR RX/OTC HIM/VITACRAVES TEEN 1 QL(2 ea daily); MULTI GUMMIES CHEW 1 AL(At least 12 QL(2 ea daily); NICAZEL TABS yrs old); ONE-A-DAY MENOPAUSE 1 AL(At least 12 RX/OTC FORMULA TABS yrs old); QL(2 ea daily); RX/OTC NO IRON MULTIPLE 1 AL(At least 12 QL(2 ea daily); VITAMIN/MINERALS yrs old); TABS ONE-A-DAY MENS 50+ 1 AL(At least 12 RX/OTC ADVANTAGE TABS yrs old); QL(2 ea daily); RX/OTC 1 AL(At least 12 QL(2 ea daily); NUTRICAP TABS yrs old); ONE-A-DAY MENS 50+ 1 AL(At least 12 RX/OTC TABS yrs old); QL(2 ea daily); RX/OTC 1 AL(At least 12 QL(2 ea daily); OCULAR VITAMINS TABS yrs old); ONE-A-DAY MENS 1 AL(At least 12 RX/OTC HEALTH FORMULA TABS yrs old); OCUVITE ADULT 50+ 1 RX/OTC RX/OTC CAPS QL(2 ea daily); OCUVITE ADULT 1 RX/OTC ONE-A-DAY MENS PRO 1 AL(At least 12 FORMULA CAPS EDGE TABS yrs old); RX/OTC OCUVITE LUTEIN CAPS 1 RX/OTC

Nebraska Total Care Formulary September 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE-A-DAY MENS TABS QL(2 ea daily); QL(2 ea daily); 0.9 MG-1.32 MG-1.43 MG- AL(At least 12 OPURITY TABS 1 AL(At least 12 2.17 MG-2.3 MG-6.24 yrs old); yrs old); MCG-11 MG-15 MG-15.5 RX/OTC RX/OTC MG-17.6 MG-25 MCG-30 1 OPURITY/BYPASS 1 MCG-35 MCG-43 MCG-55 OPTIMIZED CHEW MCG-99 MG-120 MG-150 QL(2 ea daily); MCG-210 MG-240 MCG- OSTEOPRIME 300 MCG-900 MCG PLUS/CALCIUM & 1 AL(At least 12 MAGNESIUM TABS yrs old); ONE-A-DAY MENS RX/OTC VITACRAVES GUMMIES 1 CHEW QL(2 ea daily); 1 AL(At least 12 QL(2 ea daily); PARVLEX TABS yrs old); ONE-A-DAY PROACTIVE 1 AL(At least 12 RX/OTC 65+ TABS yrs old); RX/OTC QL(2 ea daily); AL(At least 12 QL(2 ea daily); PHYTOMULTI TABS 1 ONE-A-DAY TEEN yrs old); 1 AL(At least 12 RX/OTC ADVANTAGEFOR HIM yrs old); TABS RX/OTC PRESERVISION AREDS 2 1 RX/OTC + MULTI VITAMIN CAPS ONE-A-DAY VITACRAVES 1 ADULT CHEW PRESERVISION AREDS 2 RX/OTC CAPS 0.4 MG-0.5 MG-2.5 ONE-A-DAY VITACRAVES 1 MG-17.4 MG-87.5 MG-100 CHEW UNIT-113 MG-162.5 MG- ONE-A-DAY VITACRAVES 250 MG, 1 MG-1 MG-5 1 GUMMIES/IMMUNITY 1 MG-40 MG-200 UNIT-250 SUPPORT CHEW MG, 1 MG-1 MG-5 MG-40 MG-90 MG-250 MG, 40 ONE-A-DAY VITACRAVES 1 SOURGUMMIES CHEW MG-1 MG-1 MG-5 MG-200 UNIT-250 MG ONE-A-DAY VITACRAVES 1 WOMENS MULTI CHEW PRESERVISION AREDS 2 CHEW 1 MG-1 MG-5 MG- 1 QL(2 ea daily); 40 MG-200 UNIT-250 MG ONE-A-DAY WOMENS 1 AL(At least 12 TABS yrs old); PRESERVISION AREDS RX/OTC RX/OTC CAPS 0.8 MG-34.8 MG- 1 200 UNIT-226 MG-14320 ONE-A-DAY WOMENS UNIT VITACRAVES GUMMIES 1 CHEW PRESERVISION AREDS QL(2 ea daily); TABS 0.4 MG-17.4 MG- 1 AL(At least 12 ONE-DAILY MULTI CAPS 1 RX/OTC 100 UNIT-113 MG-7160 yrs old); CAPS UNIT RX/OTC OPTIFAST POST 1 PRESERVISION/LUTEIN 1 RX/OTC BARIATRIC CHEW CAPS OPTIMUM AIRVITES 1 QL(2 ea daily); CHEW 1 AL(At least 12 OPTISOURCE POST PRO-CAL TABS yrs old); BARIATRIC SURGERY 1 RX/OTC CHEW

Nebraska Total Care Formulary September 1, 2021

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); SAVISION CAPS 1 RX/OTC AL(At least 12 PROCERV HP TABS 1 yrs old); QL(2 ea daily); RX/OTC AL(At least 12 SENTRY SENIOR TABS 1 QL(2 ea daily); yrs old); AL(At least 12 RX/OTC PRORENAL+D TABS 1 yrs old); QL(2 ea daily); RX/OTC SENTRY SENIOR/LUTEIN 1 AL(At least 12 TABS yrs old); PRORENAL+D/OMEGA-3 1 RX/OTC CAPS RX/OTC QL(2 ea daily); PROTECT CARDIO AF 1 RX/OTC CAPS 1 AL(At least 12 SENTRY TABS yrs old); PROTECT PLUS SO 1 RX/OTC CAPS RX/OTC QL(2 ea daily); PROTEGRA CAPS 1 RX/OTC 1 AL(At least 12 SIDEROL TABS yrs old); QL(2 ea daily); RX/OTC 1 AL(At least 12 PROVIT TABS yrs old); QL(2 ea daily); RX/OTC SM ONE DAILY MENS 1 AL(At least 12 TABS yrs old); QL(2 ea daily); RX/OTC 1 AL(At least 12 QC MULTI-VITE TABS yrs old); QL(2 ea daily); RX/OTC SM ONE DAILY WOMENS 1 AL(At least 12 TABS yrs old); QC OCUHEALTH VISION 1 RX/OTC RX/OTC SUPPORT 2 CAPS QL(2 ea daily); QL(2 ea daily); AL(At least 12 AL(At least 12 SOLO TABS 1 QUIN B STRONG TABS 1 yrs old); yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); AL(At least 12 AL(At least 12 SPECTRAVITE TABS 1 QUINTABS-M TABS 1 yrs old); yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); AL(At least 12 AL(At least 12 STROVITE ONE TABS 1 RA CENTRAL-VITE TABS 1 yrs old); yrs old); RX/OTC RX/OTC SUPER ANTIOXIDANT 1 RX/OTC QL(2 ea daily); CAPS AL(At least 12 RENAPLEX-D TABS 1 yrs old); SUPPORT LIQD 1 RX/OTC RX/OTC SYSTANE ICAPS AREDS2 REPLACE CAPS 1 RX/OTC CHEW 1 MG-1 MG-5 MG- 1 12.5 MG-200 UNIT-250 QL(2 ea daily); MG 1 AL(At least 12 REQ 49+ TABS yrs old); RX/OTC

Nebraska Total Care Formulary September 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYSTANE ICAPS AREDS2 QL(2 ea daily); QL(2 ea daily); TABS 1 MG-1 MG-1 MG-5 AL(At least 12 1 THEREMS-H TABS 1 AL(At least 12 MG-12.5 MG-94.3 MG-200 yrs old); yrs old); UNIT-250 MG RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); T-VITES TABS 1 AL(At least 12 1 AL(At least 12 yrs old); THEREMS-M TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); THERA M PLUS TABS 1 AL(At least 12 1 AL(At least 12 yrs old); UNICOMPLEX-M TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); THERA-M TABS 1 AL(At least 12 1 AL(At least 12 yrs old); VENEXA FE TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); AL(At least 12 THERA-TABS M TABS 1 1 AL(At least 12 yrs old); VENEXA TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); THERABETIC MULTI- AL(At least 12 1 VENTRIXYL FE TABS 1 AL(At least 12 VITAMIN TABS yrs old); yrs old); RX/OTC RX/OTC QL(2 ea daily); VISTA ADVANCED RX/OTC THERAGRAN-M 1 1 AL(At least 12 AREDS2 FORMULA CAPS ADVANCED 50 PLUS yrs old); TABS VISTA ADVANCED DRY 1 RX/OTC RX/OTC EYE FORMULA CAPS QL(2 ea daily); VITABEX CAPS 1 RX/OTC THERAGRAN-M 1 AL(At least 12 ADVANCED TABS yrs old); RX/OTC RX/OTC VITABEX PLUS CAPS 1 QL(2 ea daily); QL(2 ea daily); THERAGRAN-M PREMIER AL(At least 12 1 VITALINE TOTAL 1 AL(At least 12 50 PLUS TABS yrs old); FORMULA 2 TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); THERAGRAN-M PREMIER AL(At least 12 1 VITALINE TOTAL 1 AL(At least 12 TABS yrs old); FORMULA 3 TABS yrs old); RX/OTC RX/OTC QL(2 ea daily); QL(2 ea daily); AL(At least 12 THERAGRAN-M TABS 1 VITAMIN D3 COMPLETE 1 AL(At least 12 yrs old); TABS yrs old); RX/OTC RX/OTC THERAMILL FORTE CAPS 1 RX/OTC QL(2 ea daily); AL(At least 12 VITASANA TABS 1 THERANATAL 1 RX/OTC yrs old); LACTATION ONE CAPS RX/OTC

Nebraska Total Care Formulary September 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); QL(2 ea daily); VITATRUM TABS 1 AL(At least 12 1 AL(At least 12 yrs old); VITREXYL TABS yrs old); RX/OTC RX/OTC VITEYES CLASSIC 1 RX/OTC QL(2 ea daily); ADVANCED CAPS AL(At least 12 VITREXYL/IRON TABS 1 RX/OTC yrs old); VITEYES CLASSIC CAPS 1 RX/OTC VITEYES CLASSIC RX/OTC QL(2 ea daily); MACULAR SUPPORT 1 VITRUM 50+ ADULT- 1 AL(At least 12 CAPS MULTI IRON FREE TABS yrs old); QL(2 ea daily); RX/OTC QL(2 ea daily); VITEYES CLASSIC 1 AL(At least 12 MULTIIVITAMIN TABS yrs old); VITRUM 50+ SENIOR 1 AL(At least 12 RX/OTC MULTI TABS yrs old); QL(2 ea daily); RX/OTC WAL-BORN VITAMIN C VITEYES CLASSIC 1 AL(At least 12 1 MULTIVITAMIN TABS yrs old); CHEW RX/OTC QL(2 ea daily); VITEYES RX/OTC WHOLE FOOD 1 AL(At least 12 CLASSIC+OMEGA-3 1 MULTIVITAMIN TABS yrs old); CAPS RX/OTC VITEYES RX/OTC QL(2 ea daily); 1 WOMENS 50+ MULTI AL(At least 12 CLASSIC/OMEGA-3 CAPS VITAMIN& MINERAL 1 QL(2 ea daily); FORMULA TABS yrs old); RX/OTC VITEYES OPTIC NERVE 1 AL(At least 12 SUPPORT TABS yrs old); QL(2 ea daily); RX/OTC WOMENS BIOMULTIPLE 1 AL(At least 12 QL(2 ea daily); TABS yrs old); AL(At least 12 RX/OTC VITRAMYN TABS 1 yrs old); WOMENS MULTI 1 RX/OTC GUMMIES CHEW QL(2 ea daily); QL(2 ea daily); WOMENS MULTI VITAMIN AL(At least 12 1 AL(At least 12 VITRANOL FE TABS 1 & MINERAL FORMULA yrs old); yrs old); TABS RX/OTC RX/OTC QL(2 ea daily); WOMENS MULTIVITAMIN + COLLAGEN GUMMIES 1 1 AL(At least 12 VITRANOL TABS yrs old); CHEW RX/OTC QL(2 ea daily); QL(2 ea daily); YELETS TEENAGE 1 AL(At least 12 FORMULA TABS yrs old); 1 AL(At least 12 VITREXATE FE TABS yrs old); RX/OTC RX/OTC YOUR LIFE MULTI ADULT 1 QL(2 ea daily); GUMMIES CHEW AL(At least 12 VITREXATE TABS 1 YOUR LIFE TEEN yrs old); MULTIVITAMIN GUMMIES 1 RX/OTC CHEW

Nebraska Total Care Formulary September 1, 2021

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZINC LOZG 10 MG-100 NASAL AGENTS - SYSTEMIC AND TOPICAL - MG-50 MG-15 MG-500 Drugs to treat the Nose or Sinus UNIT, 10 MG-15 MG-50 MG-100 MG-500 UNIT, Nasal Agents - Misc. 100 MG-10 MG-15 MG-50 1 AYR NASAL DROPS 1 MG-500 UNIT, 5 MG-10 SOLN MG-10 MG-10 MG-15 MG- 60 MG-500 UNIT, 500 saline gel 1 UNIT-15 MG-50 MG-100 MG saline soln 1 ZYVANA CAPS 1 RX/OTC Nasal Antiallergy cromolyn sodium (nasal) 1 QL(0.867 ml Multivitamins aers daily) ESTROFACTORS TABS 1 Nasal Steroids HIGH POTENCY 1 budesonide (nasal) susp 1 MULTIVITAMIN TABS FLONASE SENSIMIST 1 MULTI VITAMIN TABS 1 SUSP NASACORT ALLERGY 1 MULTI VITAMIN/D-3 TABS 1 24HR AERO multiple vitamin tabs 1 triamcinolone acetonide 1 (nasal) aero MULTIVITAMIN ADULT 1 Sympathomimetic Decongestants TABS BENZEDREX INHALER 1 MULTIVITAMIN TABS 0.1 INHA MG-1 MG-1.5 MG-2 MG-10 1 MCG-20 MG-28.5 MG-37.5 oxymetazoline hcl soln 1 MG-1500 MCG phenylephrine hcl (oral) 1 NEOMULTIVITE TABS 1 tabs

OMNICAP TABS 1 phenylephrine hcl soln 1

ONE DAILY ESSENTIAL 1 pseudoephedrine hcl liqd 1 TABS pseudoephedrine hcl tabs 1 QUINTABS TABS 1 pseudoephedrine hcl tb12 1 THERA TABS 1 SUDAFED CHILDRENS 1 THEREMS MULTIVITAMIN 1 LIQD TABS NEUROMUSCULAR AGENTS - Drugs to Prenatal Vitamins Relax/Paralyze Muscles PRENATAL-U CAPS 1 ALS Agents Vitamin Mixtures riluzole tabs 1 cod liver oil caps 1 NUTRIENTS

Nebraska Total Care Formulary September 1, 2021

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Misc. Nutritional Substances REFRESH OPTIVE GEL 1 omega-3 fatty acids caps 1 REFRESH OPTIVE MEGA- 1 3 SOLN omega-3 fatty acids cpdr 1 REFRESH OPTIVE PRESERVATIVE FREE 1 Proteins SOLN LEVOCARNITINE TABS 1 REFRESH RELIEVA PF 1 SOLN OPHTHALMIC AGENTS - Drugs to Treat the Eye REFRESH SOLN 1 Artificial Tears and Lubricants SYSTANE GEL GEL 1 artificial tear solution soln 1 SYSTANE OVERNIGHT carboxymethylcellulose 1 THERAPY LUBRICANT 1 sodium (ophth) gel EYE GEL carboxymethylcellulose 1 sodium (ophth) soln VISTA GEL GEL 1 white petrolatum-mineral oil dextran 70-hypromellose 1 1 soln oint GENTEAL SEVERE GEL 1 Cycloplegic Mydriatics ATROPINE SULFATE 1 GENTEAL SEVERE 1 SOLN OP 1 % TEARS GEL cyclopentolate hcl soln 1 GENTEAL TEARS 1 SEVERE DAY/NIGHT GEL glycerin-hypromellose- ISOPTO ATROPINE SOLN 1 polyethylene glycol 400 1 phenylephrine hcl 1 soln (mydriatic) soln ISOPTO TEARS SOLN 1 tropicamide soln 1 polyethylene glycol- propylene glycol (ophth) 1 Ophthalmic Anti-infectives soln trifluridine soln 1 polyvinyl alcohol soln 1 Ophthalmic Decongestants polyvinyl alcohol-povidone 1 naphazoline-glycerin soln 1 (ophth) soln tetrahydrozoline hcl (ophth) REFRESH DIGITAL PF 1 1 SOLN soln tetrahydrozoline-dextran- REFRESH DIGITAL SOLN 1 polyethylene glycol- 1 REFRESH OPTIVE povidone soln ADVANCED SENSITIVE 1 Ophthalmics - Misc. SOLN JETREA SOLN 1 SP REFRESH OPTIVE 1 ADVANCED SOLN MURO 128 SOLN 2 % 1

Nebraska Total Care Formulary September 1, 2021

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ophthalmic irrigation 1 GRX WHITE 1 RX/OTC solution soln PETROLATUM OINT sodium chloride hypertonic 1 LIP BALM BASE OINT 1 RX/OTC oint PCCA POLYPEG BASE RX/OTC sodium chloride hypertonic 1 1 soln OINT RX/OTC OTIC AGENTS - Drugs to Treat the Ear PEG OINT 1 Otic Agents - Miscellaneous PEG OINTMENT BASE 1 RX/OTC OINT carbamide peroxide (otic) 1 soln PETROLATUM OINT 1 RX/OTC isopropyl alcohol (otic) liqd 1 PETROLATUM WHITE 1 RX/OTC OINT Otic Steroids PETROLEUM JELLY OINT 1 RX/OTC fluocinolone acetonide 1 (otic) oil PETROLEUM JELLYBABY 1 RX/OTC OXYTOCICS - Drugs to Prevent/Control Uterine OINT Bleeding POLYBASE OINT 1 RX/OTC Oxytocics POLYETHYLENE GLYCOL 1 RX/OTC methylergonovine maleate 1 BLEND OINT tabs RA PETROLEUM JELLY 1 RX/OTC PASSIVE IMMUNIZING AND TREATMENT OINT AGENTS - Antibody Drugs to Treat Low Immune SKIN PROTECTANT 1 RX/OTC System PETROLATUM OINT Immune Serums white petrolatum gel 1 AL(At least 19 HYPERTET S/D INJ 1 yrs old) WHITE PETROLATUM 1 RX/OTC OINT Monoclonal Antibodies YELLOW PETROLATUM 1 RX/OTC SYNAGIS SOLN 1 PA; SP OINT PROGESTINS - Hormone Replacement/Modifying PENICILLINS - Drugs to Treat Bacterial Infections Drugs Penicillin Combinations Progestins medroxyprogesterone MP ampicillin & sulbactam 1 1 sodium solr acetate tabs MP piperacillin sodium- 1 QL(1 ea daily) norethindrone acetate tabs 1 tazobactam sodium solr PHARMACEUTICAL ADJUVANTS progesterone caps 1 Semi Solid Vehicles PSYCHOTHERAPEUTIC AND NEUROLOGICAL RX/OTC AGENTS - MISC. - Drugs to Treat Mental and ALPAWASH OINT 1 Emotional Conditions FATTIBASE OINT 1 RX/OTC Agents for Chemical Dependency

Nebraska Total Care Formulary September 1, 2021

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits disulfiram tabs 1 PA; QL(2 ea CHANTIX CONTINUING 1 daily); AL(At Anti-Cataplectic Agents MONTHPAK TABS least 18 yrs old) PA; SP XYREM SOLN 1 PA; QL(2 ea CHANTIX STARTING 1 daily); AL(At Combination Psychotherapeutics MONTH PAK TABS least 18 yrs olanzapine-fluoxetine hcl 1 AL(At least 6 old) caps yrs old); MP PA; QL(2 ea perphenazine-amitriptyline AL(At least 6 1 1 daily); AL(At tabs yrs old); MP CHANTIX TABS least 18 yrs Fibromyalgia Agents old) QL(2 ea daily); PA; QL(10.27 ea daily); AL(At SAVELLA TABS 1 AL(At least 13 nicotine polacrilex gum 1 yrs old) least 18 yrs old) QL(2 ea daily); SAVELLA TITRATION 1 AL(At least 13 PA; QL(10.27 PACK MISC yrs old) 1 ea daily); AL(At nicotine polacrilex lozg least 18 yrs Premenstrual Dysphoric Disorder (PMDD) Agents old) fluoxetine hcl (pmdd) caps 1 MP PA; QL(1 ea 10 mg, 20 mg 1 daily); AL(At nicotine pt24 least 18 yrs fluoxetine hcl (pmdd) tabs 1 10 mg, 20 mg old) Pseudobulbar Affect (PBA) Agents PA; QL(1 ea NICOTINE daily); AL(At PA; QL(2 ea TRANSDERMAL SYSTEM 1 NUEDEXTA CAPS 1 KIT least 18 yrs daily) old) Psychotherapeutic and Neurological Agents - PA; QL(168 ea per fill ergoloid mesylates tabs 1 retail,504 ea NICOTROL INHALER QL(10 ea 1 per 90 days INHA retail); AL(At 1 daily); AL(At pimozide tabs 1 mg least 6 yrs old); least 18 yrs MP old) QL(5 ea daily); PA; QL(40 ml pimozide tabs 2 mg 1 AL(At least 6 per fill yrs old); MP retail,120 ml NICOTROL NS SOLN 1 per 90 days Smoking Deterrents retail); AL(At PA; QL(2 ea least 18 yrs old) 1 daily); AL(At APO-VARENICLINE TABS least 18 yrs Vasomotor Symptom Agents old) paroxetine mesylate 1 MP PA; QL(2 ea (vasomotor) caps bupropion hcl (smoking 1 daily); AL(At deterrent) tb12 least 18 yrs RESPIRATORY AGENTS - MISC. - Drugs to old) Treat Lung Conditions Cystic Fibrosis Agents Nebraska Total Care Formulary September 1, 2021

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PULMOZYME SOLN 1 SP hyoscyamine sulfate tbdp 1 THYROID AGENTS - Drugs to Regulate Thyroid Misc. Anti-Ulcer Hormones AL(Up to 6 yrs sucralfate susp 1 gm/10ml 1 Antithyroid Agents old ) methimazole tabs 1 MP sucralfate tabs 1 gm 1 propylthiouracil tabs 1 MP Ulcer Drugs - Prostaglandins misoprostol tabs 1 TOXOIDS Ulcer Therapy Combinations Toxoid Combinations famotidine-calcium AL(At least 19 ADACEL SUSP 1 carbonate-magnesium 1 yrs old) hydroxide chew AL(At least 19 BOOSTRIX SUSP 1 URINARY ANTISPASMODICS - Drugs to Treat yrs old) Miscellaneous Bladder Spasms TDVAX SUSP 1 AL(At least 19 yrs old) Urinary Antispasmodics - Cholinergic Agonists AL(At least 19 MP TENIVAC INJ 1 bethanechol chloride tabs 1 yrs old) TETANUS/DIPHTHERIA AL(At least 19 VACCINES TOXOIDS-ADSORBED 1 yrs old) ADULT SUSP Bacterial Vaccines ULCER DRUGS - Drugs to Treat Bowel, Intestine QL(1 ml per and Stomach Conditions 365 days BEXSERO SUSY 1 retail); AL(At Antispasmodics least 19 yrs old) atropine sulfate sosy ij 0.25 1 mg/5ml QL(1 ml per 365 days dicyclomine hcl caps 1 MENACTRA INJ 1 retail); AL(At least 19 yrs dicyclomine hcl soln 1 old) QL(1 ml per dicyclomine hcl tabs 1 365 days MENQUADFI INJ 1 retail); AL(At glycopyrrolate tabs 1 least 19 yrs old) hyoscyamine sulfate elix 1 QL(1 ea per 365 days hyoscyamine sulfate soln 1 MENVEO SOLR 1 retail); AL(At least 19 yrs hyoscyamine sulfate subl 1 old) hyoscyamine sulfate tabs 1 hyoscyamine sulfate tb12 1

Nebraska Total Care Formulary September 1, 2021

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl MAX fill,180 rtl AFLURIA QUADRIVALENT MAX fill,180 rtl PNEUMOVAX 23 INJ 1 1 day(s) supply,; 2020-2021 SUSP day(s) supply,; AL(At least 19 AL(At least 19 yrs old) yrs old) QL(0.5 ml per QL(0.25 ml per fill retail)1 rtl fill retail)1 rtl PNEUMOVAX 23/1 DOSE 1 MAX fill,180 rtl pack lmt amt,1 INJ day(s) supply,; AFLURIA QUADRIVALENT 1 rtl MAX fill,180 AL(At least 19 2020-2021 SUSY rtl day(s) yrs old) supply,; AL(At QL(0.5 ml per least 19 yrs fill retail)1 rtl old) PREVNAR 13 SUSP 1 MAX fill,180 rtl QL(0.5 ml per day(s) supply,; fill retail)1 rtl AL(At least 19 pack lmt amt,1 yrs old) AFLURIA QUADRIVALENT 1 rtl MAX fill,180 AL(At least 19 2020-2021 SUSY rtl day(s) PREVNAR 20 SUSY 1 yrs old - Up to supply,; AL(At 64 yrs old) least 19 yrs old) QL(1 ml per 365 days QL(0.5 ml per TRUMENBA SUSY 1 retail); AL(At fill retail)1 rtl least 19 yrs AFLURIA QUADRIVALENT 1 MAX fill,180 rtl old) 2021-2022 SUSP day(s) supply,; AL(At least 19 Viral Vaccines yrs old) QL(0.5 ml per QL(0.25 ml per fill retail)1 rtl fill retail)1 rtl AFLURIA QUADRIVALENT 1 MAX fill,180 rtl pack lmt amt,1 2019-2020 SUSP day(s) supply,; AFLURIA QUADRIVALENT 1 rtl MAX fill,180 AL(At least 19 2021-2022 SUSY rtl day(s) yrs old) supply,; AL(At QL(0.5 ml per least 19 yrs fill retail)1 rtl old) pack lmt amt,1 QL(0.5 ml per AFLURIA QUADRIVALENT 1 rtl MAX fill,180 fill retail)1 rtl 2019-2020 SUSY rtl day(s) pack lmt amt,1 supply,; AL(At AFLURIA QUADRIVALENT 1 rtl MAX fill,180 least 19 yrs 2021-2022 SUSY rtl day(s) old) supply,; AL(At QL(0.25 ml per least 19 yrs fill retail)1 rtl old) pack lmt amt,1 AL(At least 19 ENGERIX-B INJ 1 AFLURIA QUADRIVALENT 1 rtl MAX fill,180 yrs old) 2019-2020 SUSY rtl day(s) AL(At least 19 supply,; AL(At ENGERIX-B SUSP 1 least 19 yrs yrs old) old)

Nebraska Total Care Formulary September 1, 2021

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl FLUBLOK FLUAD 2019-2020 SUSY 1 MAX fill,180 rtl 1 MAX fill,180 rtl day(s) supply,; QUADRIVALENT 2019- day(s) supply,; AL(At least 19 2020 SOSY AL(At least 19 yrs old) yrs old) QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl FLUBLOK FLUAD 2020-2021 SUSY 1 MAX fill,180 rtl 1 MAX fill,180 rtl day(s) supply,; QUADRIVALENT 2020- 2021 SOSY day(s) supply,; AL(At least 19 AL(At least 19 yrs old) yrs old) QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl FLUBLOK FLUAD QUADRIVALENT 1 MAX fill,180 rtl 1 MAX fill,180 rtl 2021-2022 PRSY day(s) supply,; QUADRIVALENT 2021- 2022 SOSY day(s) supply,; AL(At least 65 AL(At least 19 yrs old) yrs old) QL(0.5 ml per QL(0.5 ml per FLUAD QUADRIVALENT fill retail)1 rtl fill retail)1 rtl MAX fill,180 rtl FLUCELVAX MAX fill,180 rtl INFLUENZA VACCINE 1 QUADRIVALENT 2019- 1 FOR ADULTS PRSY day(s) supply,; day(s) supply,; AL(At least 65 2020 SUSP AL(At least 19 yrs old) yrs old) QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl FLUCELVAX pack lmt amt,1 1 MAX fill,180 rtl FLUARIX QUADRIVALENT rtl MAX fill,180 QUADRIVALENT 2019- 1 2020 SUSY day(s) supply,; 2019-2020 SUSY rtl day(s) AL(At least 19 supply,; AL(At yrs old) least 19 yrs QL(0.5 ml per old) fill retail)1 rtl FLUCELVAX QL(0.5 ml per 1 MAX fill,180 rtl fill retail)1 rtl QUADRIVALENT 2020- day(s) supply,; pack lmt amt,1 2021 SUSP AL(At least 19 FLUARIX QUADRIVALENT 1 rtl MAX fill,180 yrs old) 2020-2021 SUSY rtl day(s) QL(0.5 ml per supply,; AL(At fill retail)1 rtl least 19 yrs FLUCELVAX 1 MAX fill,180 rtl old) QUADRIVALENT 2020- day(s) supply,; QL(0.5 ml per 2021 SUSY AL(At least 19 fill retail)1 rtl yrs old) pack lmt amt,1 QL(0.5 ml per FLUARIX QUADRIVALENT 1 rtl MAX fill,180 fill retail)1 rtl 2021-2022 SUSY rtl day(s) FLUCELVAX 1 MAX fill,180 rtl supply,; AL(At QUADRIVALENT 2021- day(s) supply,; least 19 yrs 2022 SUSP AL(At least 19 old) yrs old)

Nebraska Total Care Formulary September 1, 2021

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.5 ml per QL(0.7 ml per fill retail)1 rtl fill retail)1 rtl FLUCELVAX QUADRIVALENT 2021- 1 MAX fill,180 rtl FLUZONE HIGH-DOSE PF 1 MAX fill,180 rtl 2022 SUSY day(s) supply,; 2021-2022 SUSY day(s) supply,; AL(At least 19 AL(At least 65 yrs old) yrs old) QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl FLULAVAL FLUZONE QUADRIVALENT 2019- 1 MAX fill,180 rtl 1 MAX fill,180 rtl day(s) supply,; QUADRIVALENT 2019- 2020 SUSP 2020 SUSP day(s) supply,; AL(At least 19 AL(At least 19 yrs old) yrs old) QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl pack lmt amt,1 pack lmt amt,1 FLULAVAL FLUZONE QUADRIVALENT 2019- 1 rtl MAX fill,180 1 rtl MAX fill,180 rtl day(s) QUADRIVALENT 2019- 2020 SUSY 2020 SUSP rtl day(s) supply,; AL(At supply,; AL(At least 19 yrs least 19 yrs old) old) QL(0.5 ml per QL(0.25 ml per fill retail)1 rtl fill retail)1 rtl pack lmt amt,1 pack lmt amt,1 FLULAVAL rtl MAX fill,180 FLUZONE QUADRIVALENT 2020- 1 QUADRIVALENT 2019- 1 rtl MAX fill,180 2021 SUSY rtl day(s) rtl day(s) supply,; AL(At 2020 SUSY supply,; AL(At least 19 yrs least 19 yrs old) old) QL(0.5 ml per QL(0.5 ml per fill retail)1 rtl fill retail)1 rtl pack lmt amt,1 pack lmt amt,1 FLULAVAL rtl MAX fill,180 FLUZONE QUADRIVALENT 2021- 1 QUADRIVALENT 2019- 1 rtl MAX fill,180 2022 SUSY rtl day(s) rtl day(s) supply,; AL(At 2020 SUSY supply,; AL(At least 19 yrs least 19 yrs old) old) QL(1 ea per fill QL(0.5 ml per retail)1 rtl MAX fill retail)1 rtl FLUZONE fill,180 rtl MAX fill,180 rtl FLUMIST 1 QUADRIVALENT 2020- 1 QUADRIVALENT SUSP day(s) supply,; day(s) supply,; AL(At least 19 2021 SUSP AL(At least 19 yrs old - Up to yrs old) 49 yrs old) QL(0.5 ml per QL(0.7 ml per fill retail)1 rtl fill retail)1 rtl pack lmt amt,1 FLUZONE HIGH-DOSE PF MAX fill,180 rtl FLUZONE 1 QUADRIVALENT 2020- 1 rtl MAX fill,180 2020-2021 SUSY day(s) supply,; rtl day(s) AL(At least 65 2021 SUSP supply,; AL(At yrs old) least 19 yrs old)

Nebraska Total Care Formulary September 1, 2021

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.5 ml per RECOMBIVAX HB SUSP 1 AL(At least 19 fill retail)1 rtl yrs old) pack lmt amt,1 AL(At least 50 FLUZONE SHINGRIX SUSR 1 1 rtl MAX fill,180 yrs old) QUADRIVALENT 2020- rtl day(s) 2021 SUSY AL(At least 19 supply,; AL(At TWINRIX SUSY 1 least 19 yrs yrs old) AL(At least 19 old) VAQTA SUSP 1 QL(0.5 ml per yrs old) AL(At least 50 fill retail)1 rtl ZOSTAVAX SUSR 1 FLUZONE yrs old) QUADRIVALENT 2021- 1 MAX fill,180 rtl 2022 SUSP day(s) supply,; AL(At least 19 VAGINAL AND RELATED PRODUCTS yrs old) Miscellaneous Vaginal Products QL(0.5 ml per PA fill retail)1 rtl INTRAROSA INST 1 pack lmt amt,1 FLUZONE Spermicides 1 rtl MAX fill,180 QUADRIVALENT 2021- rtl day(s) OPTIONS GYNOL II 2022 SUSP supply,; AL(At VAGINALCONTRACEPTIV 1 least 19 yrs E GEL old) VCF VAGINAL QL(0.5 ml per CONTRACEPTIVE FILM 1 fill retail)1 rtl FILM pack lmt amt,1 FLUZONE VCF VAGINAL QUADRIVALENT 2021- 1 rtl MAX fill,180 CONTRACEPTIVE FOAM 1 rtl day(s) FOAM 2022 SUSY supply,; AL(At least 19 yrs VCF VAGINAL old) CONTRACEPTIVEGEL 1 GEL AL(At least 19 GARDASIL 9 SUSP 1 yrs old) Vaginal Anti-infectives GARDASIL 9 SUSY 1 AL(At least 19 clotrimazole vaginal crea 1 yrs old) miconazole nitrate vaginal HAVRIX SUSP 1 AL(At least 19 1 yrs old) crea AL(At least 19 miconazole nitrate vaginal HEPLISAV-B SOLN 1 1 yrs old) kit miconazole nitrate vaginal HEPLISAV-B SOSY 1 AL(At least 19 1 yrs old) supp terconazole vaginal crea 1 JANSSEN COVID-19 1 VACCINE SUSP terconazole vaginal supp 1 M-M-R II SOLR 1 AL(At least 19 yrs old) tioconazole vaginal oint 1 MODERNA COVID-19 1 VACCINE SUSP Vaginal Estrogens PFIZER-BIONTECH 1 COVID-19VACCINE SUSP estradiol vaginal crea 1

Nebraska Total Care Formulary September 1, 2021

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMARIN CREA 1 ascorbic acid tabs or 1000 1 mg, 37 mg-1000 mg Vaginal Progestins ascorbic acid tabs or 250 QL(3.34 ea PA mg, 10 mg-500 mg, 14 mg- daily) CRINONE GEL 1 25 mg-500 mg, 25 mg-35 1 mg-500 mg, 37 mg-500 VASOPRESSORS - Drugs to Treat Heart and mg, 500 mg-10 mg Circulation Conditions ascorbic acid tbcr or 16 1 Neurogenic Orthostatic Hypotension (NOH) - mg-25 mg-500 mg PA; QL(3 ea droxidopa caps 1 daily); SP calcium ascorbate tabs 1 Vasopressors niacin cpcr 1 midodrine hcl tabs 1 niacin tabs 1

VITAMINS niacin tbcr 1 Oil Soluble Vitamins niacinamide tabs 1 cholecalciferol caps 1.25 1 QL(0.286 ea mg, 50000 unit daily) pyridoxine hcl tabs 25 mg, 1 cholecalciferol caps 10000 100 mg unit, 250 mcg, 1000 unit, 1 1 MP 25 mcg, 2000 unit, 50 mcg pyridoxine hcl tabs 50 mg QL(3.34 ea cholecalciferol caps 125 1 QL(2 ea daily) thiamine hcl tabs 1 mcg, 5000 unit daily) QL(3.34 ea cholecalciferol liqd 10 1 thiamine mononitrate tabs 1 mcg/ml, 400 unit/ml daily) cholecalciferol tabs 50000 unit, 400 unit, 2000 unit, 50 1 mcg, 1000 unit, 25 mcg ergocalciferol caps 1.25 1 AL(At least 17 mg, 50000 unit yrs old); MP ergocalciferol soln 200 1 QL(2 ml daily) mcg/ml, 8000 unit/ml vitamin a caps 1 vitamin e caps 1 vitamin e soln 1 Water Soluble Vitamins ascorbic acid chew or 250 mg, , 500 mg, 7.5 mg-500 1 mg ascorbic acid lozg mt 60 1 mg

Nebraska Total Care Formulary September 1, 2021

127 Index 10 SERIES BLOOD ADJUSTABLE LANCING ADVOCATE SAFETY LANCETS PRESSUREMONITOR/UPPER DEVICE 31 26G 31 ARM 26 ADRENAL C FORMULA 77 AEROBIKA 68 1ST TIER UNILET ADULT AEROSOL MASK 67 AEROCHAMBER MINI COMFORTOUCH LANCETS ADULT MASK 67 AEROSOLCHAMBER 68 28G 30 AEROCHAMBER MV 68 1ST TIER UNILET ADULT MASK LARGE 67 COMFORTOUCH LANCETS AEROCHAMBER PLUS FLOW ADULT ONE DAILY VU 68 30G 30 GUMMIES 77 3 SERIES BLOOD PRESSURE AEROCHAMBER PLUS FLOW- ADVANCED C PLUS 77 VU 68 MONITOR/WRIST 26 ADVANCED A + D PERSONAL CARE AEROCHAMBER PLUS FLOW- CALCIUM/VITAMIND/MAGNES VU/LARGE MASK 68 LOTION 14 IUM 74 AEROCHAMBER PLUS FLOW- A+D FIRST AID 21 ADVANCED DIABETIC VU/MASK 68 ABC COMPLETE SENIOR MULTIVITAMIN AEROCHAMBER PLUS FLOW- WOMENS 50+ 77 FORMULA 77 VU/MEDIUM MASK 68 ABILIFY MAINTENA 11 ADVANCED MOBILE LANCET AEROCHAMBER PLUS FLOW- ABSORBASE 21 30G 31 VU/SMALL MASK 68 ACCU-CHEK FASTCLIX ADVOCATE ARM BLOOD AEROCHAMBER Z-STAT PLUS LANCETDEVICE KIT 30 PRESSURE VALVED HOLDING CHAMBER ACCU-CHEK FASTCLIX MONITOR/LARGE 26 W/FLOW VU 68 LANCETS 30 ADVOCATE INSULIN AEROCHAMBER Z-STAT ACCU-CHEK MULTICLIX SYRINGE/U- PLUS/FLOWSIGNAL 68 LANCET DEVICE KIT 30 100/0.3ML/29GX1/2" 44 AEROCHAMBER Z-STAT ACCU-CHEK MULTICLIX ADVOCATE INSULIN PLUS/LARGE MASK 68 LANCETS 30 SYRINGE/U- AEROCHAMBER Z-STAT ACCU-CHEK SAFE-T-PRO 100/0.3ML/30GX5/16" 44 PLUS/MEDIUM MASK 68 LANCETS 30 ADVOCATE INSULIN AEROCHAMBER Z-STAT ACCU-CHEK SAFE-T-PRO SYRINGE/U- PLUS/SMALL MASK 68 PLUSLANCETS 30 100/0.3ML/31GX5/16" 44 AEROCHAMBER/FLOWSIGNAL ACCU-CHEK SOFTCLIX ADVOCATE INSULIN 68 LANCETDEVICE KIT 30 SYRINGE/U- AEROTRACH PLUS 68 ACCU-CHEK SOFTCLIX 100/0.5ML/29GX1/2" 44 AEROVENT PLUS HOLDING LANCETS 30 ADVOCATE INSULIN CHAMBER/COLLAPSIBLE 68 ACE AEROSOL CLOUD SYRINGE/U- AFLURIA QUADRIVALENT ENHANCER 67 100/0.5ML/30GX5/16" 44 2019-2020 123 acetaminophen 1 ADVOCATE INSULIN AFLURIA QUADRIVALENT SYRINGE/U- 2020-2021 123 acetaminophen-caffeine 1 100/0.5ML/31GX5/16" 44 AFLURIA QUADRIVALENT acetaminophen-pamabrom- ADVOCATE INSULIN 2021-2022 123 pyrilamine 1 SYRINGE/U- AGAMATRIX ULTRA-THIN acetazolamide 23 100/1ML/29GX1/2" 44 LANCETS 33G 31 acetylcysteine 13 ADVOCATE INSULIN AIMSCO LUBRICATED 29 ACTI-LANCE LANCETS SYRINGE/U- AIMSCO TWIST LANCETS 28G 30 100/1ML/30GX5/16" 44 32G 31 ACTI-LANCE LITE SAFETY ADVOCATE INSULIN AIMSCO TWIST LANCETS LANCETS 28G 30 SYRINGE/U- 33G 31 ACTI-LANCE SPECIAL SAFETY 100/1ML/31GX5/16" 44 AIRBORNE 77 LANCETS 17G 30 ADVOCATE LANCETS 31 ACTI-LANCE SPECIAL ADVOCATE LANCETS AIRBORNE KIDS 77 SAFETYLANCETS 17G 31 30G 31 AIRBORNE+GOOD REST 77 ACTI-LANCE UNIVERSAL ADVOCATE LANCING AIRBORNE+NATURAL SAFETY LANCETS 23G 31 DEVICE 31 ENERGY 77 ACTIVITY POUCH 67 ADVOCATE RAPID-SAFE AIRBORNE+PROBIOTIC 77 ACTIVNUTRIENTS 77 LANCING DEVICE 31 AIRS PEDIATRIC AEROSOL ADVOCATE SAFETY ADACEL 122 MASK 68 LANCETS 31 AKTIPAK 13

Index 1 ALA-HIST IR 8 ANTACID 2 ASSURE HAEMOLANCE PLUS ALCOHOL PADS 44 ANTACID SOFT CHEWS 2 MICRO FLOW 28G 31 ASSURE HAEMOLANCE PLUS ALCOHOL PREP PADS 44 ANTIOXIDANT FORMULA 78 NORMAL FLOW 21G 31 ALCOHOL PREPS 44 APLENZIN 5 ASSURE HAEMOLANCE PLUS ALCOHOL SWABS 44 APO-VARENICLINE 121 PEDIATRIC BLADE 31 ASSURE ID INSULIN ALCOHOL WIPES 21 APTIOM 4 SAFETYSYRINGE/U- ALGAE BASED CALCIUM 78 AQUA GLYCOLIC FACE 100/0.5ML/29G X 1/2" 44 ALIVE ENERGY 50+ 78 CREAM 14 ASSURE ID INSULIN AQUA GLYCOLIC HAND & ALIVE MENS ENERGY 78 SAFETYSYRINGE/U- BODYLOTION 14 100/1ML/29G X 1/2" 44 ALIVE MULTI-VITAMIN 78 AQUA LACTEN 14 ASSURE LANCE LANCETS 31 ALIVE ONCE DAILY WOMENS AQUA LANCE ADJUSTABLE ASSURE LANCE LANCETS 50+ ULTRA POTENCY 78 LANCING DEVICE 31 21G 31 ALIVE ONCE DAILY WOMENS AQUADEKS 78 ASSURE LANCE PLUS ULTRA POTENCY 78 AQUALANCE LANCETS SAFETYLANCETS 25G 31 ALIVE WOMENS 50+ 78 ULTRA THIN 30G 31 ASSURE LANCE PLUS ALIVE WOMENS ENERGY 78 AQUAMED 14 SAFETYLANCETS 30G 31 ALIVE WOMENS GUMMY AQUAPHILIC 14 ASSURE LANCE SAFETY VITAMINS 78 LANCET 28G 31 ALL FLOW 1000 PFT AQUAPHOR 14 ASSURE LANCETS 31 AQUAPHOR ADVANCED FILTER 68 ATROPINE SULFATE 119 ALL FLOW 1000 PULMONARY THERAPY 14 FUNCTION FILTER 68 AQUAPHOR ADVANCED atropine sulfate 122 ALL FLOW 2000 PFT THERAPY BABY 14 AURORA LANCET SUPER FILTER 68 AQUAPHOR ADVANCED THIN30G 31 ALL FLOW 3000 PFT THERAPY HEALING 14 AURORA LANCET THIN FILTER 68 AQUAPHOR LIP REPAIR 21 23G 31 ALL FLOW 4000 PFT AQUORAL 75 AUTO-LANCET 31 FILTER 68 ARIAL CHAMBER 68 AUTO-LANCET MINI 31 ALL FLOW 5000 PFT AUTOLET II CLINISAFE 31 FILTER 68 aripiprazole 11 ALL FLOW 6000 PFT ARISTADA 11 AUTOLET IMPRESSION LANCING DEVICE 31 FILTER 68 ARTHRITIS PAIN ALL FLOW 7000 PFT AUTOLET LANCING RELIEVING 20 DEVICE 31 FILTER 68 artificial tear solution 119 ALOE AFTERSUN LOTION 14 AUTOLET LITE CLINISAFE 31 ascorbic acid 127 AUTOLET LITE STARTER ALOE VESTA PROTECTIVE21 asenapine maleate 10 PACK 31 ALORA 23 aspirin 1 AUTOLET MINI 31 ALPAWASH 120 ASPIRIN 1,2 AUTOLET PLUS 31 ALTERNATE SITE LANCING aspirin 2 AUTOMATIC BLOOD DEVICE 31 PRESSUREMONITOR 26 alum & mag hydrox- aspirin buffered (cal carb-mag carb-mag oxide) 1 AVEENO ACTIVE NATURALS simethicone 2 DAILY MOISTURIZING BODY ALUMINUM HYDROXIDE 2 aspirin effervescent 1 YOGURT 14 aluminum hydroxide-mag aspirin-acetaminophen- AVEENO ACTIVE NATURALS carb 2 caffeine 1 SKIN RELIEF MOISTURE AMERIDERM PERISHIELD 21 aspirin-caffeine 1 REPAIR 14 aminocaproic acid 25 ASSURE COMFORT AVEENO DAILY MOISTURIZING LANCETS ULTRA THIN SHEER HYDRATION 14 amiodarone hcl 3 28G 31 AVEENO DAILY amitriptyline hcl 7 ASSURE HAEMOLANCE MOISTURIZINGSPF 15 14 AMLACTIN ULTRA 14 PLUS HIGH FLOW 18G 31 AVEENO INTENSE RELIEF ASSURE HAEMOLANCE HAND 14 amoxapine 7 PLUS LOW FLOW 25G 31 AVEENO POSITIVELY ampicillin & sulbactam AGELESSFIRMING BODY 14 sodium 120

Index 2 AVEENO POSITIVELY BD LO-DOSE INSULIN BD INSULIN SYRINGE RADIANT 14 SYRINGE MICROFINE ULTRAFINE/0.3ML/31G X AVEENO POSITIVELY IV/0.5ML/28G X 1/2" 45 5/16" 45 RADIANTINTENSIVE BD AUTOSHIELD 29G X BD INSULIN SYRINGE NIGHT 14 5/16" 45 ULTRAFINE/0.5ML/30G X AVEENO POSITIVELY BD AUTOSHIELD DUO 30G X 1/2" 45 RADIANTOVERNIGHT 5MM 45 BD INSULIN SYRINGE HYDRATING FACIAL BD INSULIN SYRINGE LUER- ULTRAFINE/0.5ML/31G X MOISTURI 14 LOK/U-100/1ML 45 5/16" 45 AVEENO RESTORATIVE SKIN BD INSULIN SYRINGE BD INSULIN SYRINGE THERAPY OAT REPAIRING14 MICROFINE IV/U- ULTRAFINE/1ML/30G X AVEENO STRESS RELIEF 100/0.5ML/28G X 1/2" 45 1/2" 45 MOISTURIZING 15 BD INSULIN SYRINGE BD INSULIN SYRINGE AYR NASAL DROPS 118 MICROFINE IV/U- ULTRAFINE/U-100/0.3ML/29G X AZO HORMONAL HEALTH 100/1ML/27G X 5/8" 45 1/2" 45 CYCLE CARE & COMFORT 78 BD INSULIN SYRINGE BD INSULIN SYRINGE AZO HORMONAL HEALTH MICROFINE IV/U- ULTRAFINE/U-100/0.5ML/29G X HAPPY CYCLE 78 100/1ML/28G X 1/2" 45 1/2" 46 b complex w/ c 76 BD INSULIN SYRINGE BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G ULTRAFINE/U-100/1ML/29G X b-complex vitamins 76 X 1/2" 45 1/2" 46 b-complex w/ c & folic BD INSULIN SYRINGE BD INSULIN SYRINGE acid 76,77 MICROFINE/U-100/1ML/27G X ULTRAFINE/U-100/1ML/31G X b-complex w/ folic acid 77 5/8" 45 5/16" 46 b-complex w/ minerals 77 BD INSULIN SYRINGE BD INSULIN b-complex w/biotin & folic MICROFINE/U-100/1ML/28G X SYRINGE/0.3ML/29G X acid 77 1/2" 45 12.7MM 46 B-COMPLEX/VITAMIN C/FOLIC BD INSULIN SYRINGE BD INSULIN ACID/ BIOTIN 77 SAFETYGLIDE/1ML/29G X SYRINGE/0.5ML/29G X B-D INSULIN SYRINGE 1/2" 45 12.7MM 46 ULTRAFINE II/0.3ML/31G X BD INSULIN SYRINGE SLIP BD INSULIN SYRINGE/1ML/27G 5/16" 44 TIP/U-100/1ML 45 X 12.7MM 46 B-D INSULIN SYRINGE BD INSULIN SYRINGE BD INSULIN SYRINGE/1ML/29G ULTRAFINE II/0.5ML/31G X ULTRA-FINE/0.3ML/30G X X 12.7MM 46 5/16" 45 12.7MM 45 BD INSULIN B-D INSULIN SYRINGE BD INSULIN SYRINGE SYRINGE/DETACHABLE ULTRAFINE II/1ML/31G X ULTRA-FINE/0.3ML/31G X NEEDLE/U-100/1ML/25G X 5/16" 45 8MM 45 1" 46 B-D INSULIN SYRINGE BD INSULIN SYRINGE BD INSULIN ULTRAFINE/0.3ML/30G X ULTRA-FINE/0.5ML/30G X SYRINGE/DETACHABLE 1/2" 45 12.7MM 45 NEEDLE/U-100/1ML/25G X B-D INSULIN SYRINGE BD INSULIN SYRINGE 5/8" 46 ULTRAFINE/0.5ML/30G X ULTRA-FINE/0.5ML/31G X BD INSULIN 1/2" 45 8MM 45 SYRINGE/DETACHABLE BACMIN 78 BD INSULIN SYRINGE NEEDLE/U-100/1ML/26G X ULTRA-FINE/1/2 1/2" 46 BAG BALM 15 UNIT/0.3ML/31G X 8MM 45 BD INSULIN SYRINGE/U- BARIATRIC FUSION 78 BD INSULIN SYRINGE 100/1ML/27G X 1/2" 46 BARIATRIC ULTRA-FINE/1ML/30G X BD LANCET ULTRAFINE MULTIVITAMINS/IRON 78 12.7MM 45 30G 31 BASIC AM 79 BD INSULIN SYRINGE BD LANCET ULTRAFINE ULTRA-FINE/1ML/31G X 33G 31 BASIC PM 79 8MM 45 BD MICROTAINER BASIS FACIAL BD INSULIN SYRINGE LANCETS 32 MOISTURIZER 21 ULTRAFINE HALF- BD NESTABLE SHARPS BASIS OVERNIGHT 21 UNIT/0.3ML/31G X 5/16" 45 COLLECTOR 46 BASLE 15 BD INSULIN SYRINGE BD PEN ULTRAFINE/0.3ML/30G X NEEDLE/MICRO/ULTRA- 1/2" 45 FINE/32G X 6MM 46

Index 3 BD PEN NEEDLE/MINI/ULTRA- benzocaine-isopropyl BLOOD PRESSURE FINE/31G X 5MM 46 alcohol 20 MONITOR/PREMIUM ARM 27 BD PEN NEEDLE/NANO 2ND benzocaine-menthol (mouth- BLOOD PRESSURE GEN/32G X 5/32" 46 throat) 75 MONITORDIGITAL/AUTOMATIC BD PEN benzocaine-triclosan 20 27 NEEDLE/NANO/ULTRA- benzonatate 12 BONE DENSITY BUILDER 74 FINE/32G X 4MM 46 BOOSTRIX 122 BD PEN BETA CARE 15 NEEDLE/ORIGINAL/ULTRA- BETA XMA 15 BOUDREAUXS BABY BUTT SMOOTH DRY SKIN 15 FINE/29G X 12.7MM 46 bethanechol chloride 122 BD PEN BREATHE EASE NEBULIZER NEEDLE/SHORT/ULTRA- BEXSERO 122 MASK/CHILD 68 BIO-35 GLUTEN-FREE 79 BREATHE EASE NEBULIZER FINE/31G X 8MM 46 MASK/INFANT 68 BD SAFETY-GLIDE INSULIN BIO-35 IRON FREE 79 BREATHE EASE/LARGE SYRINGE/0.5ML/29G X 1/2" 46 BIOCAL 79 MASK 68 BD SAFETY-LOK INSULIN BREATHE EASE/MEDIUM SYRINGE/PERM bioflavonoid products 77 BIOLYTE 74 MASK 68 NEEDLE/UF/1ML/29G X BREATHE EASE/SMALL 1/2" 46 BIOSUPP 79 MASK 69 BD SAFETYGLIDE INSULIN BIOTECT PLUS 79 SYRINGE/0.3ML/29G X 1/2" 46 BREATHERITE 69 BD SAFETYGLIDE INSULIN BIOTENE DRY MOUTH BREATHERITE SYRINGE/0.3ML/31G X MOISTURIZING SPRAY 76 COLLAPSIBLEADULT SPACER 5/16" 46 bisacodyl 26 W/MASK 69 BD SAFETYGLIDE INSULIN bismuth subsalicylate 8 BREATHERITE SYRINGE/0.5ML/31G X BLOOD PRESSURE COLLAPSIBLECHILD SPACER 15/64" 46 MONITOR 3SERIES 26 W/MASK 69 BD SAFETYGLIDE INSULIN BLOOD PRESSURE BREATHERITE SYRINGE/1ML/31G X MONITOR AUTOMATIC COLLAPSIBLEINFANT SPACER 15/64" 46 WRIST 26 W/MASK 69 BD SAFETYGLIDE INSULIN BLOOD PRESSURE BREATHERITE SYSYRINGE/0.5ML/30G X MONITOR COLLAPSIBLESMALL CHILD 5/16" 46 AUTOMATIC/ARM 26 SPACER W/MASK 69 BD SHARPS COLLECTOR 46 BLOOD PRESSURE BREATHERITE MONITOR COLLAPSIBLESPACER W/ BD SHARPS NEONATE MASK 69 COLLECTOR/EXTRALARGE AUTOMATIC/WRIST 26 BLOOD PRESSURE BREATHERITE RIGID 46 SPACERW/MASK 69 BD SHARPS MONITOR PREMIUM ARM/VOICE ASSIST 26 BREATHERITE VALVED MDI COLLECTOR/SMALL 46 CHAMBER/COLLAPSIBLE 69 BD SHARPS CONTAINER BLOOD PRESSURE MONITOR/AUTO ARM 26 BREATHERITE VALVED MDI HOME 46 CHAMBER/RIGID 69 BD SHARPS DISPOSAL BY BLOOD PRESSURE MONITOR/AUTOMATIC 27 BREATHERITE W/LARGE MAIL 1.4 QUART 47 MASK 69 BD VEO INSULIN SYRINGE BLOOD PRESSURE MONITOR/AUTOMATIC BREATHERITE W/MEDIUM ULTR-FINE/U-100/0.5ML/31G X MASK 69 15/64" 47 DELUXE 26 BLOOD PRESSURE BREATHERITE W/SMALL BD VEO INSULIN SYRINGE MASK 69 ULTRA-FINE/0.5ML/31G X MONITOR/AUTOMATIC/WRIS 6MM 47 T 27 BRIVIACT 4 BD VEO INSULIN SYRINGE BLOOD PRESSURE brompheniramine & ULTRA-FINE/1ML/31G X MONITOR/BASIC ARM 27 phenyleph 12 6MM 47 BLOOD PRESSURE brompheniramine & BD VEO INSULIN SYRINGE MONITOR/DELUXE ARM 27 pseudoeph 12 ULTRA-FINE/U-100/1ML/31G X BLOOD PRESSURE BUBBLES THE FISH II 15/64" 47 MONITOR/DELUXE PEDIATRIC MASK/PVC 69 BENLYSTA 75 WRIST 27 budesonide (nasal) 118 BLOOD PRESSURE BULLSEYE MINI SAFETY BENZEDREX INHALER 118 MONITOR/FULLY LANCETS 32 AUTOMATIC 27

Index 4 BULLSEYE SAFETY camphor-menthol-methyl CARETOUCH SAFETY LANCETS 32 salicylate 20 LANCETS/26G 32 bupropion hcl 5 CAPHOSOL 76 CARETOUCH SAFETY bupropion hcl (smoking CAPLYTA 9 LANCETS/28G 32 CARETOUCH SAFETY deterrent) 121 capsaicin 20 BURIED TREASURE ACTIVE LANCETS/30G 32 55PLUS SENIOR CAPZASIN 20 CARETOUCH TWIST LANCETS COMPLEX 79 carbamazepine 4 28G 32 butalbital-acetaminophen 1 CARETOUCH TWIST LANCETS carbamide peroxide (otic) 120 30G 32 butalbital-acetaminophen- carbonyl iron 24 CARETOUCH TWIST LANCETS caffeine 1 carboxymethylcellulose sodium 33G 32 butalbital-aspirin-caffeine 1 (ophth) 119 CARETOUCH UNIVERSAL BUTALBITAL/ASPIRIN/CAFFEIN CARDIOCOM LANCING CPAPFILTERS 69 E 1 DEVICE 32 CARMEX CLASSIC LIP caffeine 1 CAREONE ADVANCED BALM 21 caffeine citrate 1 LANCINGDEVICE 32 CARRINGTON MOISTURE CAREONE INSULIN BARRIER 21 CAL MAG ZINC +D3 74 SYRINGES/0.3ML/30G X CARRINGTON MOISTURE CAL-DAY 1000 79 1/2" 47 BARRIER/ZINC 21 CAL-MAG-ZINC-D 74 CAREONE INSULIN castor oil 26 CAL-MAG-ZINC-D3 74 SYRINGES/0.3ML/31G X ceftriaxone sodium 12 5/16" 47 CELEBRATE MULTI- CALCET PETITES 73 CAREONE INSULIN COMPLETE18 79 calcitriol 23 SYRINGES/0.5ML/30G X CELEBRATE MULTI- CALCIUM 73 1/2" 47 COMPLETE36 79 CAREONE INSULIN CELEBRATE MULTI- calcium ascorbate 127 SYRINGES/0.5ML/31G X CALCIUM CARBONATE 2,73 COMPLETE45 79,80 5/16" 47 CELEBRATE MULTI- calcium carbonate 73 CAREONE INSULIN COMPLETE60 80 SYRINGES/1ML/30G X calcium carbonate (antacid) 2 CELLULAR SECURITY 80 calcium carbonate- 1/2" 47 CAREONE INSULIN CELONTIN 5 cholecalciferol 73 calcium carbonate-mag SYRINGES/1ML/31GX5/16" CENTRAVITES 50 PLUS 80 hydrox 2 47 CENTRAVITES ADULTS 80 CAREONE LANCET SUPER calcium carbonate- CENTRUM 80 simethicone 2 THIN/30G 32 CAREONE LANCET THIN 32 CENTRUM CARDIO 80 calcium carbonate-vitamin d 73 CENTRUM FLAVOR calcium carbonate-vitamin d w/ CARESENS LANCETS 32 CARETOUCH 2 CPAP HOSE BURST 80 minerals 73 CENTRUM FLAVOR BURST calcium citrate 73 HANGER 69 CARETOUCH BLOOD ADULT 80 calcium citrate-vitamin d 73 PRESSUREMONITOR/AUTOM CENTRUM FRESH/FRUITY ADULTS 50+ 80 calcium polycarbophil 25 ATIC/ARM 27 80 calcium-magnesium-zinc 74 CARETOUCH BLOOD CENTRUM MEN CALCIUM/MAGNESIUM/ZINC PRESSUREMONITOR/AUTOM CENTRUM MULTIGUMMIES 74 ATIC/WRIST 27 ADULTS 80 CALCIUM/MAGNESIUM/ZINC/VI CARETOUCH CPAP & BIPAP CENTRUM MULTIGUMMIES HOSE/6FT 69 MEN 80 TAMIN D3 74 CENTRUM MULTIGUMMIES CAM 15 CARETOUCH CPAP MASK WIPES 69 MULTI +OMEGA 3 80 camphor & menthol 14 CARETOUCH CPAP CENTRUM MULTIGUMMIES camphor & phenol 14 NEUTRALIZING PRE- WOMEN 80 camphor-eucalyptus-menthol WASH 69 CENTRUM SILVER 81 13 CARETOUCH CPAP TUBE CENTRUM SILVER ULTRA camphor-eucalyptus-menthol- CLEANING BRUSH 69 WOMENS 81 turpentine oil-white CARETOUCH LANCING CENTRUM SPECIALIST petrolatum 13 DEVICEWITH EJECTOR 32 HEART 81

Index 5 CENTRUM SPECIALIST CHAPSTICK ULTRASMOOTH CLEVER CHOICE BLOOD IMMUNE SUPPORT 81 REJUVENATE 21 PRESSURE CENTRUM SPECIALIST CHAPSTICK ULTRASMOOTH MONITOR/ARM 27 VISION 81 SOOTHE 21 CLEVER CHOICE BLOOD CENTRUM ULTRA CHEMET 8 PRESSURE MONITOR/UPPER WOMENS 81 CHEMSTRIP-K 22 ARM 27 CENTRUM VITAMINTS 81 CLEVER CHOICE COMFORT CHEST RUB 13 CERALYTE 70 74 EZINSULIN chlorhexidine gluconate 12 SYRINGE/0.3ML/29G X 1/2" 47 CERASPORT 74 chlorhexidine gluconate CLEVER CHOICE COMFORT CERASPORT EX1 74 (mouth-throat) 75 EZINSULIN CERAVE 15 chloroquine phosphate 9 SYRINGE/0.3ML/30G X 1/2" 47 CERAVE AM FACIAL chlorpheniramine & CLEVER CHOICE COMFORT MOISTURIZING phenylephrine 12 EZINSULIN LOTION/SPF30 15 chlorpheniramine & SYRINGE/0.3ML/30G X CERAVE AM SPF 30 15 pseudoeph 12 5/16" 47 chlorpheniramine maleate 8 CLEVER CHOICE COMFORT CERAVE DAILY EZINSULIN MOISTURIZING 15 chlorpromazine hcl 11 SYRINGE/0.3ML/31G X CERAVE HEALING 15 CHOICEFUL 5/16" 47 CERAVE MOISTURIZING 15 MULTIVITAMIN 81 CLEVER CHOICE COMFORT CERAVE PM 15 cholecalciferol 127 EZINSULIN CERAVE PM FACIAL CICAPLAST BAUME B5 SYRINGE/0.5ML/28G X 1/2" 47 MOISTURIZING LOTION ULTRA SOOTHING MULTI-PURPOSE CLEVER CHOICE COMFORT LIGHTWEIGHT 15 BALM 15 EZINSULIN CERAVE RENEWING SA 15 cilostazol 24 SYRINGE/0.5ML/29G X 1/2" 47 cinacalcet hcl 23 CLEVER CHOICE COMFORT CERAVE SA RENEWING 15 EZINSULIN CERAVE SA/ROUGH AND citalopram hydrobromide 6 SYRINGE/0.5ML/30G X 1/2" 47 BUMPYSKIN 15 CITRACAL MAXIMUM CLEVER CHOICE COMFORT CEROVEL 14 PLUS 74 EZINSULIN CERTAVITE SENIOR 81 CITRACAL PLUS 74 SYRINGE/0.5ML/30G X CERTAVITE CLEANLET LANCETS 5/16" 47 SENIOR/ANTIOXIDANT 28G 32 CLEVER CHOICE COMFORT NUTRIENTS 81 clemastine fumarate 8 EZINSULIN CERTAVITE/ANTIOXIDANTS CLEVER CHEK LANCETS SYRINGE/0.5ML/31G X 81 ULTRATHIN 32 5/16" 47 CETAPHIL DAILY ADVANCE CLEVER CHEK LANCETS CLEVER CHOICE COMFORT ULTRA HYDRATING 15 ULTRATHIN 30G 32 EZINSULIN CETAPHIL DAILY FACIAL CLEVER CHOICE ANTI- SYRINGE/1.0ML/30G X 1/2" 47 MOISTURIZER 15 STATICVALVED HOLDING CLEVER CHOICE COMFORT CETAPHIL DERMACONTROL CHAMBER/ADULT EZINSULIN SYRINGE/1ML/28G MOISTURIZER/SPF 30 15 LARGE 69 X 1/2" 47 CETAPHIL MOISTURIZING 15 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G CETAPHIL STATICVALVED HOLDING CHAMBER/MEDIUM 69 X 1/2" 47 RESTORADERM 15 CLEVER CHOICE COMFORT CETAPHIL THERAPEUTIC CLEVER CHOICE ANTI- STATICVALVED HOLDING EZINSULIN SYRINGE/1ML/30G HAND 15 X 5/16" 47 CHANTIX 121 CHAMBER/MEDIUM/3 YEA 69 CLEVER CHOICE COMFORT CHANTIX CONTINUING CLEVER CHOICE ANTI- EZINSULIN SYRINGE/U- MONTHPAK 121 100/1ML/31GX5/16" 47 CHANTIX STARTING MONTH STATICVALVED HOLDING CHAMBER/SMALL 69 CLEVER CHOICE COMFORT PAK 121 CLEVER CHOICE ANTI- EZLANCETS 21G 32 CHAPSTICK OVERNIGHT 21 STATICVALVED HOLDING CLEVER CHOICE COMFORT CHAPSTICK ULTRASMOOTH CHAMBER/SMALL EZLANCETS 23G 32 FORTIFY 21 INFANT 69 CLEVER CHOICE COMFORT CHAPSTICK ULTRASMOOTH EZLANCETS 28G 32 NOURISH 21

Index 6 CLEVER CHOICE COMFORT ASSIST INSULIN CVS ALCOHOL PREP ELECTRONICBLOOD SYRINGE/0.5ML/31G X PADS 44 PRESSURE 5/16" 48 CVS ANTACID SOFT CHEWS MONITOR/WRIST 27 COMFORT ASSIST INSULIN ULTRA STRENGTH 2 CLEVER CHOICE PREMIUM SYRINGE/1ML/29G X 1/2" 48 CVS BEAUTY 360 DRY BLOOD PRESSURE COMFORT ASSIST INSULIN SKIN 15 MONITOR/UPPER ARM 27 SYRINGE/1ML/30G X CVS BLOOD PRESSURE CLINDAMYCIN/SODIUM 5/16" 48 MONITOR CHLORIDE 3 COMFORT ASSIST INSULIN PREMIUM/WRIST 27 CLINICAL NUTRIENTS 45-PLUS SYRINGE/1ML/31G X CVS BLOOD PRESSURE WOMEN 81 5/16" 48 MONITOR CLINICAL NUTRIENTS 50-PLUS COMFORT ASSURED PROFESSIONAL/ARM 27 MEN 81 LANCETS MICRO THIN CVS BLOOD PRESSURE CLINICAL NUTRIENTS 33G 32 MONITOR/AUTOMATIC 27 ANTIOXIDANT 81 COMFORT ASSURED CVS CALCIUM CLINICAL NUTRIENTS FOR LANCETS SUPER THIN CITRATE+D/MAGNESIUM 74 FEMALE TEENS 81 28G 32 CVS CALCIUM CITRATE+D3 CLINICAL NUTRIENTS FOR COMFORT EZ INSULIN W/MAGNESIUM 74 MALE TEENS 81 SYRINGE/U-100/0.5ML/31G X CVS CAPSAICIN 20 CLINICAL NUTRIENTS FOR 5/16" 48 CVS DAILY ULTRA MEN 81 COMFORT EZ INSULIN MOISTURELOTION 15 CLINICAL NUTRIENTS FOR SYRINGE/U-100/1ML/31G X CVS DRY MOUTH SPRAY 76 WOMEN 81 5/16" 48 CVS DRY SKIN THERAPY 15 CLN FACIAL MOISTURIZER COMFORT LANCETS 32 NOURISHING 15 CVS EYE HEALTH ADULT COMFORT TOUCH LANCETS 50+ 82 clobazam 3 ULTRA THIN 31G 32 clomipramine hcl 7 COMFORT TOUCH PLUS CVS GLUCOSE 7 CVS ISOPROPYL ALCOHOL clonazepam 3 SAFETY LANCETS PRESSURE ACTIVATED WIPES 21 clotrimazole vaginal 126 30G 32 CVS LANCETS 21G 32 clozapine 10 COMPACT SPACE CVS LANCETS MICRO THIN CO MONITOR 69 CHAMBER/ANTI-STATIC 69 33G 32 CO MONITOR REPLACEMENT COMPACT SPACE CVS LANCETS MICRO-THIN TPIECES 69 CHAMBER/ANTI- 33G 32 COAGUCHEK LANCETS 32 STATIC/LARGE MASK 69 CVS LANCETS ORIGINAL 32 COMPACT SPACE CVS LANCETS THIN 26G 32 coal tar extract 22 CHAMBER/ANTI- COARTEM 9 CVS LANCETS ULTRA THIN STATIC/MEDIUM MASK 70 30G 32 COATS ALOE LINIMENT 20 COMPACT SPACE CVS LANCETS ULTRA-THIN COCOA BUTTER 15 CHAMBER/ANTI- 30G 32 STATIC/SMALL MASK 70 COCOA BUTTER HAND & COMPLETE NEEDLE CVS LANCING DEVICE 32 BODYLOTION 15 COLLECTION & DISPOSAL CVS MOISTURIZING COCONUT OIL BEAUTY 15 SYSTEM 48 CREAM 15 cod liver oil 118 CRINONE 127 CVS ONE DAILY MENS 50+ ADVANCED 82 COMFORT ASSIST INSULIN cromolyn sodium 3 CVS ONE DAILY WOMENS SYRINGE 0.3ML/29G X 1/2" 47 COMFORT ASSIST INSULIN cromolyn sodium (nasal) 118 50+ADVANCED 82 SYRINGE/0.3ML/30G X CULTURELLE PROBIOTICS + CVS PREP PADS 44 5/16" 48 MULTIVITAMIN 81 CVS SERIES 100 BLOOD COMFORT ASSIST INSULIN CVS ADULT 50+ EYE PRESSURE MONITOR 27 SYRINGE/0.3ML/31G X HEALTH 81 CVS SERIES 400 BLOOD 5/16" 48 CVS ADVANCED BLOOD PRESSURE MONITOR/UPPER COMFORT ASSIST INSULIN PRESSURE MONITOR 27 ARM 27 SYRINGE/0.5ML/29G X 1/2" 48 CVS AFTERSUN ALOE VERA CVS SERIES 400W BLOOD COMFORT ASSIST INSULIN COOLING PRESSURE SYRINGE/0.5ML/30G X GEL/LIDOCAINE 20 MONITOR/WRIST 27 5/16" 48 CVS AIRSHIELD IMMUNITY CVS SERIES 600 BLOOD SUPPORT 81 PRESSURE MONITOR 27

Index 7 CVS SOFT GLUCOSE 7 DERMAL THERAPY HEEL digoxin 12 CVS SPECTRAVITE ADULT CARE 16 DILANTIN 5 DERMAVITE 83 50+ 82 dimethicone (topical) 21 CVS SPECTRAVITE DERMEND ALPHA + BETA ADULTS 82 HYDROXY THERAPY 16 diphenhydramine hcl 8 CVS SPECTRAVITE ULTRA DERMEND FRAGILE SKIN diphenhydramine hcl (sleep) 25 MEN50+ 82 MOISTURIZING DIPHENHYDRAMINE CVS SPECTRAVITE ULTRA FORMULA 16 HYDROCHLORIDE 8 MENS HEALTH 82 DERMEND MOISTURIZING diphenhydramine-acetaminophen CVS SPECTRAVITE ULTRA BRUISE FORMULA 16 (sleep) 25 MENS HEALTH SENIOR 82 desipramine hcl 7 diphenhydramine-zinc CVS SPECTRAVITE ULTRA desmopressin acetate 23 acetate 13 WOMEN 82 diphenoxylate w/ atropine 8 CVS SPECTRAVITE ULTRA desmopressin acetate WOMENS HEALTH 82 spray 23 disopyramide phosphate 3 CVS SPECTRAVITE ULTRA desmopressin acetate spray disulfiram 121 refrigerated 23 WOMENS HEALTH divalproex sodium 5 desvenlafaxine 7 SENIOR 82 DMAE 16 CVS SPECTRAVITE DESVENLAFAXINE ER 6 DML FORTE 16 WOMEN 82 desvenlafaxine succinate 7 DOCETAXEL 9 CVS TENSION HEADACHE 1 DEX4 7 CVS ULTRA THIN DEX4 FAST ACTING docosanol 14 LANCETS 32 GLUCOSE 7 docusate calcium 26 CVS VISION HEALTH 82 DEX4 NATURALS 7 docusate sodium 26 cyanocobalamin 24 DEX4 POUCH PACK 7 DOCUSOL PLUS MINI- cyclopentolate hcl 119 DEX4 QUICK DISSOLVE ENEMA 26 cyproheptadine hcl 9 GLUCOSE 7 dofetilide 3 DAILY CONDITIONING dexamethasone sodium doxepin hcl 7 TREATMENT 15 phosphate 12 doxylamine succinate DAILY MOISTURIZING 15 DEXAMETHASONE SODIUM (sleep) 25 DAILY MOISTURIZING PHOSPHATE 12 DR SMITHS ADULT LOTION 15 dextran 70-hypromellose 119 BARRIER 21 DAYAVITE 82 dextromethorphan DR SMITHS DIAPER 21 polistirex 12 DECUBI-VITE 82 DR SMITHS DIAPER QUICK dextromethorphan-benzocaine RELIEF 21 deferasirox 8 75 DROPLET GENTEEL LANCING DEKAS BARIATRIC 82 dextromethorphan-guaifenesin DEVICE 32 DEKAS PLUS 82,83 13 DROPLET INSULIN SYRINGE dextrose (diabetic use) 7 DENTIVA 75 0.3ML/29G X 1/2" 48 DIABETIC TUSSIN COUGH DROPLET INSULIN SYRINGE DERMABASEOIL IN DROPS 75 0.5ML/29G X 1/2" 48 WATER 15 DIABETIDERM 16 DROPLET INSULIN SYRINGE DERMACINRX RIBOTIN-E 83 DIABETIDERM FOOT 1ML/29G X 1/2" 48 DERMACINRX ZINTREXYL- REJUVENATING 16 DROPLET INSULIN SYRINGE C 83 DIABETIDERM HAND & U-100/0.3/31G X 5/16" 48 DERMADROX 21 BODY 16 DROPLET INSULIN SYRINGE DERMAIDE ALOE 15 DIACOMIT 4 U-100/0.3ML/30G X 1/2" 48 DERMAL THERAPY EXTRA DROPLET INSULIN SYRINGE DIATHRIVE LANCETS 32 U-100/0.3ML/30G X 5/16" 48 STRENGTH BODY LOTION 16 DIATHRIVE LANCETS ULTRA DERMAL THERAPY FACE DROPLET INSULIN SYRINGE THIN 30G 32 U-100/0.5ML/30G X 1/2" 48 CAREMOISTURIZING DIATHRIVE LANCING DROPLET INSULIN SYRINGE 16 LOTION DEVICE 32 U-100/0.5ML/30G X 5/16" 48 DERMAL THERAPY FOOT DROPLET INSULIN SYRINGE MASSAGE 16 diazepam (anticonvulsant) 3 dibucaine 20 U-100/0.5ML/31G X 5/16" 48 DERMAL THERAPY HAND DROPLET INSULIN SYRINGE 16 ELBOW & KNEE CREAM dicyclomine hcl 122 U-100/1ML/30G X 1/2" 48

Index 8 DROPLET INSULIN SYRINGE E-Z JECT LANCETS THIN EASY FLOW WHITE/WHITE70 U-100/1ML/30G X 5/16" 48 26G 33 EASY FLOW DROPLET INSULIN SYRINGE E-ZJECT LANCETS MICRO- WHITE/YELLOW 70 U-100/1ML/31G X 15/64" 48 THIN 33G 33 EASY MINI EJECT LANCING DROPLET INSULIN SYRINGE EASIVENT 70 DEVICE 33 U-100/1ML/31G X 5/16" 48 EASIVENT/MASK-LARGE 70 EASY MINI LANCING DROPLET INSULIN EASIVENT/MASK-MEDIUM DEVICE 33 SYRINGE/U-100/0.3ML/31G X EASY TOUCH FLIPLOCK 5/16" 48 70 EASIVENT/MASK-SMALL 70 SAFETY INSULIN SYRINGE DROPLET INSULIN 1ML/29GX1/2" 49 SYRINGE/U-100/0.5ML/30G X EASY COMFORT INSULIN EASY TOUCH FLIPLOCK 1/2" 48 SYRINGE/0.5ML/30G X SAFETY INSULIN SYRINGE DROPLET INSULIN 5/16" 49 1ML/30GX1/2" 49 SYRINGE/U-100/0.5ML/31G X EASY COMFORT INSULIN EASY TOUCH FLIPLOCK 15/64" 49 SYRINGE/0.5ML/31G X SAFETY INSULIN SYRINGE DROPLET INSULIN 5/16" 49 1ML/30GX5/16" 49 SYRINGE/U-100/0.5ML/31G X EASY COMFORT INSULIN EASY TOUCH FLIPLOCK 5/16" 49 SYRINGE/1ML/30G X SAFETY INSULIN SYRINGE DROPLET INSULIN 5/16" 49 1ML/31GX5/16" 49 SYRINGE/U-100/1ML/30G X EASY COMFORT INSULIN EASY TOUCH INSULIN 1/2" 49 SYRINGE/1ML/31G X SYRINGE/0.3ML/30G X DROPLET INSULIN 5/16" 49 5/16" 49 SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN EASY TOUCH INSULIN 15/64" 49 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/31G X DROPLET INSULIN 1/2" 49 5/16" 49 SYRINGE/U-100/1ML/31G X EASY COMFORT INSULIN EASY TOUCH INSULIN 5/16" 49 SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/29G X 1/2" 49 DROPLET LANCETS ULTRA 1/2" 49 EASY TOUCH INSULIN THIN 30G 32 EASY COMFORT SYRINGE/0.5ML/30G X DROPLET LANCING LANCETS 33 5/16" 49 DEVICE 33 EASY COMFORT LANCETS EASY TOUCH INSULIN DROPLET PERSONAL 30G/PULL TOP 33 SYRINGE/1ML/30G X 5/16" 49 LANCETS30G 33 EASY COMFORT LANCETS EASY TOUCH INSULIN droxidopa 127 30G/THIN TOP 33 SYRINGE/SAFETY/U- EASY COMFORT LANCETS DRUG MART ADJUSTABLE 100/0.5ML/29G X 1/2" 49 LANCING DEVICE 33 TWIST TOP 33 EASY TOUCH INSULIN DRUG MART LANCETS EASY FLOW 300 MM SYRINGE/SAFETY/U- HOSE 70 THIN 33 EASY FLOW 400 MM 100/0.5ML/30G X 5/16" 49 DRUG MART ON-THE-GO EASY TOUCH INSULIN LANCETS GENTLE 30G 33 HOSE 70 SYRINGE/SAFETY/U- DRUG MART UNILET EASY FLOW AIR NOZZLE70 100/1ML/29G X 1/2" 49 LANCETSSUPER THIN 30G33 EASY FLOW EASY TOUCH INSULIN DRUG MART UNILET BLACK/BLUE 70 SYRINGE/SAFETY/U- LANCETSULTRA THIN 28G 33 EASY FLOW 100/1ML/30G X 1/2" 49 DRUG MART UNILET MICRO BLACK/ORANGE 70 EASY TOUCH INSULIN THIN LANCETS 33G 33 EASY FLOW BLACK/RED 70 SYRINGE/U-100/0.3ML/30G X DRYSOL 21 EASY FLOW 1/2" 49 duloxetine hcl 7 BLACK/WHITE 70 EASY TOUCH INSULIN EASY FLOW SYRINGE/U-100/0.5ML/27G X DUOFILM 20 BLACK/YELLOW 70 1/2" 49 DUREX EXTRA SENSITIVE 29 EASY FLOW HEPA EASY TOUCH INSULIN E-Z JECT LANCETS 33 FILTER 70 SYRINGE/U-100/0.5ML/28G X E-Z JECT LANCETS 21G 33 EASY FLOW 1/2" 49 WHITE/BLUE 70 EASY TOUCH INSULIN E-Z JECT LANCETS EASY FLOW SYRINGE/U-100/0.5ML/29G X COLOR 33 WHITE/GREEN 70 E-Z JECT LANCETS SUPER 1/2" 50 33 EASY FLOW WHITE/PINK 70 EASY TOUCH INSULIN THIN 30G SYRINGE/U-100/0.5ML/30G X 1/2" 50

Index 9 EASY TOUCH INSULIN EASY TOUCH SAFETY ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X LANCETS23G/PRESSURE SYRINGE/U-100/1ML/31G X 5/16" 50 ACTIVATED 33 5/16" 50 EASY TOUCH INSULIN EASY TOUCH SAFETY ELMIRON 24 SYRINGE/U-100/1ML/27G X LANCETS26G/BUTTON ELON SKIN REPAIR 1/2" 50 ACTIVATED 34 SYSTEM 16 EASY TOUCH INSULIN EASY TOUCH SAFETY EMBRACE LANCETS ULTRA SYRINGE/U-100/1ML/28G X LANCETS26G/PRESSURE THIN 30G 34 1/2" 50 ACTIVATED 34 EMBRACE LANCING DEVICE EASY TOUCH INSULIN EASY TOUCH SAFETY WITH EJECTOR 34 SYRINGE/U-100/1ML/29G X LANCETS28G/BUTTON EMBRACE PRESSURE 1/2" 50 ACTIVATED 34 ACTIVATED SAFETY EASY TOUCH INSULIN EASY TOUCH SAFETY LANCET/21G 34 SYRINGE/U-100/1ML/30G X LANCETS28G/PRESSURE EMBRACE PRESSURE 1/2" 50 ACTIVATED 34 ACTIVATED SAFETY EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK LANCET/28G 34 SYRINGE/U-100/1ML/31G X SAFETY INSULIN SYRINGE EMERGEN-C IMMUNE 5/16" 50 1ML/29GX1/2" 50 PLUS/VITAMIN D 83 EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK EMERGEN-C VITAMIN C 83 21G/PRESSURE SAFETY INSULIN SYRINGE ACTIVATED 33 1ML/30GX5/16" 50 EMOLLIA-CREME 16 EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK EMOLLIA-LOTION 16 23G/PRESSURE SAFETY INSULIN SYRINGE emollient 16 ACTIVATED 33 1ML/31GX5/16" 50 EMSAM 6 EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 26G/PRESSURE SAFETY SYRINGE ENEMEEZ PLUS 26 ACTIVATED 33 1ML/30GX1/2" 50 ENFAMIL ENFALYTE 74 EASY TOUCH LANCETS EASY TWIST & CAP ENGERIX-B 123 26G/PULL-TOP 33 LANCETS 34 EASY TOUCH LANCETS EBASE CONTROLLER EPIDIOLEX 4 28G/PRESSURE KIT 70 EPILYT 16 ACTIVATED 33 EFLOW SCF AEROSOL EQ COMPLETE EASY TOUCH LANCETS HEAD 70 MULTIVITAMINADULTS UNDER 28G/PULL-TOP 33 ELITE DC AUTO 50 83 EASY TOUCH LANCETS ADAPTER 70 EQ MULTIVITAMINS ADULT 28G/TWIST 33 ELITE-THIN INSULIN GUMMY 83 EASY TOUCH LANCETS SYRINGE/0.3ML/31G X EQ ONE DAILY MENS 50+ 83 30G/BUTTON-ACTIVATED 33 5/16" 50 EQ ONE DAILY MENS EASY TOUCH LANCETS ELITE-THIN INSULIN HEALTH 83 30G/PRESSURE SYRINGE/0.5ML/29G X EQ ONE DAILY WOMENS ACTIVATED 33 1/2" 50 50+ 83 EASY TOUCH LANCETS ELITE-THIN INSULIN EQ ONE DAILY WOMENS 30G/PULL-TOP 33 SYRINGE/0.5ML/30G X HEALTH 83 EASY TOUCH LANCETS 5/16" 50 EQ SPACE CHAMBER ANTI- 30G/TWIST 33 ELITE-THIN INSULIN STATIC 70 EASY TOUCH LANCETS SYRINGE/1ML/30G X EQ SPACE CHAMBER ANTI- 32G/PRESSURE 5/16" 50 STATIC/LARGE MASK 70 ACTIVATED 33 ELITE-THIN INSULIN EQ SPACE CHAMBER ANTI- EASY TOUCH LANCETS SYRINGE/U-100/0.5ML/28G X STATIC/MEDIUM MASK 70 32G/PULL-TOP 33 1/2" 50 EQ SPACE CHAMBER ANTI- EASY TOUCH LANCETS ELITE-THIN INSULIN STATIC/SMALL MASK 70 32G/TWIST 33 SYRINGE/U-100/0.5ML/31G X EQ THERAPEUTIC DRY EASY TOUCH LANCETS 5/16" 50 SKIN 16 33G/TWIST 33 ELITE-THIN INSULIN EQ THERAPEUTIC EASY TOUCH LANCING SYRINGE/U-100/1ML/28G X MOISTURIZING CREAM 16 DEVICE/EJECTOR 33 1/2" 50 EQ VAPORIZING RUB 13 EASY TOUCH SAFETY ELITE-THIN INSULIN EQL ADVANCED RECOVERY LANCETS21G/PRESSURE SYRINGE/U-100/1ML/29G X SKIN CARE 16 ACTIVATED 33 1/2" 50

Index 10 EQL CENTURY MATURE EUCERIN ADVANCED famotidine-calcium carbonate- ADULTS50+ 83 REPAIR 16 magnesium hydroxide 122 EQL CENTURY MENS 83 EUCERIN BABY 16 FANAPT 10 EQL CENTURY WOMENS 83 EUCERIN DAILY FANAPT TITRATION PACK 10 EQL COLOR LANCETS 21G34 PROTECTION/SPF 30 16 FANTASY LUBRICATED 29 EUCERIN INTENSIVE EQL COLOR LANCETS MICRO REPAIR 16 FANTASY THIN 33G 34 EUCERIN INTENSIVE LUBRICATED/SPERMICIDE EQL DRY MOUTH ORAL REPAIRHAND 16 29 RINSE 76 EUCERIN ORIGINAL FATTIBASE 120 EQL INSULIN HEALINGSOOTHING felbamate 5 SYRINGE/0.3ML/29G X 1/2" 50 REPAIR 16 EQL INSULIN FEM-CAL CITRATE 74 SYRINGE/0.3ML/30G X EUCERIN PLUS 16 FERRETTS 24 EUCERIN PROFESSIONAL 5/16" 50 FERRETTS IPS 24 EQL INSULIN REPAIR RICH FEEL 16 SYRINGE/0.3ML/31G X EUCERIN ROUGHNESS ferrous fumarate 24 5/16" 50 RELIEF 16 FERROUS GLUCONATE 24 EQL INSULIN EUCERIN SMOOTHING ferrous gluconate 24 REPAIRADVANCED SYRINGE/0.5ML/29G X 1/2" 50 ferrous sulfate 24 EQL INSULIN FORMULA 16 SYRINGE/0.5ML/30G X EXEL COMFORT POINT FERROUS SULFATE 24 5/16" 50 INSULIN SYRINGE/0.3ML/29G ferrous sulfate 24 X 1/2" 51 EQL INSULIN FERROUS SULFATE 24 SYRINGE/0.5ML/31G X EXEL COMFORT POINT 5/16" 50 INSULIN SYRINGE/0.3ML/30G ferrous sulfate 24 EQL INSULIN X 5/16" 51 FETZIMA 7 SYRINGE/1ML/29G X 1/2" 50 EXEL COMFORT POINT FETZIMA TITRATION PACK 7 INSULIN SYRINGE/0.5ML/28G EQL INSULIN FEVERALL INFANTS 1 SYRINGE/1ML/30G X 5/16" 51 X 1/2" 51 EQL INSULIN EXEL COMFORT POINT FEVERALL JUNIOR SYRINGE/1ML/31G X 5/16" 51 INSULIN SYRINGE/0.5ML/29G STRENGTH 1 EQL MOISTURIZING X 1/2" 51 FIFTY50 ALCOHOL PREP CREAM 16 EXEL COMFORT POINT PADS 44 EQL ONE DAILY ADULT INSULIN SYRINGE/0.5ML/30G FIFTY50 SAFETY SEAL 83 X 5/16" 51 LANCETS 30G 34 GUMMIES FIFTY50 SAFETY SEAL EQL ONE DAILY MENS 83 EXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X LANCETS 32G 34 EQL SUPER THIN LANCETS FIFTY50 SUPERIOR 30G 34 1/2" 51 EXEL COMFORT POINT COMFORTINSULIN EQL THIN LANCETS 26G 34 INSULIN SYRINGE/1ML/29G X SYRINGE/0.3ML/31G X EQL ULTRA MOISTURIZING 1/2" 51 5/16" 51 DAILY LOTION 16 EXEL COMFORT POINT FIFTY50 SUPERIOR EQUETRO 9 INSULIN SYRINGE/1ML/30G X COMFORTINSULIN ergocalciferol 127 5/16" 51 SYRINGE/0.5ML/31G X EYE HEALTH 83 5/16" 51 ergoloid mesylates 121 FIFTY50 SUPERIOR escitalopram oxalate 6 EYE HEALTH/LUTEIN 83 COMFORTINSULIN estradiol 23 EYE MULTIVITAMIN/LUTEIN SYRINGE/1ML/31G X 5/16" 51 83 FIFTY50 UNILET LANCETS estradiol & norethindrone EYE MULTIVITAMIN/SODIUM acetate 23 33G 34 83 FILTER AIR PP 70 estradiol vaginal 126 34 EZ-LETS LANCETS 21G FINE 30 34 ESTROFACTORS 118 EZ-LETS LANCETS 26G ESTROVEN MENOPAUSE SUPER-SOFT 34 FINGERSTIX LANCETS 34 SUPPLEMENT 83 EZ-LETS LANCETS 28G FITNESS TABS FOR MEN ethosuximide 5 ULTRA-SOFT 34 AM/PM/LYCOPENE 83 etonogestrel-ethinyl estradiol12 EZ-LETS LANCETS 30G 34 FITNESS TABS FOR WOMEN AM/PM/LYCOPENE 83 24 EUCERIN 16 EZFE 200 flecainide acetate 3

Index 11 FLEET BISACODYL 26 FLYP HYPERSONIQ gabapentin 4 FLEET LIQUID GLYCERIN CARTRIDGE 70 GANCICLOVIR 12 folic acid 24 SUPPOSITORIES 25 GARDASIL 9 126 FLEXICHAMBER 70 folic acid-vitamin b6-vitamin GAVISCON 2 FLONASE SENSIMIST 118 b12 24 FOLIKA-CI 83 GENADEK STEP 1 84 FLUAD 2019-2020 124 FOLIKA-MG 84 GENADEK STEP 2 84 FLUAD 2020-2021 124 GENTEAL SEVERE 119 FLUAD QUADRIVALENT 2021- FOLITIN-Z 84 2022 124 FORA GTEL BLOOD KETONE GENTEAL SEVERE FLUAD QUADRIVALENT TEST STRIPS 22 TEARS 119 INFLUENZA VACCINE FOR FORA LANCETS 34 GENTEAL TEARS SEVERE ADULTS 124 DAY/NIGHT 119 FORA LANCING DEVICE 34 GENTEEL BUTTERFLY TOUCH FLUARIX QUADRIVALENT FORA LANCING 2019-2020 124 LANCETS 34 DEVICE/CLEARCAP 34 GENTEEL LANCING FLUARIX QUADRIVALENT FORA P20 BLOOD 2020-2021 124 DEVICE/GLORIOUS GOLD 34 PRESSURE MONITORING GENTEEL LANCING FLUARIX QUADRIVALENT SYSTEM 27 2021-2022 124 DEVICE/PRECIOUS FORA TEST N' GO BP PLATINUM 34 FLUBLOK QUADRIVALENT BLOODPRESSURE 2019-2020 124 GENTEEL LANCING MONITORING SYSTEM 27 DEVICE/STATELY SILVER 34 FLUBLOK QUADRIVALENT formaldehyde 12 2020-2021 124 GENTEEL LANCING FLUBLOK QUADRIVALENT FORTAVIT 84 KIT/BUTTERFLY BLUE 34 2021-2022 124 fosphenytoin sodium 5 GENTEEL PLUS LANCING DEVICE/BUFF BLACK 34 FLUCELVAX QUADRIVALENT FREDS PHARMACY 2019-2020 124 GENTEEL PLUS LANCING AUTOLET LANCING DEVICE/BUTTERFLY BLUE 34 FLUCELVAX QUADRIVALENT DEVICE 34 2020-2021 124 GENTEEL PLUS LANCING FREDS PHARMACY UNILET DEVICE/PLAYFUL PURPLE 34 FLUCELVAX QUADRIVALENT LANCETS SUPER THIN 2021-2022 124 GENTEEL PLUS LANCING 30G 34 DEVICE/PRINCESS PINK 35 fludrocortisone acetate 12 FREDS PHARMACY UNILET GENTEEL PLUS LANCING FLULAVAL QUADRIVALENT LANCETS ULTRA THIN DEVICE/WILLOWY WHITE 35 2019-2020 125 28G 34 GENTLE 17 FLULAVAL QUADRIVALENT FREEDAVITE 84 GENTLE-LET GP LANCETS 35 2020-2021 125 FREESTYLE LANCETS 34 FLULAVAL QUADRIVALENT GENTLE-LET LANCETS 2021-2022 125 FREESTYLE PRECISION GENERAL PURPOSE INSULIN SYRINGE/U- FLUMIST QUADRIVALENT125 STYLE/FINE POINT 35 100/0.5ML/30G X 5/16" 51 GENTLE-LET LANCETS fluocinolone acetonide FREESTYLE PRECISION (otic) 120 GENERAL PURPOSE INSULIN SYRINGE/U- STYLE/MEDIUM POINT 35 fluorouracil (topical) 14 100/0.5ML/31G X 5/16" 51 GENTLE-LET LANCETS fluoxetine hcl 6 FREESTYLE PRECISION SAFETY STYLE/FINE fluoxetine hcl (pmdd) 121 INSULIN SYRINGE/U- POINT 35 100/1ML/31G X 5/16" 51 fluphenazine decanoate 11 GENTLE-LET LANCETS FREESTYLE PRECISION SAFETY STYLE/MEDIUM fluphenazine hcl 11 INSULIN SYRINGES/U- POINT 35 fluvoxamine maleate 6 100/1ML/30G X 5/16" 51 GERI PROTECT 21 FREESTYLE UNISTICK II FLUZONE HIGH-DOSE PF 2020- GERI-FREEDA SENIOR 2021 125 LANCETS 34 FULL KIT NEBULIZER FORMULA 84 FLUZONE HIGH-DOSE PF 2021- GLEOSTINE 9 2022 125 SET 70 FLUZONE QUADRIVALENT FULL SPECTRUM B/VITAMIN GLOBAL EASY GLIDE INSULIN 2019-2020 125 C 77 SYRINGE/0.5ML/31G X FLUZONE QUADRIVALENT furosemide 23 15/64" 51 2020-2021 125 GLOBAL EASY GLIDE INSULIN FUSION 24 SYRINGE/1ML/31G X FLUZONE QUADRIVALENT FYCOMPA 3 2021-2022 126 15/64" 51

Index 12 GLOBAL EASY GLIDE GLUCOCOM LANCETS GNP INSULIN INSULINSYRINGE/U- 33G 35 SYRINGE/0.5ML/30G X 100/0.3ML/31G X 5/16" 51 GLUCOPRO INSULIN 5/16" 53 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X GNP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 52 SYRINGE/0.5ML/31G X 1/2" 51 GLUCOPRO INSULIN 5/16" 53 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X GNP INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 52 SYRINGE/1ML/28G X 1/2" 53 1/2" 51 GLUCOPRO INSULIN GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/31G X SYRINGE/1ML/29G X 1/2" 53 SYRINGE/U-100/0.3ML/30G X 5/16" 52 GNP INSULIN 5/16" 51 GLUCOPRO INSULIN SYRINGE/1ML/30G X 5/16" 53 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X GNP INSULIN SYRINGE/U-100/0.3ML/31G X 1/2" 52 SYRINGE/1ML/31G X 5/16" 53 5/16" 51 GLUCOPRO INSULIN GNP INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/30G X SYRINGES/1ML/28GX1/2" 53 SYRINGE/U-100/0.5ML/28G X 5/16" 52 GNP INSULIN 1/2" 52 GLUCOPRO INSULIN SYRINGES/3ML/31GX5/16" 53 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/31G X GNP ISOPROPYL ALCOHOL SYRINGE/U-100/0.5ML/29G X 5/16" 52 WIPES 21 1/2" 52 GLUCOPRO INSULIN GNP LANCETS 21G 35 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X GNP LANCETS MICRO THIN SYRINGE/U-100/0.5ML/30G X 1/2" 52 33G 35 1/2" 52 GLUCOPRO INSULIN GNP LANCETS SUPER THIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 30G 35 SYRINGE/U-100/0.5ML/30G X 5/16" 52 GNP LANCETS THIN 35 5/16" 52 GLUCOPRO INSULIN GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X GNP LANCETS THIN 26G 35 SYRINGE/U-100/0.5ML/31G X 5/16" 52 GNP QUICK DISSOLVE 5/16" 52 glucosamine-chondroitin-vit c- GLUCOSE 7 GLOBAL INJECT EASE INSULIN manganese 1 GNP STERILE LANCETS SYRINGE/U-100/1ML/28G X 28G 35 GLUCOSE 7 GNP STERILE LANCETS 1/2" 52 GLUCOSE INSTANT GLOBAL INJECT EASE INSULIN 30G 35 ENERGY 7 GNP STERILE LANCETS SYRINGE/U-100/1ML/29G X glycerin (laxative) 25 1/2" 52 33G 35 GLOBAL INJECT EASE INSULIN glycerin (topical) 17 GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X glycerin-hypromellose- INSULIN SYRINGE/0.3ML/29G X 1/2" 52 polyethylene glycol 400 119 1/2" 53 GLOBAL INJECT EASE INSULIN glycopyrrolate 122 GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X INSULIN SYRINGE/0.3ML/30G X GNP ALCOHOL SWABS 44 5/16" SHORT 53 5/16" 52 GNP CAPSAICIN 20 GLOBAL INJECT EASE INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/31G X GNP GLUCOSE 7 INSULIN SYRINGE/0.5ML/28G X 5/16" 52 GNP INSULIN 1/2" 53 GLOBAL INJECT EASE SYRINGE/0.3ML/29G X GNP ULTRA COMFORT LANCETS 28G 35 1/2" 52 INSULIN SYRINGE/0.5ML/29G X GLOBAL INJECT EASE GNP INSULIN 1/2" 53 LANCETS 30G 35 SYRINGE/0.3ML/30G X GNP ULTRA COMFORT GLOBAL INSULIN SYRINGE/U- 5/16" 52 INSULIN SYRINGE/1ML/28G X 100/0.3ML/30G X 1/2" 52 GNP INSULIN 1/2" 53 GLOBAL INSULIN SYRINGES/U- SYRINGE/0.3ML/31G X GNP ULTRA COMFORT 100/0.3ML/30GX5/16" 52 5/16" 52 INSULIN SYRINGE/1ML/29G X GLOBAL LANCING DEVICE 35 GNP INSULIN 1/2" 53 SYRINGE/0.5ML/28G X GOJJI BLOOD KETONE TEST GLUCOCOM LANCETS STRIPS 22 28G 35 1/2" 52 GNP INSULIN GOJJI LANCING GLUCOCOM LANCETS DEVICE/CLEAR CAP 35 30G 35 SYRINGE/0.5ML/29G X 1/2" 52

Index 13 GOJJI STERILE LANCETS GUARDIAN SHARPS GUARDIAN SHARPS 30G 35 COLLECTORHORIZONTAL COLLECTORONE-PIECE GOLD BOND MEDICATED NESTABLE 5.4 QT 53 PHLEBOTOMY 1QT 54 BODYLOTION 17 GUARDIAN SHARPS GUARDIAN SHARPS GOLD BOND MEDICATED COLLECTORHORIZONTAL COLLECTORONE-PIECE X-L BODYLOTION EXTRA PRE-ASSEMBLED 5.4 QT 53 LARGE FUNNEL 5 GAL 54 STRENGTH 17 GUARDIAN SHARPS GUARDIAN SHARPS GOLD BOND ULTIMATE 17 COLLECTORNESTABLE 16 COLLECTORONE-PIECE X-L GOLD BOND ULTIMATE GAL 53 OPEN TOP 5 GAL 54 DIABETICS DRY SKIN GUARDIAN SHARPS GUARDIAN SHARPS RELIEF 17 COLLECTORNESTABLE 8 COLLECTORONE-PIECE X-L GOLD BOND ULTIMATE QT 53 OPEN TOP NV 5 GAL 54 DIABETICS' DRY RELIEF 17 GUARDIAN SHARPS GUARDIAN SHARPS GOLD BOND ULTIMATE COLLECTORNESTABLE COLLECTORSIDE ENTRY HEALING 17 LARGE FUNNEL 14 QT 53 NESTABLE 5.4 QT 54 GOLD BOND ULTIMATE GUARDIAN SHARPS GUARDIAN SHARPS OVERNIGHT 17 COLLECTORNESTABLE COLLECTORSIDE ENTRY PRE- GOLD BOND ULTIMATE LARGE FUNNEL 6 GAL 53 ASSEMBLED 5.4 QT 54 PROTECTION 17 GUARDIAN SHARPS GUARDIAN SHARPS GOLD BOND ULTIMATE COLLECTORNESTABLE NON- COLLECTORVERTICAL ENTRY RESTORING 17 VENTED 8 QT 53 3.2 QT 54 GOLD BOND ULTIMATE GUARDIAN SHARPS GUARDIAN SHARPS ROUGH& BUMPY SKIN 17 COLLECTORNESTABLE COLLECTORVERTICAL ENTRY GOLD BOND ULTIMATE OPEN 14 QT 53 NON-VENTED 3.2 QT 54 SHEERRIBBONS GUARDIAN SHARPS H-E-B INCONTROL PEARLRADIANCE 17 COLLECTORNESTABLE ADVANCEDLANCING GOLD BOND ULTIMATE OPEN TOP 6 GAL 53 DEVICE 35 SHEERRIBBONS GUARDIAN SHARPS H-E-B INCONTROL FULLY SILKSOFTNESS 17 COLLECTORNESTABLE AUTOMATIC BLOOD GOLD BOND ULTIMATE OPEN TOP NV 6 GAL 53 PRESSURE MONITOR 27 SOFTENING 17 GUARDIAN SHARPS H-E-B INCONTROL LANCETS GOLD BOND ULTIMATE COLLECTORNESTABLE MICRO THIN 33G 35 SOOTHING 17 SMALL FUNNEL 14 QT 53 H-E-B INCONTROL LANCETS GOODSENSE CAPSAICIN GUARDIAN SHARPS SUPER THIN 30G 35 ARTHRITIS PAIN RELIEF 20 COLLECTORNESTABLE H-E-B INCONTROL LANCETS GOODSENSE COLOR SMALL FUNNEL NV 14 ULTRA THIN 28G 35 LANCETS MICRO-THIN 33G QT 53 HAEMOLANCE 35 UNIVERSAL 35 GUARDIAN SHARPS HAEMOLANCE LOW FLOW GOODSENSE GLUCOSE 7 COLLECTORONE-PIECE LANCETS 35 GOODSENSE LANCETS HOME CARE 1QT 53 HAEMOLANCE PLUS 36 MICRO-THIN 33G 35 GUARDIAN SHARPS HAEMOLANCE PLUS HIGH GOODSENSE LANCETS COLLECTORONE-PIECE FLOW 35 MICRO-THIN 33G LARGE 8.2 QT 53 HAEMOLANCE PLUS LOW UNIVERSAL 35 GUARDIAN SHARPS FLOW 35 GOODSENSE LANCETS COLLECTORONE-PIECE HAEMOLANCE PLUS MAX ULTRA-THIN 26G LARGE NON-VENTED 8.2 FLOW 35 UNIVERSAL 35 QT 54 HAEMOLANCE PLUS GOODSENSE LANCETS GUARDIAN SHARPS PEDIATRIC FLOW 36 ULTRA-THIN 30G 35 COLLECTORONE-PIECE HAIR SKIN & NAILS ADVANCED GOODSENSE LANCETS MEDIUM 6.9 QT 54 FORMULA 84 ULTRA-THIN 30G GUARDIAN SHARPS HAIR/SKIN/NAILS 84 UNIVERSAL 35 COLLECTORONE-PIECE GOODSENSE LANCING MEDIUM NON-VENTED 6.9 haloperidol 10 DEVICE 35 QT 54 haloperidol decanoate 10 GRX VITAMIN E 17 GUARDIAN SHARPS haloperidol lactate 10 GRX WHITE COLLECTORONE-PIECE OFFSET NECK 9.2 QT 54 HAVRIX 126 PETROLATUM 120 HEALTH CARE LANCING guaifenesin 13 DEVICE 36

Index 14 HEALTH SENSE BLOOD HM COMPLETE MEN 84 IN-CHECK DIAL PRESSURE MONITOR/UPPER- HM DELUXE BLOOD INSPIRATORYFLOW ARM 27 PRESSUREMONITOR/WRIST TRAINER 70 HEALTH SENSE BLOOD 28 IN-CHECK INSPIRATORY PRESSURE MONITOR/XL SIZE HM GLUCOSE 7 FLOWMETER/NASAL WITH CUFF 28 MASK 71 HEALTHWISE INSULIN HM HAIR/SKIN/NAILS 84 IN-CHECK INSPIRATORY SYRINGE/U-100/0.3ML/30G X HM ONE DAILY FLOWMETER/ORAL 71 5/16" 54 ESSENTIAL 77 INFLECTRA 23 HEALTHWISE INSULIN HM ONE DAILY MENS 84 INNOSPIRE REPLACEMENT SYRINGE/U-100/0.3ML/31G X HM ONE DAILY WOMENS84 FILTER 71 5/16" 54 HM STERILE ALCOHOL PREP INSPIRACHAMBER/ANTI- HEALTHWISE INSULIN PADS 44 STATIC SYRINGE/U-100/0.5ML/30G X HM ULTICARE INSULIN VALVED/MOUTHPIECE 71 5/16" 54 SYRINGE/1ML/30G X 1/2" 54 INSPIRACHAMBER/LARGE HEALTHWISE INSULIN HM ULTICARE INSULIN 71 SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.3ML/31G X INSPIRACHAMBER/SOOTHER 5/16" 54 5/16" 54 MASK/INSPIRAMASK/MEDIUM HEALTHWISE INSULIN HUDSON RCI SEE-THRU 71 SYRINGE/U-100/1ML/30G X AEROSOL MASK INSPIRACHAMBER/SOOTHER 5/16" 54 ELONGATED/ADULT 70 MASK/INSPIRAMASK/SMALL HEALTHWISE INSULIN HY-VEE GLUCOSE 7 71 SYRINGE/U-100/1ML/31G X INSPIREASE DRUG 5/16" 54 HY-VEE LANCETS 36 DELIVERYSYSTEM 71 HEALTHY ACCENTS AUTOLET HY-VEE THIN LANCETS 36 INSTA-GLUCOSE 7 IMPRESSION LANCING hydralazine hcl 9 INSULIN SYRINGE/0.3ML/29G X DEVICE 36 1/2" 54 HEALTHY ACCENTS UNILET HYDRALYTE 74 HYDRALYTE FREEZER INSULIN SYRINGE/0.3ML/30G X LANCETS SUPER THIN 5/16" 54 30G 36 POPS 74 HYDRASYN25 17 INSULIN SYRINGE/0.3ML/31G X HEART CHECK BLOOD 5/16" 54 PRESSURE HYDRAZONE LOTION 17 INSULIN SYRINGE/0.5ML/27G X MONITOR/WRIST 28 HYDROCERIN 21 1/2" 54 3 heparin sodium (porcine) hydrocortisone (intrarectal) 2 INSULIN SYRINGE/0.5ML/28G X 126 1/2" 54 HEPLISAV-B hydroxychloroquine sulfate 9 HIGH POTENCY INSULIN SYRINGE/0.5ML/30G X MULTIVITAMIN 118 hydroxyzine hcl 3 1/2" 54 HIGH POTENCY hydroxyzine pamoate 3 INSULIN SYRINGE/0.5ML/30G X MULTIVITAMIN/BETA- HYLAZINC 84 5/16" 54 CAROTENE 84 INSULIN SYRINGE/0.5ML/31G X HIGH POTENCY hyoscyamine sulfate 122 5/16" 55 MULTIVITAMIN/FOLIC HYPERTET S/D 120 INSULIN SYRINGE/1ML/28G X ACID 84 HYPOLANCE AST LANCING 1/2" 55 HISTAFLEX 1 KIT 36 INSULIN SYRINGE/1ML/29G X ibuprofen-diphenhydramine 1/2" 55 HM ADVANCED BLOOD INSULIN SYRINGE/1ML/30G X PRESSURE MONITOR citrate 25 ICAPS AREDS FORMULA 84 5/16" 55 AUTOMATIC 28 INSULIN SYRINGE/NEEDLE HM AUTOMATIC BLOOD ICAPS LUTEIN & ZEAXANTHIN 84 0.3ML/30G X 5/16" 55 PRESSURE MONITOR INSULIN SYRINGE/NEEDLE DELUXE 28 imipramine hcl 7 0.3ML/31G X 5/16" 55 HM BLOOD PRESSURE imipramine pamoate 7 INSULIN SYRINGE/NEEDLE MONITORFULLY IMMUNE SUPPORT 84 0.5ML/29G X 1/2" 55 AUTOMATIC 28 INSULIN SYRINGE/NEEDLE HM COMPLETE 84 IN TOUCH LANCING DEVICE 36 0.5ML/30G X 5/16" 55 HM COMPLETE 50+ MENS IN TOUCH STERILE INSULIN SYRINGE/NEEDLE ULTIMATE 84 LANCETS30G 36 0.5ML/31G X 5/16" 55 HM COMPLETE 50+ WOMENS INSULIN SYRINGE/NEEDLE ULTIMATE 84 1ML/29G X 1/2" 55

Index 15 INSULIN SYRINGE/NEEDLE isosorbide dinitrate 3 KIMONO PS LUBRICATED 30 1ML/30G X 5/16" 55 isotretinoin 13 KIMONO PS PLUS INSULIN SYRINGE/NEEDLE ITCH-X 20 SPERMICIDE/LUBRICATED 1ML/31G X 5/16" 55 30 INSULIN SYRINGE/U- J & J BURN CREAM 17 KIMONO SENSATION 100/0.3ML/29G X 1/2" 55 JANSSEN COVID-19 LUBRICATED 30 INSULIN SYRINGE/U- VACCINE 126 KIMONO SENSATION PLUS 100/0.5ML/29G X 1/2" 55 JETREA 119 SPERMICIDE LUBRICATED30 INSULIN SYRINGE/U- JOHNSONS SKIN NOURISH KIMONO SPECIAL 30 100/1ML/29G X 1/2" 55 VANILLA OAT LOTION 17 KINDERLYTE 74 INSULIN SYRINGE/U- K-PAX IMMUNE SUPPORT 100/1ML/30G X 5/16" 55 FORMULA DOUBLE KINDERLYTE PREMAX 74 INSULIN SYRINGE/U- STRENGTH 84 KINNEY LANCETS 36 100/1ML/31G X 5/16" 55 K-PAX IMMUNE SUPPORT KINNEY THIN LANCETS 36 INSULIN FORMULA PROFESSIONAL SYRINGES/0.5ML/27GX1/2" KINRAY INSULIN SYRINGE STRENGTH 84 PREFERRED PLUS/0.3ML/31G 55 K-PAX IMMUNE SUPPORT INSULIN X 5/16" 55 FORMULA SINGLE KINRAY INSULIN SYRINGE SYRINGES/0.5ML/28GX1/2" STRENGTH 84 55 PREFERRED PLUS/0.5ML/31G K-Y ME & YOU EXTRA X 5/16" 56 INSULIN LUBRICATED 29 SYRINGES/0.5ML/29GX1/2" KINRAY INSULIN SYRINGE 55 K-Y ME & YOU INTENSE 29 PREFERRED PLUS/1ML/31G X INSULIN KAMELEON 5/16" 56 SYRINGES/0.5ML/30GX5/16" LUBRICATED 29 KINRAY INSULIN 55 KERADAN 17 SYRINGE/0.5ML/29G X 1/2" 56 INSULIN KERI ADVANCED MOISTURE KMART VALU PLUS INSULIN SYRINGES/0.5ML/31GX THERAPY 17 SYRINGE/0.3ML/30G 56 5/16" 55 KERI BASIC ESSENTIALS17 KMART VALU PLUS INSULIN INSULIN SYRINGE/1ML/29G 56 KERI LONG LASTING 17 KMART VALU PLUS INSULIN SYRINGES/0.5ML/31GX5/16" KERI NOURISHING SHEA 55 SYRINGE/1ML/30G 56 INSULIN BUTTER 17 KONSYL DAILY FIBER 25 SYRINGES/1ML/27GX/1/2" 55 KERI ORIGINAL 17 KONSYL DAILY PSYLLIUM INSULIN KERI ORIGINAL DAILY FIBER 25 SYRINGES/1ML/27GX1/2" 55 MOISTURE 17 KONSYL ORIGINAL DAILY INSULIN KERI OVERNIGHT 17 FIBER 25 SYRINGES/1ML/28GX1/2" 55 KERI RENEWAL MILK KONSYL-D 25 INSULIN BODY 17 KROGER AUTOLET LANCING SYRINGES/1ML/29GX1/2" 55 KERI RENEWAL SKIN DEVICE 36 INSULIN FIRMING 17 KROGER BLOOD PRESSURE SYRINGES/1ML/30GX1/2" 55 KERI RENEWAL STRETCH MONITOR/AUTOMATIC 28 INSULIN MARK MINIMIZER 17 KROGER BLOOD PRESSURE SYRINGES/1ML/31GX5/16" 55 KERI SENSITIVE SKIN 17 MONITOR/DELUXE WRIST 28 INTEGRA 24 KETONE 22 KROGER BLOOD PRESSURE MONITOR/PREMIUM INTRAROSA 126 KETONE TEST STRIPS 22 INVEGA SUSTENNA 10 AUTOMATIC 28 KETOSTIX 22 KROGER GLUCOSE 7 INVEGA TRINZA 10 KIMONO COLORS 29 KROGER HEALTHPRO TWIST iron-docusate-b12-folic acid-vit c- KIMONO LUBRICATED 29 LANCETS/26G 36 vit e-copper-biotin 24 KROGER INSULIN iron-vitamin c 24 KIMONO MICRO THIN PLUS SPERMICIDE SYRINGE/0.3ML/29G X 1/2" 56 isoniazid 9 LUBRICATED 29 KROGER INSULIN isopropyl alcohol (otic) 120 KIMONO PLUS SPERMICIDE SYRINGE/0.3ML/30G X ISOPROPYL ALCOHOL LUBRICATED 29 5/16" 56 WIPES 21 KIMONO PLUS KROGER INSULIN SYRINGE/0.3ML/31G X ISOPTO ATROPINE 119 SPERMICIDE/LUBRICATED 29 5/16" 56 ISOPTO TEARS 119

Index 16 KROGER INSULIN LANCETS 33G EXTRA LEADER INSULIN SYRINGE/0.5ML/29G X 1/2" 56 FINE 36 SYRINGE/1ML/28G X 1/2" 56 KROGER INSULIN LANCETS 33G UNIVERSAL LEADER INSULIN SYRINGE/0.5ML/30G X DESIGN 36 SYRINGE/1ML/29G X 1/2" 56 5/16" 56 LANCETS MICRO THIN LEADER INSULIN KROGER INSULIN 33G 36 SYRINGE/1ML/30G X 5/16" 56 SYRINGE/0.5ML/31G X LANCETS SAFETY SEAL LEADER INSULIN 5/16" 56 21G 36 SYRINGE/1ML/31G X 5/16" 56 KROGER INSULIN LANCETS SAFETY SEAL LEADER QUICK DISSOLVE SYRINGE/1ML/29G X 1/2" 56 26G 36 GLUCOSE 7 KROGER INSULIN LANCETS SAFETY SEAL leflunomide 1 SYRINGE/1ML/30G X 5/16" 56 28G 36 leucovorin calcium 9 KROGER INSULIN LANCETS SAFETY SEAL SYRINGE/1ML/31G X 5/16" 56 30G 36 levetiracetam 4 KROGER LANCETS 36 LANCETS SUPER THIN levetiracetam in sodium chloride 4 KROGER LANCETS 21G 36 28G 36 LANCETS THIN 36 LEVOCARNITINE 119 KROGER LANCETS MICRO levocarnitine (metabolic THIN33G 36 LANCETS TWIST TOP 36 modifiers) 23 KROGER LANCETS SUPER LANCETS ULTRA FINE 36 LIBERTY MEDICAL LANCETS THIN 36 LANCETS ULTRA THIN 37 30G 37 KROGER LANCETS THIN 36 LANCETS ULTRA THIN LIBERTY MINI LANCING KROGER LANCETS THIN 30G 36 DEVICE 37 26G 36 LANCETSBULLSEYE lidocaine 21 KROGER LANCETS SAFETY 37 LIDOCAINE 21 ULTRATHIN30G 36 LANCING DEVICE 37 lidocaine 21 KROGER LANCING LANCING DEVICE DEVICE 36 ADJUSTABLE 37 lidocaine (anorectal) 2 KYLEENA 12 LANTISEPTIC SKIN lidocaine hcl 21 lactase 23 PROTECTANT 21 lidocaine hcl (mouth-throat) 75 lactic acid (ammonium LANZO 37 lidocaine-prilocaine 21 lactate) 17 LATUDA 9 LACTINOL HX 17 LIFESCAN UNISTIK 2 DEEP LEADER ADVANCED PENETRATION 37 lactobacillus acidophilus- LANCING DEVICE 37 LIFESCAN UNISTIK II pectin 8 LEADER FINGER CREAM 18 LANCETS 37 lactulose 25 LEADER GLUCOSE 7 LIP BALM BASE 120 lactulose (encephalopathy) 24 LEADER INSULIN LITE TOUCH LANCETS 37 LADY ESTHER 4 PURPOSE SYRINGE/0.3ML/29G X LITE TOUCH LANCING FACE CREAM 17 1/2" 56 PEN 37 LAMICTAL ODT 4 LEADER INSULIN LITEAIRE 71 LAMICTAL XR 4 SYRINGE/0.3ML/30G X LITETOUCH INSULIN lamotrigine 4 5/16" 56 SYRINGE/0.3ML/29G X 1/2" 56 LEADER INSULIN LANAPHILIC 17 LITETOUCH INSULIN SYRINGE/0.3ML/31G X SYRINGE/0.3ML/30G X LANCET DEVICE 5/16" 56 ADJUSTABLE 36 5/16" 56 LEADER INSULIN LITETOUCH INSULIN LANCET DEVICE WITH SYRINGE/0.5ML/28G X EJECTOR 36 SYRINGE/0.3ML/31G X 1/2" 56 5/16" 56 LANCETS 36 LEADER INSULIN LITETOUCH INSULIN LANCETS 26G TWIST TOP 36 SYRINGE/0.5ML/29G X SYRINGE/0.5ML/30G X 1/2" 56 5/16" 56 LANCETS 28G 36 LEADER INSULIN LANCETS 30G 36 LITETOUCH INSULIN SYRINGE/0.5ML/30G X SYRINGE/0.5ML/31G X LANCETS 30G TWIST TOP 36 5/16" 56 5/16" 56 LANCETS 30G/TWIST TOP 36 LEADER INSULIN LITETOUCH INSULIN SYRINGE/0.5ML/31G X SYRINGE/1ML/30G X 5/16" 57 LANCETS 31G TWIST TOP 36 5/16" 56

Index 17 LITETOUCH INSULIN loxapine succinate 10 MAGONATE 74 SYRINGE/U-100/0.3ML/30G X lubricants 21 maprotiline hcl 6 5/16" 57 LITETOUCH INSULIN LUBRIDERM 18 MARPLAN 6 SYRINGE/U-100/0.3ML/31G X LUBRIDERM ADVANCED MAXAM 18 5/16" 57 THERAPY 18 MAXI-COMFORT INSULIN LITETOUCH INSULIN LUBRIDERM DAILY SYRINGE/U- SYRINGE/U-100/0.5ML/28G X MOISTURE/NORMAL TO DRY 100/0.5ML/28GX1/2" 57 1/2" 57 SKIN 18 MAXI-COMFORT INSULIN LITETOUCH INSULIN LUBRIDERM DAILY SYRINGE/U-100/1ML/28GX1/2" SYRINGE/U-100/0.5ML/29G X MOISTURESHEA + CALMING 57 1/2" 57 LAVENDER JASMINE 18 MAXICOMFORT INSULIN LITETOUCH INSULIN LUBRIDERM INTENSE SKIN SYRINGES 27G X 1/2" 57 SYRINGE/U-100/0.5ML/30G X REPAIR 18 MAXX LUBRICATED 30 LUBRIDERM MENS 3-IN- 5/16" 57 MAXX PLUS SPERMICIDE LITETOUCH INSULIN 1 18 LUBRIDERM SERIOUSLY LUBRICATED 30 SYRINGE/U-100/0.5ML/31G X MEDERMA AG FACE 5/16" 57 SENSITIVE 18 LUBRIDERM SKIN CREAM 18 LITETOUCH INSULIN MEDERMA AG HAND & BODY SYRINGE/U-100/1ML/28G X NOURISHINGWITH SHEA AND COCOA BUTTERS 18 LOTION 18 1/2" 57 MEDERMA STRETCH MARKS LITETOUCH INSULIN LUBRISOFT 18 THERAPY 18 SYRINGE/U-100/1ML/29G X LUTEIN MEDIC INSULIN 1/2" 57 PLUS/ZEAXANTHIN 84 SYRINGE/0.3ML/30G X LITETOUCH INSULIN LYCELLE 22 5/16" 57 SYRINGE/U-100/1ML/30G X M-CLEAR WC 13 MEDIC INSULIN 5/16" 57 M-M-R II 126 SYRINGE/0.5ML/30G X LITETOUCH INSULIN 5/16" 57 SYRINGE/U-100/1ML/31G X MACULAR VITAMIN MEDICHOICE PRE-SET 5/16" 57 BENEFIT 85 SAFETY LANCET DUAL LITETOUCH LANCETS MICRO MAG-AL 2 USE 37 THIN 33G 37 MAGELLAN INSULIN SAFETY MEDICHOICE PRE-SET LITETOUCH MASK LARGE 71 SYRINGE/U-100/0.3ML/29G X SAFETY LANCET LOW LITETOUCH MASK 1/2" 57 FLOW 37 MEDIUM 71 MAGELLAN INSULIN SAFETY MEDICHOICE PRE-SET LITETOUCH MASK SMALL 71 SYRINGE/U-100/0.3ML/30G X SAFETY LANCET MEDIUM 5/16" 57 LITHIUM 9 FLOW 37 MAGELLAN INSULIN SAFETY MEDICHOICE PRE-SET lithium carbonate 9 SYRINGE/U-100/0.5ML/29G X SAFETY LANCET MODERATE LIVE BETTER ADVANCED 1/2" 57 FLOW 37 LANCING DEVICE 37 MAGELLAN INSULIN SAFETY MEDICHOICE SAFETY LIVE BETTER LANCET SYRINGE/U-100/0.5ML/30G X LANCETEXTRA 37 SUPERTHIN 30G 37 5/16" 57 MEDICHOICE SAFETY LIVE BETTER LANCET MAGELLAN INSULIN SAFETY LANCETNORMAL 37 ULTRATHIN 28G 37 SYRINGE/U-100/1ML/29G X MEDISENSE THIN LONGS GLUCOSE 7 1/2" 57 LANCETS 37 LONGS INSULIN MAGELLAN INSULIN SAFETY MEDLANCE PLUS EXTRA SYRINGE/0.5ML/31G X SYRINGE/U-100/1ML/30G X LANCETS 21G 37 5/16" 57 5/16" 57 MEDLANCE PLUS LONGS LANCETS magnesium 74 LANCETS 37 STANDARD 37 magnesium chloride 74 MEDLANCE PLUS LANCETS LITE 25G 37 LONGS LANCETS THIN 37 magnesium citrate 26 LONGS LANCETS ULTRA MEDLANCE PLUS LITE THIN 37 magnesium hydroxide 26 LANCETS 25G 37 magnesium oxide 2 MEDLANCE PLUS SPECIAL loperamide hcl 8 LANCETS 0.8MM 37 loratadine & MAGNESIUM OXIDE 74 MEDLANCE PLUS SUPERLITE pseudoephedrine 13 magnesium sulfate 30G 37 lorazepam 3 (laxative) 26

Index 18 MEDLANCE PLUS SUPERLITE methazolamide 23 MISTASSIST 71 30G/COMFORT MAX 37 methenamine hippurate 3 MM INSULIN SYRINGE/U- MEDLANCE PLUS UNIVERSAL methenamine mandelate 3 100/0.3ML/30G X 5/16" 57 LANCETS 21G 37 MM INSULIN SYRINGE/U- MEDLANCE PLUS/LITE methimazole 122 100/0.3ML/31G X 5/16" 57 25G 37 methylcellulose (laxative) 25 MM INSULIN SYRINGE/U- MEDLANCE/EXTRA 37 methylergonovine 100/1/2ML/30G X 5/16" 57 MEDLANCE/LITE 37 maleate 120 MM INSULIN SYRINGE/U- MEDLANCE/UNIVERSAL 37 metronidazole (topical) 22 100/1/2ML/31G X 5/16" 58 MM INSULIN SYRINGE/U- MEDPURA ALCOHOL mexiletine hcl 3 100/1ML/30G X 5/16" 58 PADS 22 miconazole nitrate MM INSULIN SYRINGE/U- medroxyprogesterone vaginal 126 100/1ML/31G X 5/16" 58 acetate 120 MICROCHAMBER 71 medroxyprogesterone acetate MM LANCING DEVICE 38 MICROELITE FILTER MM TWIST LANCETS 38 (contraceptive) 12 REPLACEMENTS 71 mefloquine hcl 9 MICROELITE MODERNA COVID-19 MEGA MULTI FOR MEN 85 RECHARGEABLE VACCINE 126 MOI-STIR 76 MEGA MULTI FOR WOMEN85 BATTERY 71 MEGA MULTIVITAMIN FOR MICROLET LANCETS 38 MOISTURIZING CREAM 18 MEN 85 MICROLET NEXT 38 molindone hcl 11 MEGA MULTIVITAMIN FOR MICROLIFE BLOOD MONOJECT INSULIN WOMEN 85 PRESSUREMONITOR/ADVAN SYRINGE/1ML 58 MEGAVITE FRUITS & CED AUTOMATIC 28 MONOJECT INSULIN VEGGIES 85 MICROLIFE BLOOD SYRINGE/1ML/31G X 5/16" 58 MEGAVITE GOLDEN YEARS PRESSUREMONITOR/ADVAN MONOJECT INSULIN 55+ 85 CED WRIST 28 SYRINGE/DETACH megestrol acetate 9 MICROLIFE BLOOD NEEDLE/1ML/25G X 5/8" 58 MEIJER COLOR LANCETS PRESSUREMONITOR/AUTOM MONOJECT INSULIN UNIVERSAL 33G 37 ATIC 28 SYRINGE/DETACH MEIJER GLUCOSE 7 MICROLIFE BLOOD NEEDLE/1ML/27G X 1/2" 58 MONOJECT INSULIN MEIJER LANCETS 37 PRESSUREMONITOR/AUTOM ATIC DELUXE 28 SYRINGE/PERM MEIJER LANCETS THIN 37 MICROLIFE BPM 6 PREMIUM NEEDLE/1ML/28G X 1/2" 58 MEIJER LANCETS BLOOD PRESSURE MONOJECT INSULIN UNIVERSAL21G 38 MONITOR 28 SYRINGE/PERM NEEDLE/U- MEIJER LANCETS MICROLIFE DELUXE BLOOD 100/0.5ML/28G X 1/2" 58 UNIVERSAL30G 38 PRESSURE MONITOR 28 MONOJECT INSULIN MEIJER LANCETS MICROSPACER 71 SYRINGE/SAFETY/PERM UNIVERSAL33G 38 MICROTAINER SAFETY NEEDLE/0.3ML/29G X 1/2" 58 MEIJER SUPER THIN MONOJECT INSULIN FLOW LANCETS 38 LANCET/STERILE/SINGLE- SYRINGE/SAFETY/PERM NEEDLE/0.3ML/29GX1/2" 58 melatonin 1 USE 38 MENACTRA 122 MONOJECT INSULIN midodrine hcl 127 SYRINGE/SAFETY/PERM MENQUADFI 122 mineral oil 25 NEEDLE/0.5ML/29G X 1/2" 58 MENS 50+ ADVANCED 85 MINERAL OIL 25 MONOJECT INSULIN MENS 50+ MULTI VITAMIN mineral oil 25 SYRINGE/SAFETY/PERM &MINERAL FORMULA 85 NEEDLE/1ML/29G X 1/2" 58 MENS MULTI VITAMIN & MINI LANCING DEVICE 38 MONOJECT INSULIN MINERAL FORMULA 85 MINIELITE FILTER SYRINGE/SOFTPACK/1ML/27G MENS MULTIVITAMIN 85 REPLACEMENTS 71 X 1/2" 58 MINIELITE RECHARGEABLE menthol (mouth-throat) 75 MONOJECT INSULIN BATTERY 71 SYRINGE/SOFTPACK/U- menthol (topical analgesic) 13 minoxidil 9 100/0.5ML/28G X 1/2" 58 menthol-methyl salicylate mirtazapine 5 MONOJECT INSULIN (liniments) 20 SYRINGE/U-100/0.3ML/30G X MENVEO 122 misoprostol 122 5/16" 58

Index 19 MONOJECT INSULIN MS INSULIN naphazoline-glycerin 119 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/31G X NASACORT ALLERGY 5/16" 58 5/16" 59 24HR 118 MONOJECT INSULIN MS INSULIN NAT-RUL THERAVITE- SYRINGE/U-100/1ML/28G X SYRINGE/0.5ML/31G X M/HIGHPOTENCY 113 1/2" 58 5/16" 59 NATRUL-VITES 113 MONOJECT INSULIN MS INSULIN NEBULIZER AIR SYRINGE/U-100/1ML/30G X SYRINGE/1ML/31G X TUBE/PLUGS 71 5/16" 58 5/16" 59 NEBULIZER CUP/TUBING 71 MONOJECT INSULIN MSM SKIN LOTION 18 NEBULIZER PEDIATRIC SYRINGEREGULAR LUER MULTI MEGA MINERALS 74 TIP/SOFTPACK/1ML 58 MASK 71 MONOJECT SHARPS MULTI VITAMIN 118 nefazodone hcl 6 CONTAINER/14 QUART 58 MULTI VITAMIN/D-3 118 NEOMULTIVITE 118 MONOJECT ULTRA COMFORT MULTI-BETIC DIABETES 85 neomycin/polymyxin b gu 24 INSULIN SYRINGE/0.3ML/29G X 1/2" 58 MULTI-LANCET DEVICE 38 NEOSPORIN LIP HEALTH MONOJECT ULTRA COMFORT MULTI-LANCET DEVICE OVERNIGHT RENEWAL INSULIN SYRINGE/0.3ML/30G X 2 38 THERAPY 22 5/16" 58 MULTI-VITAMIN NEOVITE 113 MONOJECT ULTRA COMFORT MONOCAPS 85 NEUTROGENA BODY LIGHT INSULIN SYRINGE/0.3ML/31G X MULTI-VITE 85 SESAME FORMULA 18 5/16" 58 MULTILEX 85 NEUTROGENA HAND 18 MONOJECT ULTRA COMFORT MULTILEX T&M 85 NEUTROGENA HEALTHY INSULIN SYRINGE/0.5ML/28G X multiple minerals w/ SKIN 18 1/2" 58 vitamins 74 NEUTROGENA HEALTHY SKIN MONOJECT ULTRA COMFORT FACE SPF 15 18 INSULIN SYRINGE/0.5ML/29G X multiple vitamin 118 NEUTROGENA MOISTURE 1/2" 58 multiple vitamins w/ SENSITIVE SKIN 18 MONOJECT ULTRA COMFORT calcium 77 niacin 127 multiple vitamins w/ iron 77 INSULIN SYRINGE/0.5ML/30G X niacinamide 127 5/16" 59 multiple vitamins w/ MONOJECT ULTRA COMFORT minerals 89,90 NICADAN 113 INSULIN SYRINGE/0.5ML/31G X MULTISOURCE CALCIUM NICADAN ZX 113 5/16" 59 MAGNESIUM & D NICAZEL 113 MONOJECT ULTRA COMFORT FORMULA 74 NICAZEL FORTE 113 INSULIN SYRINGE/1ML/28G X MULTIVITAMIN 112,118 nicotine 121 1/2" 59 MULTIVITAMIN ADULT 112 MONOJECT ULTRA COMFORT MULTIVITAMIN ADULT nicotine polacrilex 121 INSULIN SYRINGE/1ML/29G X EXTRAVITAMIN C 112 NICOTINE TRANSDERMAL 1/2" 59 MULTIVITAMIN ADULTS 112 SYSTEM 121 MONOLET LANCETS 38 NICOTROL INHALER 121 MULTIVITAMIN MEN 112 MONOLET OPD LANCETS 38 NICOTROL NS 121 MULTIVITAMIN WOMEN 112 MONOLETTOR SAFETY NISEKO HYDRATING FACIAL LANCETS 38 MULTIVITAMIN/ZINC MOISTURIZER 18 STRESSFORMULA 112 MOTHERS FRIEND 18 nit remover 22 MURO 128 119 MOUTH KOTE 76 MVW COMPLETE NITYR 23 MOUTH KOTE REMINT 76 FORMULATION 112 NIVEA 18 MPD SAFETY LANCET MVW COMPLETE NIVEA EXTRA ENRICHED 18 21G/1.8MM 38 FORMULATIOND3000 112 MPD SAFETY LANCET NIVEA EXTRA ENRICHED MVW COMPLETE LOTION 18 28G/1.8MM 38 FORMULATIOND500 112 MPD SAFETY LANCET NIVEA GENTLE BODY MVW COMPLETE EXFOLIATOR 18 30G/1.8MM 38 FORMULATIONMINIS 112 MPD SAFETY LANCETS MYGLUCOHEALTH MGH NIVEA LIGHT 18 23G/1.8MM 38 SOFTLANCE LANCETS NIVEA ORIGINAL 18 30G 38

Index 20 NIVEA ORIGINAL OMRON 10 SERIES BLOOD ONE-A-DAY MENS 50+ 113 MOISTURE 18 PRESSURE ONE-A-DAY MENS 50+ NIVEA SOFT 18 MONITOR/ARM/BLUETOOTH ADVANTAGE 113 NIVEA VISAGE 18 SMART 28 ONE-A-DAY MENS HEALTH OMRON 10 SERIES BLOOD NIVEA VISAGE INNER BEAUTY FORMULA 113 PRESSURE NIGHTTIME RENEWAL 18 ONE-A-DAY MENS PRO NO IRON MULTIPLE MONITOR/UPPER EDGE 113 VITAMIN/MINERALS 113 ARM/BLUETOOTH 28 ONE-A-DAY MENS norelgestromin-ethinyl OMRON 3 SERIES BLOOD VITACRAVES GUMMIES 114 estradiol 12 PRESSURE ONE-A-DAY PROACTIVE MONITOR/UPPER ARM 28 norethindrone acetate 120 65+ 114 OMRON 3 SERIES BLOOD ONE-A-DAY TEEN NORPACE CR 3 PRESSURE ADVANTAGEFOR HIM 114 nortriptyline hcl 7 MONITOR/WRIST 28 ONE-A-DAY VITACRAVES 114 NOSE CLIP 71 OMRON 5 SERIES BLOOD ONE-A-DAY VITACRAVES PRESSURE ADULT 114 NOVA MAX PLUS KETONE MONITOR/UPPER TESTSTRIPS 22 ONE-A-DAY VITACRAVES NOVA SAFETY LANCETS ARM/BLUETOOTH 28 GUMMIES/IMMUNITY OMRON 7 SERIES BLOOD 23G 38 SUPPORT 114 NOVA SAFETY LANCETS PRESSURE MONITOR 28 ONE-A-DAY VITACRAVES OMRON 7 SERIES BLOOD 28G 38 SOURGUMMIES 114 NOVA SUREFLEX PRESSURE ONE-A-DAY VITACRAVES LANCETS 38 MONITOR/UPPER WOMENS MULTI 114 NOVA SUREFLEX LANCING ARM/BLUETOOTH 28 ONE-A-DAY WOMENS 114 DEVICE 38 OMRON 7 SERIES BLOOD PRESSURE ONE-A-DAY WOMENS NU-MAG 74 MONITOR/WRIST/BLUETOOT VITACRAVES GUMMIES 114 NUEDEXTA 121 H 28 ONE-DAILY MULTI CAPS 114 NUMOISYN 76 ON CALL LANCETS 38 ONETOUCH CLUB LANCETS ON CALL LANCING FINE POINT 38 NUPLAZID 9 ONETOUCH DELICA LANCETS DEVICE 38 NUTRADERM 18 EXTRA FINE 33G 38 NUTRADERM ADVANCED ON CALL PLUS LANCETS38 ONETOUCH DELICA LANCETS FORMULA 18 ON CALL PLUS LANCING FINE 30G 38 NUTRICAP 113 DEVICE 38 ONETOUCH DELICA LANCING ONCOVITE 113 OCULAR VITAMINS 113 DEVICE 38 ondansetron hcl 8 ONETOUCH DELICA PLUS OCUVITE ADULT 50+ 113 ONE A DAY MENS LANCETS EXTRA FINE OCUVITE ADULT VITACRAVES MULTI 33G 38 FORMULA 113 GUMMIES 113 ONETOUCH DELICA PLUS OCUVITE LUTEIN 113 ONE DAILY ESSENTIAL 118 LANCETS FINE 30G 38 OINTMENT BASE 18 ONETOUCH DELICA PLUS ONE DAILY MENS FORMULA LANCING DEVICE 38 OKEEFFES WORKING W/O IRON 113 HANDS 19 ONETOUCH DELICA SAFETY ONE DAILY WOMENS 113 LACING DEVICE 38 olanzapine 10 ONE FLOW FVC ONETOUCH FINEPOINT olanzapine-fluoxetine hcl 121 MONITORING LANCETS 38 OMBRA TABLE TOP SPIROMETER 71 ONETOUCH ULTRASOFT COMPRESSOR 71 ONE-A-DAY ENERGY 113 LANCETS 39 omega-3 fatty acids 119 ONE-A-DAY FOR HER ophthalmic irrigation OMNICAP 118 VITACRAVES TEEN MULTI solution 120 OPTICHAMBER OMNIPOD 5 PACK 38 GUMMIES 113 ONE-A-DAY FOR ADVANTAGE/LARGE OMNIPOD DASH 5 PACK 38 HIM/VITACRAVES TEEN MASK 71 OMNIPOD DASH SYSTEM 38 MULTI GUMMIES 113 OPTICHAMBER ADVANTAGE/MEDIUM FACE OMNIPOD STARTER KIT 38 ONE-A-DAY MENOPAUSE FORMULA 113 MASK 71 ONE-A-DAY MENS 114

Index 21 OPTICHAMBER PALMERS COCOA BUTTER peg 3350-kcl-nacl-na sulfate-na ADVANTAGE/SMALL FACE FORMULA LOTION ascorbate-ascorbic acid 25 MASK 71 FRAGRANCE FREE 19 peg 3350-kcl-sod bicarb-sod OPTICHAMBER DIAMOND 71 PALMERS COCOA BUTTER chloride-sod sulfate 25 OPTICHAMBER FORMULA MASSAGE peg 3350-potassium chloride-sod DIAMOND/LARGEFACE CREAM/STRETCH bicarbonate-sod chloride 25 MASK 71 MARKS 19 PEG OINTMENT BASE 120 OPTICHAMBER PALMERS COCOA BUTTER PEGANONE 5 FORMULA MASSAGE DIAMOND/MEDIUM FACE PEN-KERA 19 MASK 71 LOTION/STRETCH MARKS 19 PENLET II AUTOMATIC OPTICHAMBER BLOODSAMPLER 39 DIAMOND/SMALLFACE PALMERS COCOA BUTTER MASK 71 FORMULA NIGHT CREAM pentoxifylline 24 OPTICHAMBER FACE MOISTURE RICH 19 PENTRAVAN 19 MASK/LARGE 72 PALMERS COCONUT OIL PENTRAVAN PLUS 19 FORMULA BODY LOTION19 OPTICHAMBER FACE PERFECT LANCETS 30G 39 MASK/MEDIUM 72 PALMERS COCONUT OIL OPTICHAMBER FACE FORMULA HAND CREAM 19 PERFECT PRESSURE MASK/SMALL 72 PALOMAR E 22 ACTIVATED SAFETY LANCETS OPTIFAST POST PARI ALTERA NEBULIZER 28G 39 BARIATRIC 114 HANDSET 72 perphenazine 11 OPTIHALER 72 PARI BABY CONVERSION perphenazine-amitriptyline 121 OPTIHALER MDI DRUG KITSIZE 1 72 PERSERIS 10 PARI BABY CONVERSION DELIVERY SYSTEM 72 PETROLATUM 19 OPTIMUM AIRVITES 114 KITSIZE 2 72 PARI BABY CONVERSION PETROLATUM WHITE 120 OPTIONS GYNOL II KITSIZE 3 72 VAGINALCONTRACEPTIVE PETROLEUM JELLY 120 PARI ERAPID NEBULIZER PETROLEUM JELLY LIP 126 HANDSET 72 OPTISOURCE POST TREATMENT 22 PARI EXPIRATORY FILTER PETROLEUM JELLYBABY 120 BARIATRIC SURGERY 114 VALVE SET 72 OPURITY 114 PARI MANUAL PEXEVA 6 OPURITY/BYPASS INTERRUPTER 72 PFIZER-BIONTECH COVID- OPTIMIZED 114 PARI MASK SET 72 19VACCINE 126 oral electrolytes 74 PARI SOFT PLASTIC ADULT PFLEX 72 ORAL RELIEF SPRAY FOR MASK 72 PHARMACIST CHOICE DRYMOUTH & PARI SOFT PLASTIC ALCOHOL PRED PADS 44 DISCOMFORT 76 PEDIATRIC MASK 72 PHARMACIST CHOICE OSTEOPRIME PLUS/CALCIUM PARI TREK S COMBO ALCOHOLPREP PADS 44 & MAGNESIUM 114 PACK 72 PHARMACIST CHOICE oxcarbazepine 4 PARI VORTEX ADULT NEBULIZER/CPAP/INHALER OXTELLAR XR 4 MASK 72 CHAMBER MASK WIPES 72 PHARMACIST CHOICE ULTRA oxymetazoline hcl 118 paroxetine hcl 6 paroxetine mesylate THIN LANCETS 39 oyster shell 74 (vasomotor) 121 PHARMACIST CHOICE ULTRA paliperidone 10 THIN LANCETS 28G 39 PARVLEX 114 PHARMACIST CHOICE ULTRA PALMERS COCOA BUTTER PAXIL 6 FORMULA CONCENTRATED THIN LANCETS 30G 39 PC LANCETS SUPER THIN CREAM 19 PHARMACIST CHOICE ULTRA PALMERS COCOA BUTTER 30G 39 THIN LANCETS 31G 39 FORMULA CREAM 19 PCCA POLYPEG BASE 120 PHARMACIST CHOICE ULTRA PALMERS COCOA BUTTER PEDIA-LAX 26 THIN LANCETS 33G 39 FORMULA INTENSIVE RELIEF PHARMACY COUNTER PEDIATRIC LANCETS 39 HAND CREAM 19 MOUTHPIECE/DISPOSABLE PALMERS COCOA BUTTER 72 phenazopyridine hcl 24 FORMULA LOTION 19 PEDIAVENT 8 phenelzine sulfate 6 PEG 120 phenobarbital 25 phenol (antiseptic) 75

Index 22 phenylephrine hcl 118 potassium chloride 75 PREFERRED PLUS INSULIN phenylephrine hcl potassium chloride SYRINGE/U-100/1ML/30G X (mydriatic) 119 microencapsulated crystals 5/16" 59 phenylephrine hcl (oral) 118 er 75 PREFERRED PLUS LANCETS COLORED 21G 39 phenylephrine in hard fat 2 potassium citrate (alkalinizer) 24 PREFERRED PLUS LANCETS phenylephrine w/ dm-gg 13 pramoxine hcl (rectal) 2 SUPER THIN 30G 39 phenylephrine-brompheniramine- PREFERRED PLUS LANCETS dm 13 pramoxine-calamine 21 THIN 26G 39 phenylephrine-chlorphen-dm pramoxine-phenylephrine- pregabalin 4 glycerin-petrolatum 2 13 PREMARIN 23 pramoxine-zinc acetate 21 phenylephrine-cocoa butter 2 PREMIUM CONDOMS phenylephrine-dm-gg w/ prazosin hcl 9 LUBRICATED 30 apap 13 PRECISION SURE-DOSE PREMPRO 23 phenylephrine-mineral oil- INSULIN SYRINGE/0.3ML/30G petrolatum 2 X 5/16" 59 PRENATAL-U 118 phenylephrine-shark liver oil- PRECISION SURE-DOSE PRESERVISION AREDS 114 mineral oil-petrolatum 2 INSULIN SYRINGE/0.5ML/28G PRESERVISION AREDS 2 114 phenylephrine-witch hazel 2 X 1/2" 59 PRESERVISION AREDS 2 + phenytoin 5 PRECISION SURE-DOSE MULTI VITAMIN 114 INSULIN SYRINGE/0.5ML/29G phenytoin sodium 5 PRESERVISION/LUTEIN 114 X 1/2" 59 PRESSURE ACTIVATED phenytoin sodium extended 5 PRECISION SURE-DOSE SAFETYLANCET 21G 39 PHLEBOTOMY SHARPS INSULIN SYRINGE/1ML/28G X CONTAINER 59 1/2" 59 PRETTY FEET & HANDS 19 PHYTOMULTI 114 PRECISION SURE-DOSE PREVNAR 13 123 PILLOW MASK/ADULT 72 PLUSINSULIN PREVNAR 20 123 SYRINGE/0.3ML/29G X primaquine phosphate 9 PILLOW MASK/CHILD 72 1/2" 59 PILLOW MASK/PEDIATRIC 72 PRECISION SURE-DOSE PRIMEAIRE DUAL-VALVED HOLDING CHAMBER 72 pilocarpine hcl (oral) 76 PLUSINSULIN SYRINGE/1ML/29G X 1/2" 59 primidone 4 pimozide 121 PRECISION THINS GP PRO COMFORT INHALER PIP LANCETS/28G 39 LANCET 39 SPACER CHAMBER PIP LANCETS/30G 39 PRECISION XTRA 22 ADULT 72 piperacillin sodium-tazobactam PREFERRED PLUS PRO COMFORT INHALER sodium 120 GLUCOSE 7 SPACER CHAMBER CHILD 72 PREFERRED PLUS INSULIN PRO COMFORT INHALER PNEUMOVAX 23 123 SPACER CHAMBER PNEUMOVAX 23/1 DOSE 123 SYRINGE/U-100/0.3ML/29G X 1/2" 59 INFANT 72 POCKET CHAMBER 72 PREFERRED PLUS INSULIN PRO COMFORT INSULIN POCKET SPACER 72 SYRINGE/U-100/0.3ML/30G X SYRINGES/0.5ML/30G X 5/16" 59 1/2" 59 POLYBASE 120 PRO COMFORT INSULIN polyethylene glycol 3350 25 PREFERRED PLUS INSULIN SYRINGE/U-100/0.5ML/28G X SYRINGES/0.5ML/30G X POLYETHYLENE GLYCOL 1/2" 59 5/16" 59 BLEND 120 PREFERRED PLUS INSULIN PRO COMFORT INSULIN polyethylene glycol-propylene SYRINGE/U-100/0.5ML/29G X SYRINGES/0.5ML/31G X glycol (ophth) 119 1/2" 59 5/16" 59 polysaccharide iron complex 25 PREFERRED PLUS INSULIN PRO COMFORT INSULIN polyvinyl alcohol 119 SYRINGE/U-100/0.5ML/30G X SYRINGES/1ML/30G X 1/2" 59 PRO COMFORT INSULIN polyvinyl alcohol-povidone 5/16" 59 SYRINGES/1ML/30G X (ophth) 119 PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X 5/16" 60 pot phosphate monobasic w/ sod PRO COMFORT INSULIN phosphate dibasic & 1/2" 59 PREFERRED PLUS INSULIN SYRINGES/1ML/31G X monobasic 75 5/16" 60 potassium & sodium SYRINGE/U-100/1ML/29G X PRO COMFORT LANCETS 1/2" 59 phosphates 75 30G 39

Index 23 PRO COMFORT LANCETS PTS PANELS KETONE RA BLOOD PRESSURE CUFF 31G 39 TEST 22 MONITOR AUTOMATIC 28 PRO-CAL 114 PULMOZYME 122 RA BLOOD PRESSURE CUFF PROCARE SPACER CHAMBER PURE COMFORT LANCETS MONITOR DELUXE W/ADULT MASK 72 30G 39 AUTOMATIC 28 PROCARE SPACER CHAMBER PUSH BUTTON SAFETY RA BLOOD PRESSURE CUFF W/CHILD MASK 72 LANCETS 21G 39 MONITOR PREMIUM PROCARE UPPER ARM BLOOD PUSH BUTTON SAFETY AUTOMATIC 29 PRESSURE MONITOR 28 LANCETS 28G 39 RA CENTRAL-VITE 115 PROCARE WRIST BLOOD PX ADVANCED LANCING RA DAYLOGIC HEALING DRY PRESSURE MONITOR 28 DEVICE 39 SKIN THERAPY 19 PROCERV HP 115 PX GLUCOSE 8 RA DRY MOUTH 76 prochlorperazine edisylate 11 PX INSULIN SYRINGE/U- RA E-ZJECT LANCETS 28G39 PRODIGY INSULIN SYRING/U- 100/0.5ML/30G X 1/2" 60 RA E-ZJECT LANCETS THIN 100/0.3ML/31G X 5/16" 60 PX LANCET AUTO 26G 39 PRODIGY INSULIN INJECTOR 39 RA E-ZJECT LANCETS THIN SYRINGE/1/2ML/31G X PX LANCETS MICROTHIN 28G 40 5/16" 60 33G 39 RA E-ZJECT LANCETS PRODIGY INSULIN PX LANCETS ULTRA ULTRATHIN 30G 40 SYRINGE/1ML/28G X 1/2" 60 THIN 39 RA GLUCOSE 8 PRODIGY LANCING PX LANCETS ULTRA THIN 28G 39 RA INSULIN DEVICE 39 SYRINGE/0.5ML/29G X 1/2" 60 PRODIGY PRESSURE pyrethrins-piperonyl butoxide- permethrin-nit remover 22 RA INSULIN SYRINGE/1ML/29G ACTIVATED SAFETY X 1/2" 60 LANCETS 39 pyridostigmine bromide 9 RA INSULIN SYRINGE/U- PRODIGY SAFETY pyridoxine hcl 127 100/0.5ML/30G X 5/16" 60 LANCETS 39 pyrithione zinc 14 RA INSULIN SYRINGE/U-100/1 PRODIGY TWIST TOP QC ADVANCED LANCING ML/30G X 5/16" 60 LANCETS 39 DEVICE 39 RA ISOPROPYL ALCOHOL progesterone 120 QC ALCOHOL SWABS 44 WIPES 22 promethazine & QC BLOOD PRESSURE RA PETROLEUM JELLY 120 phenylephrine 13 MONITOR/AUTOMATIC 28 RA RENEWAL DRY SKIN promethazine-dm 13 QC LANCETS SUPER THERAPY 19 PRONEB ULTRA FILTER THIN 39 RADIAGUARD ADVANCED 19 SET 72 QC LANCETS ULTRA ranolazine 3 propafenone hcl 3 THIN 39 RAYALDEE 23 propylthiouracil 122 QC MULTI-VITE 115 READYLANCE SAFETY PRORENAL+D 115 QC OCUHEALTH VISION LANCETS/21G/2.2MM 40 SUPPORT 2 115 READYLANCE SAFETY PRORENAL+D/OMEGA-3 115 QC PAIN RELIEF LIQUID PROSTEON 74 LANCETS/23G/1.8MM 40 CAPSAICIN 21 READYLANCE SAFETY PROTECT CARDIO AF 115 QC UNILET LANCETS LANCETS/26G/1.8MM 40 PROTECT PLUS SO 115 28G/ULTRA THIN 39 READYLANCE SAFETY QC UNILET LANCETS PROTEGRA 115 LANCETS/28G/1.8MM 40 33G/MICRO THIN 39 READYLANCE SAFETY protriptyline hcl 7 QUAKE 72 LANCETS/30G/1.6MM 40 PROVIT 115 quetiapine fumarate 10,11 REALITY INSULIN SYRINGE/U- pseudoephed-bromphen-dm 13 QUIN B STRONG 115 100/0.5ML/28G X 1/2" 60 pseudoephedrine hcl 118 REALITY INSULIN SYRINGE/U- quinidine gluconate 3 100/0.5ML/29G X 1/2" 60 pseudoephedrine-guaifenesin quinidine sulfate 3 REALITY INSULIN SYRINGE/U- 13 QUINTABS 118 100/1ML/28G X 1/2" 60 PSS SELECT GP LANCETS 39 REALITY INSULIN SYRINGE/U- PSS SELECT SAFETY QUINTABS-M 115 100/1ML/29G X 1/2" 60 LANCETS 39 RA ADVANCED HEALING 19 REALITY LANCETS 40 psyllium 25 RA ALCOHOL SWABS 44 REALITY LATEX CONDOMS/LUBRICATED 30

Index 24 REALITY LATEX/ULTRA RELION LANCETS THIN ROC MULTI CORREXION 5 IN1 TEXTURED 30 26G 40 RESTORING NIGHT REALITY LATEX/ULTRA RELION LANCETS ULTRA- CREAM 19 THIN 30 THIN30G 40 ROC RETINOL REALITY TRIGGER RELION LANCING CORREXION 19 LANCETS 40 DEVICE 40 ROC RETINOL CORREXION RECOMBIVAX HB 126 RELION PREMIUM BLOOD MAX 19 REFRESH 119 PRESSURE ROC RETINOL CORREXION MONITOR/UPPER ARM 29 NIGHT 19 REFRESH DIGITAL 119 RELION TRUE METRIX ROC RETINOL CORREXION REFRESH DIGITAL PF 119 BLOODGLUCOSE TEST SENSITIVE EYE 19 REFRESH OPTIVE 119 STRIPS 22 ROC RETINOL CORREXION REFRESH OPTIVE RELION ULTRA THIN SENSITIVE NIGHT 19 ADVANCED 119 LANCETS/30G 40 ROSE MILK 19 REFRESH OPTIVE ADVANCED RELION ULTRA THIN rufinamide 4,5 LANCETS30G 40 SENSITIVE 119 SAFE-T-LANCE LOW FLOW REFRESH OPTIVE MEGA- RELION ULTRA THIN PLUS LANCETS 32G 40 25G 40 3 119 SAFE-T-LANCE NORMAL REFRESH OPTIVE RELION ULTRA THIN PLUS LANCETS 33G 40 FLOW21G 40 PRESERVATIVE FREE 119 SAFE-T-LANCE PLUS REFRESH RELIEVA PF 119 REMEDY CLEAR-AID 22 SAFETYLANCET HIGH RELION 2-IN-1 LANCET REMEDY PHYTOPLEX FLOW 40 DEVICES 30G 40 HYDRAGUARD 22 SAFE-T-LANCE PLUS RELION 2-IN-1 LANCING REMODULIN 12 SAFETYLANCET LOW DEVICE 25G 40 RENAPLEX-D 115 FLOW 40 RELION 2-IN-1 LANCING RENFLEXIS 23 SAFE-T-LANCE PLUS DEVICE 30G 40 SAFETYLANCET NORMAL REPLACE 115 RELION ALCOHOL SWABS 44 FLOW 40 REPLACEMENT AIR SAFESNAP INSULIN RELION BLOOD PRESSURE FILTER 72 MONITOR/AUTOMATIC 29 SYRINGE/0.3ML/30G X RELION BP100 UPPER ARM REPLACEMENT FILTERS 72 5/16" 60 BLOOD PRESSURE REQ 49+ 115 SAFESNAP INSULIN MONITOR 29 SYRINGE/0.5ML/29G X 1/2" 60 RESTA 19 SAFESNAP INSULIN RELION BP200W WRIST RESTA LITE 19 BLOOD PRESSURE SYRINGE/0.5ML/30G X MONITOR 29 REXALL LANCETS ULTRA 5/16" 60 RELION BP300W WRIST THIN 40 SAFESNAP INSULIN BLOOD PRESSURE REXULTI 11 SYRINGE/1ML/28G X 1/2" 60 MONITOR 29 rifampin 9 SAFESNAP INSULIN SYRINGE/1ML/29G X 1/2" 60 RELION GLUCOSE 8 RIGHTEST GD500 LANCING SAFETY INSULIN SYRINGES DEVICE 40 RELION INSULIN SYRINGE 0.5ML/29GX1/2" 60 0.5ML/31G X 15/64" 60 RIGHTEST GL300 SAFETY INSULIN SYRINGES LANCETS 40 RELION INSULIN SYRINGE 0.5ML/30GX5/16" 60 1ML/31GX15/64" 60 riluzole 118 SAFETY INSULIN SYRINGES RELION INSULIN SYRINGE/U- RISABAL-PH 19 1ML/27GX1/2" 60 100/0.3ML/31G X 5/16" 60 RISACAL-D 74 SAFETY INSULIN SYRINGES RELION INSULIN SYRINGE/U- 1ML/29GX1/2" 60 100/0.5ML/29G X 1/2" 60 RISPERDAL CONSTA 10 SAFETY INSULIN SYRINGES RELION INSULIN SYRINGE/U- risperidone 10 1ML/30GX1/2" 61 100/0.5ML/31G X 5/16" 60 RITEFLO 72 SAFETY LANCET RELION INSULIN SYRINGE/U- ROC DEEP WRINKLE 21G/PRESSURE 100/1ML/31G X 15/64" 60 ACTIVATED 40 RELION INSULIN SYRINGE/U- SERUM 19 ROC MULTI CORREXION 5 SAFETY LANCET 100/1ML/31G X 5/16" 60 23G/PRESSURE RELION KETONE TEST IN1 RESTORING EYE CREAM 19 ACTIVATED 40 STRIPS 22 SAFETY LANCET RELION LANCETS MICRO- 28G/PRESSURE THIN33G 40 ACTIVATED 40

Index 25 SAFETY LANCET SELECT-LITE LANCING SIMPLE DIAGNOSTICS 30G/PRESSURE DEVICE 41 LANCING DEVICE 41 ACTIVATED 40 selenium 75 SINGLE-LET 41 SAFETY LANCETS 40 selenium sulfide 14 SKIN PROTECTANT SAFETY LANCETS 21G 40 sennosides 26 PETROLATUM 120 SAFETY LANCETS 28G 40 sennosides-docusate skin protectants, misc. 22 SAFETY LET LANCETS 40 sodium 25 SKIN REPAIR 19 SAFETY SEAL LANCETS SENSI-CARE SLOW-MAG 74 28G 40 MOISTURIZING 22 SLOWMAG MG SAFETY SEAL LANCETS SENTRY 115 MUSCLE/HEART 74 30G 40 SENTRY SENIOR 115 SM ALCOHOL PREP PADS 44 SALESE 75 SENTRY SM B-COMPLEX/VITAMIN salicylic acid 20 SENIOR/LUTEIN 115 C 77 saline 118 sertraline hcl 6 SM BLOOD PRESSURE SHARP CONTAINER 61 MONITOR/ADVANCED SAMI THE SEAL AUTOMATIC 29 REPLACEMENTFILTERS 73 SHARPS DISPOSAL BY MAIL SM BLOOD PRESSURE SANTYL 20 SYSTEM 61 MONITOR/AUTOMATIC SAPHRIS 11 SHINGRIX 126 INFLATION 29 SAPS HEALTH ALCOHOL SHOPKO AUTOLET LANCING SM BLOOD PRESSURE PREPPADS 44 DEVICE 41 MONITOR/DELUXE SAPS HEALTH CARE SHOPKO ON-THE-GO AUTOMATIC 29 ALCOHOLPREP PADS 44 COMFORTLANCETS 30G 41 SM BLOOD PRESSURE SAPS HEALTH CARE TWIST SHOPKO UNILET LANCETS MONITOR/DELUXE WRIST 29 TOP LANCETS 41 SUPER THIN 30G 41 SM BLOOD PRESSURE SAPS HEALTH TWIST TOP SHOPKO UNILET LANCETS MONITOR/FULLY LANCETS 30G 41 ULTRA THIN 28G 41 AUTOMATIC 29 SAPSCARE TWIST TOP SIDE BUTTON SAFETY SM BLOOD PRESSURE LANCETS 30G 41 LANCET21G 41 MONITORSERIES 600 29 SAVELLA 121 SIDEROL 115 SM GLUCOSE 8 SAVELLA TITRATION SIDESTREAM ADULT FACE SM MEDICATED CHEST PACK 121 MASK 73 RUB 13 SAVISION 115 SIDESTREAM PEDIATRIC SM MICRO THIN LANCETS FACEMASK 73 SB INSULIN SYRINGE/U- 33G 41 SIDESTREAM PEDIATRIC SM ONE DAILY ESSENTIAL77 100/0.5ML/29G X 1/2" 61 FACEMASK/SAMI THE SB INSULIN SYRINGE/U- SEAL 73 SM ONE DAILY MENS 115 100/0.5ML/30G X 5/16" 61 SIDESTREAM PEDIATRIC SM ONE DAILY WOMENS 115 SB INSULIN SYRINGE/U- FACEMASK/TUCKER THE SM TRUEDRAW LANCING 100/1ML/29G X 1/2" 61 TURTLE 73 DEVICE 41 SB INSULIN SYRINGE/U- SIDESTREAM PLUS ADULT SMART DIABETES VANTAGE 100/1ML/30G X 5/16" 61 FACE MASK 73 SB INSULIN SYRINGE/U- LANCING DEVICE 41 SIGNIFOR LAR 23 SMART SENSE COLOR 100/1ML/31G X 5/16" 61 LANCETS UNIVERSAL 33G 41 SB LANCETS THIN 41 SILICONE MASK FOR BREATHERITE SMART SENSE GLUCOSE 8 SB LANCETS ULTRA THIN 41 CHAMBER/ADULT 73 SMART SENSE GLUCOSE SEBEX 14 SILICONE MASK FOR TABLETS 8 SECUADO 11 BREATHERITE SMART SENSE STANDARD SECURESAFE SAFETY CHAMBER/INFANT 73 LANCETS UNIVERSAL 21G 41 INSULIN SYRINGES/U- SILICONE MASK FOR SMART SENSE SUPER THIN 100/0.5ML/29GX1/2" 61 BREATHERITE LANCETS UNIVERSAL 30G 41 SECURESAFE SAFETY CHAMBER/PEDIATRIC 73 SMART SENSE THIN INSULIN SYRINGES/U- SILICONE MASK FOR LANCETSUNIVERSAL 26G 41 100/1ML/29GX1/2" 61 BREATHRITE SMARTEST LANCETS 28G 41 SELECT-LITE CHAMBER/ADULT 73 sodium bicarbonate (antacid) 2 silver sulfadiazine 14 DEVICE/LANCETS 41 sodium chloride 75 simethicone 23

Index 26 sodium chloride (gu irrigant) 24 STROVITE ONE 115 SURE COMFORT LANCETS sodium chloride (inhalant) 13 STUDIO 35 EXTRA 18G 41 SURE COMFORT LANCETS sodium chloride flush 75 MOISTURIZING LOTION 20 STUDIO 35 MOISTURIZING 21G 41 sodium chloride hypertonic 120 SKIN 20 SURE COMFORT LANCETS sodium citrate & citric acid 24 sucralfate 122 23G 41 SURE COMFORT LANCETS sodium fluoride 74 SUDAFED CHILDRENS 118 28G 41 sodium fluoride (dental) 75 sulfamethoxazole- SURE COMFORT LANCETS sodium phosphates 26 trimethoprim 2 30G 41 sodium polystyrene SUPER ANTIOXIDANT 115 SURE COMFORT LANCING sulfonate 75 SUPER THIN LANCETS 41 PEN 41 SOLO 115 SURE-JECT INSULIN SUPPORT 115 SYRINGE/U-100/0.3ML/29G X SOLUS V2 LANCING SURE COMFORT INSULIN 1/2" 61 DEVICE 41 SYRINGE/U-100/0.3ML/29G X SURE-JECT INSULIN SOLUS V2 PRESSURE 1/2" 61 SYRINGE/U-100/0.3ML/30G X ACTIVATED SAFETY LANCETS SURE COMFORT INSULIN 5/16" 61 28G 41 SYRINGE/U-100/0.3ML/30G X SURE-JECT INSULIN SOLUS V2 TWIST LANCETS 1/2" 61 SYRINGE/U-100/0.3ML/31G X 30G 41 SURE COMFORT INSULIN 5/16" 62 SOOTHE & COOL FREE SYRINGE/U-100/0.3ML/30G X SURE-JECT INSULIN MEDSEPTIC 22 5/16" 61 SYRINGE/U-100/0.5ML/28G X SOOTHE & COOL FREE SURE COMFORT INSULIN 1/2" 62 MOISTURE BARRIER 22 SYRINGE/U-100/0.3ML/31G X SOOTHE & COOL MOISTURE SURE-JECT INSULIN 5/16 61 SYRINGE/U-100/0.5ML/29G X BARRIER 22 SURE COMFORT INSULIN 1/2" 62 SOOTHE & COOL SYRINGE/U-100/0.3ML/31G X MOISTURIZING BODY LOTION SURE-JECT INSULIN 5/16" 61 SYRINGE/U-100/0.5ML/30G X WITH ALOE 19 SURE COMFORT INSULIN SOOTHE & COOL PROTECT 5/16" 62 SYRINGE/U-100/0.5ML/28G X SURE-JECT INSULIN MOISTURE BARRIER 22 1/2" 61 SOOTHE & COOL SKIN SYRINGE/U-100/0.5ML/31G X SURE COMFORT INSULIN 5/16" 62 CREAMWITH ALOE & SYRINGE/U-100/0.5ML/29G X VITAMINS A, D & E 20 SURE-JECT INSULIN 1/2" 61 SYRINGE/U-100/1ML/28G X SOOTHENEB NBL 100 CHILD SURE COMFORT INSULIN MASK 73 1/2" 62 SYRINGE/U-100/0.5ML/30G X SURE-JECT INSULIN SOOTHENEB NBL 100 1/2" 61 MEDICATION CUP 73 SYRINGE/U-100/1ML/29G X SURE COMFORT INSULIN 1/2" 62 SOOTHENEB NBL 100 MESH SYRINGE/U-100/0.5ML/30G X CAP 73 SURE-JECT INSULIN 5/16" 61 SYRINGE/U-100/1ML/30G X SOOTHENEB NBL100 ADULT SURE COMFORT INSULIN MASK 73 5/16" 62 SYRINGE/U-100/0.5ML/31G X SURE-JECT INSULIN SORBIDON HYDRATE 22 5/16 61 SYRINGE/U-100/1ML/31G X SORBOLENE 20 SURE COMFORT INSULIN 5/16" 62 SPECIAL CARE CREAM 20 SYRINGE/U-100/1ML/28G X SURE-LANCE FLAT 1/2" 61 SPECTRAVITE 115 LANCETS 41 SURE COMFORT INSULIN SURE-LANCE LANCETS SPIRO PD 73 SYRINGE/U-100/1ML/29G X 26G 41 SPRAVATO 56MG DOSE 6 1/2" 61 SURE-LANCE THIN LANCETS SPRAVATO 84MG DOSE 6 SURE COMFORT INSULIN 28G 41 SYRINGE/U-100/1ML/30G X SURE-LANCE ULTRA THIN SPRITAM 5 1/2" 61 LANCETS 41 ST IVES SWISS FORMULA SURE COMFORT INSULIN SURE-PEN 41 24HOUR MOISTURE 20 SYRINGE/U-100/1ML/30G X SURE-TOUCH LANCETS STELARA 14 5/16" 61 UNIVERSAL 41 STERILANCE PA 41 SURE COMFORT INSULIN SURELIFE BLOOD PRESSURE SYRINGE/U-100/1ML/31G X MONITOR/ARM 29 STERILANCE TL 41 5/16" 61

Index 27 SURELIFE BLOOD PRESSURE TECHLITE LANCETS 42 thiamine mononitrate 127 MONITOR/ARM/PREMIUM 29 TECHLITE LANCETS 30G 42 THINLETS GP LANCETS 42 SURELIFE BLOOD PRESSURE MONITOR/WRIST/CLASSIC TENIVAC 122 thioridazine hcl 11 29 terconazole vaginal 126 thiothixene 11 SURELIFE BLOOD PRESSURE TETANUS/DIPHTHERIA THRESHOLD IMT 73 MONITOR/WRIST/PREMIUM TOXOIDS-ADSORBED THRESHOLD PEP 73 29 ADULT 122 SURELITE LANCETS 42 tetrahydrozoline hcl throat lozenges 75 SYNAGIS 120 (ophth) 119 tiagabine hcl 5 tetrahydrozoline-dextran- tioconazole vaginal 126 SYSTANE GEL 119 polyethylene glycol- SYSTANE ICAPS povidone 119 tobramycin sulfate 1 AREDS2 115,116 TGT GLUCOSE 8 TODAYS HEALTH ADVANCED SYSTANE OVERNIGHT LANCING DEVICE 42 THERAPY LUBRICANT TGT LANCET MICRO THIN TODAYS HEALTH SUPER EYE 119 33G 42 THINLANCETS 30G 42 T-VITES 116 TGT LANCET THIN 26G 42 TODAYS HEALTH ULTRA TAB-A-VITE TGT LANCET ULTRA THIN THINLANCETS 28G 42 MULTIVITAMIN/IRON AND 30G 42 TOPCARE LANCETS MICRO- BETA-CAROTENE 77 TGT LANCING DEVICE 42 THIN 33G 42 TALKING SENSE BLOOD THEO-24 3 TOPCARE ULTRA COMFORT PRESSURE INSULIN SYRINGE/0.3ML/30G X theophylline 3 5/16" 62 MONITOR/REGULAR SIZE THERA 118 CUFF 29 TOPCARE ULTRA COMFORT TALKING SENSE BLOOD THERA M PLUS 116 INSULIN SYRINGE/0.3ML/31G X PRESSURE MONITOR/XL SIZE THERA-M 116 5/16" 62 CUFF 29 TOPCARE ULTRA COMFORT THERA-TABS M 116 INSULIN SYRINGE/0.5ML/30G X TDVAX 122 THERABETIC MULTI- 5/16" 62 TECHLITE AST LANCETS 42 VITAMIN 116 TOPCARE ULTRA COMFORT TECHLITE INSULIN SYRINGEU- THERABETIC SKIN CARE20 INSULIN SYRINGE/0.5ML/31G X 100/0.3ML/29G X 1/2" 62 THERACAL D2000 74 5/16" 63 TECHLITE INSULIN SYRINGEU- TOPCARE ULTRA COMFORT 100/0.3ML/30G X 1/2" 62 THERACAL D4000 74 INSULIN SYRINGE/1ML/30G X TECHLITE INSULIN SYRINGEU- THERACAL RAPID 5/16" 63 100/0.3ML/30G X 5/16" 62 REPLETION 74 TOPCARE ULTRA COMFORT TECHLITE INSULIN SYRINGEU- THERAGRAN-M 116 INSULIN SYRINGE/1ML/31G X 100/0.3ML/31G X 5/16" 62 THERAGRAN-M 5/16" 63 TECHLITE INSULIN SYRINGEU- ADVANCED 116 TOPCARE ULTRA COMFORT 100/0.5ML/29G X 1/2" 62 THERAGRAN-M ADVANCED INSULIN SYRINGE/U- TECHLITE INSULIN SYRINGEU- 50 PLUS 116 100/0.3ML/29G X 1/2" 63 100/0.5ML/30G X 1/2" 62 THERAGRAN-M TOPCARE ULTRA COMFORT TECHLITE INSULIN SYRINGEU- PREMIER 116 INSULIN SYRINGE/U- 100/0.5ML/30G X 5/16" 62 THERAGRAN-M PREMIER 50 100/0.5ML/29G X 1/2" 63 TECHLITE INSULIN SYRINGEU- PLUS 116 TOPCARE ULTRA COMFORT 100/0.5ML/31G X 15/64" 62 THERAMILL FORTE 116 INSULIN SYRINGE/U- TECHLITE INSULIN SYRINGEU- THERANATAL LACTATION 100/1ML/29G X 1/2" 63 100/0.5ML/31G X 5/16" 62 ONE 116 topiramate 5 TECHLITE INSULIN SYRINGEU- THERAPEUTIC tranexamic acid 25 100/1ML/29G X 1/2" 62 MOISTURIZING 20 TECHLITE INSULIN SYRINGEU- THERAPLEX tranylcypromine sulfate 6 100/1ML/30G X 1/2" 62 HYDROLOTION 20 TRAVEL LANCETS 30G 42 TECHLITE INSULIN SYRINGEU- THEREMS TRAVEL LANCETS ADVANCED 100/1ML/30G X 5/16" 62 MULTIVITAMIN 118 28G 42 TECHLITE INSULIN SYRINGEU- THEREMS-H 116 100/1ML/31G X 15/64" 62 trazodone hcl 6 TECHLITE INSULIN SYRINGEU- THEREMS-M 116 treprostinil 12 100/1ML/31G X 5/16" 62 thiamine hcl 127 triamcinolone acetonide (mouth) 75

Index 28 triamcinolone acetonide TRUEPLUS INSULIN TRUSTEX (nasal) 118 SYRINGE/U-100/0.3ML/30G X LUBRICATED/RIBBED/STUDDE trifluoperazine hcl 11 5/16" 63 D 30 trifluridine 119 TRUEPLUS INSULIN TRUSTEX SYRINGE/U-100/0.3ML/31G X LUBRICATED/SPERMICIDE trimipramine maleate 7 5/16" 63 30 TRINTELLIX 6 TRUEPLUS INSULIN TRUSTEX triprolidine hcl 8 SYRINGE/U-100/0.5ML/28G X LUBRICATED/SPERMICIDE TRIPROLIDINE 1/2" 63 EXTRA LARGE 30 HYDROCHLORIDE 8 TRUEPLUS INSULIN TRUSTEX TRIPTODUR 23 SYRINGE/U-100/0.5ML/29G X LUBRICATED/SPERMICIDE 1/2" 63 EXTRA STRENGTH 30 trolamine salicylate 20 TRUEPLUS INSULIN TRUSTEX NATURAL tropicamide 119 SYRINGE/U-100/0.5ML/30G X CONDOMS TRUE COMFORT INSULIN 5/16" 63 +LUBE/LUBRICATED 30 SYRINGE/0.5ML/31G X TRUEPLUS INSULIN TRUSTEX WITH NONOXYNOL- 5/16" 63 SYRINGE/U-100/0.5ML/31G X 9/RIBBED/STUDDED 30 TRUE COMFORT INSULIN 5/16" 63 TRUSTEX/RIA SYRINGE/1ML/31G X 5/16" 63 TRUEPLUS INSULIN LUBRICATED 30 TRUE COMFORT PRO SYRINGE/U-100/1ML/28G X TRUSTEX/RIA LUBRICATED INSULINSYRINGE/0.5ML/30G X 1/2" 63 SPERMICIDE 30 5/16" 63 TRUEPLUS INSULIN TRUSTEX/RIA TRUE COMFORT PRO SYRINGE/U-100/1ML/29G X LUBRICATED/SPERMICIDE INSULINSYRINGE/0.5ML/31G X 1/2" 63 30 5/16" 63 TRUEPLUS INSULIN TUBING/WING TIP 73 TRUE COMFORT PRO SYRINGE/U-100/1ML/30G X TUMS CHEWY DELIGHTS 2 5/16" 63 INSULINSYRINGE/1ML/30G X TWINRIX 126 5/16" 63 TRUEPLUS INSULIN TRUE COMFORT PRO SYRINGE/U-100/1ML/31G X UDDERLY SMOOTH 20 INSULINSYRINGE/1ML/31G X 5/16" 63 UDDERLY SMOOTH EXTRA 5/16" 63 TRUEPLUS LANCETS CARE 20 TRUE COMFORT PRO 26G 42 UDDERLY SMOOTH EXTRA INSULINSYRINGE/U- TRUEPLUS LANCETS CARE20 20 100/0.5ML/30G X 1/2" 63 28G 42 ULTI-LANCE AUTOMATIC/ TRUE COMFORT PRO TRUEPLUS LANCETS 28G CLEAR TIP 42 INSULINSYRINGE/U- SUPER THIN 42 ULTICARE ALCOHOL 100/1ML/30G X 1/2" 63 TRUEPLUS LANCETS SWABS 44 TRUE COMFORT TWIST TOP 30G 42 ULTICARE INSULIN SAFETY LANCETS 30G 42 TRUEPLUS LANCETS 30G SYRINGE/0.5ML/29G X 1/2" 63 TRUE METRIX BLOOD ULTRA THIN 42 ULTICARE INSULIN SAFETY GLUCOSETEST STRIPS 22 TRUEPLUS LANCETS SYRINGE/1ML/29G X 1/2" 64 TRUE METRIX CONTROL 33G 42 ULTICARE INSULIN SOLUTION LEVEL 1 42 TRUEPLUS LANCETS 33G SYRINGE/0.3ML/29G X 1/2" 64 TRUE METRIX CONTROL MICRO THIN 42 ULTICARE INSULIN SOLUTION LEVEL 2 42 TRUEPLUS SAFETY SYRINGE/0.3ML/30G X 1/2" 64 TRUE METRIX CONTROL LANCETS 28G 42 ULTICARE INSULIN SOLUTION LEVEL 3 42 TRUETEST STRIPS 22 SYRINGE/0.3ML/30G X TRUE METRIX SELF TRUETRACK BLOOD 5/16" 64 MONITORING BLOOD GLUCOSE TEST 23 ULTICARE INSULIN GLUCOSE STRIPS 22 TRUETRACK TEST 23 SYRINGE/0.5ML/28G X 1/2" 64 ULTICARE INSULIN TRUECONTROL GLUCOSE TRUMENBA 123 CONTROL LEVEL 0 42 SYRINGE/0.5ML/29G X 1/2" 64 TRUECONTROL GLUCOSE TRUSTEX COLOR CONDOMS ULTICARE INSULIN CONTROL LEVEL 1 42 + LUBE 30 SYRINGE/0.5ML/30G X 1/2" 64 TRUEDRAW LANCING TRUSTEX LUBRICATED 30 ULTICARE INSULIN DEVICE 42 TRUSTEX LUBRICATED SYRINGE/0.5ML/30G X TRUEPLUS INSULIN EXTRALARGE 30 5/16" 64 SYRINGE/U-100/0.3ML/29G X TRUSTEX LUBRICATED ULTICARE INSULIN 1/2" 63 EXTRASTRENGTH 30 SYRINGE/1ML/28G X 1/2" 64

Index 29 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGE/U- SYRINGE/1ML/29G X 1/2" 64 INSULIN SYRINGE 1ML 30G X 100/0.5ML/30G X 1/2" 65 ULTICARE INSULIN 1/2"/SHARPS CON 65 ULTILET INSULIN SYRINGE/U- SYRINGE/1ML/30G X 1/2" 64 ULTIGUARD SAFEPACK 100/0.5ML/31GX6MM 65 ULTICARE INSULIN INSULIN SYRINGE 1ML 31G X ULTILET INSULIN SYRINGE/U- SYRINGE/1ML/30G X 5/16" 64 5/16"/SHARPS CO 65 100/1ML/30G X 1/2" 65 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET LANCETS 42 SYRINGE/SHORT/0.3ML/30G X INSULIN SYRINGE/0.3ML/30G ULTILET LANCETS 33G 42 5/16" 64 X 1/2"/SHARPS C 65 ULTILET SAFETY LANCETS ULTICARE INSULIN ULTIGUARD SAFEPACK 21G X 2.2MM 42 SYRINGE/SHORT/0.3ML/31G X INSULIN SYRINGE/0.3ML/31G ULTILET SAFETY LANCETS 5/16" 64 X 5/16"/SHARPS 65 23G 42 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET SHARPS SYRINGE/SHORT/0.5ML/30G X INSULIN SYRINGE/0.5ML/30G CONTAINER1 QUART 65 5/16" 64 X 1/2"/SHARPS C 65 ULTILET SHARPS ULTICARE INSULIN ULTIGUARD CONTAINER2 QUART 65 SYRINGE/SHORT/0.5ML/31G X SAFEPACK/SYRINGE/NEEDL ULTRA COMFORT INSULIN 5/16" 64 E/31G X 5/16"/SHARPS SYRINGE/U-100/0.3ML/30G X ULTICARE INSULIN CONTAIN 65 5/16" 65 SYRINGE/SHORT/1ML/30G X ULTILET CLASSIC ULTRA FLO INSULIN SYRINGE 5/16" 64 LANCETS 42 0.3ML/29G X 1/2" 65 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE/SHORT/1ML/31G X SYRINGE/0.3ML/30G X 0.3ML/30GX1/2" 65 5/16" 64 8MM 65 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 0.3ML/30GX5/16" 65 SYRINGE/U-100/0.3ML/30G X SYRINGE/0.3ML/31G X ULTRA FLO INSULIN SYRINGE 1/2" 64 8MM 65 0.3ML/31GX5/16" 66 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/0.3ML/31G X SYRINGE/0.5ML/30G X 0.5ML/29GX1/2" 66 5/16" 64 8MM 65 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 0.5ML/30GX1/2" 66 SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/30G X ULTRA FLO INSULIN SYRINGE 1/2" 64 8MM 65 0.5ML/30GX5/16" 66 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/0.5ML/31G X SYRINGE/1ML/31G X 0.5ML/31GX5/16" 66 5/16" 64 8MM 65 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 1/2 UNIT/0.3ML/30GX1/2" 66 SYRINGE/U-100/1ML/30G X SYRINGE/SHORT/0.3ML/30G ULTRA FLO INSULIN SYRINGE 1/2" 64 X 12.7MM 65 1/2 UNIT/0.3ML/30GX5/16" 66 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE/U-100/1ML/31G X SYRINGE/SHORT/0.3ML/30G 1/2 UNIT/0.3ML/31GX5/16" 66 5/16" 64 X 5/16" 65 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 1M/29GX1/2" 66 SYRINGEULTRAFINE U- SYRINGE/SHORT/0.3ML/31G ULTRA FLO INSULIN SYRINGE 100/0.3ML/31G X 5/16" 64 X 5/16" 65 1ML/30GX1/2" 66 ULTICARE INSULIN ULTILET INSULIN ULTRA FLO INSULIN SYRINGE SYRINGEULTRAFINE U- SYRINGE/SHORT/0.5ML/30G 1ML/30GX5/16" 66 100/0.5ML/31G X 5/16" 64 X 5/16" 65 ULTRA FLO INSULIN SYRINGE ULTICARE INSULIN ULTILET INSULIN 1ML/31GX5/16" 66 SYRINGEULTRAFINE U- SYRINGE/SHORT/0.5ML/31G ULTRA THIN LANCETS 100/1ML/31G X 5/16" 64 X 5/16" 65 31G 42 ULTIGUARD SAFEPACK ULTILET INSULIN ULTRA-CARE ALCOHOL PREP INSULIN SYRINGE 0.3ML/30G X SYRINGE/SHORT/1ML/30G X PADS 44 1/2"/SHARPS C 64 5/16" 65 ULTRA-CARE LANCETS ULTIGUARD SAFEPACK ULTILET INSULIN 30G 42 INSULIN SYRINGE 1/2ML 30G X SYRINGE/SHORT/1ML/31G X ULTRA-COMFORT INSULIN 1/2"/SHARPS C 65 5/16" 65 SYRINGE/U-100/0.3ML/29G X 1/2" 66

Index 30 ULTRA-COMFORT INSULIN ULTRA-THIN II LANCETS UNISTIK TOUCH SAFETY SYRINGE/U-100/0.3ML/30G X 30G 42 LANCETS 21G 43 5/16" 66 ULTRACARE INSULIN UNISTIK TOUCH SAFETY ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X LANCETS 23G 43 SYRINGE/U-100/0.3ML/31G X 5/16" 67 UNISTIK TOUCH SAFETY 5/16" 66 ULTRACARE INSULIN LANCETS 28G 43 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X UNISTIK TOUCH SAFETY SYRINGE/U-100/0.5ML/28G X 5/16" 67 LANCETS 30G 43 1/2" 66 ULTRACARE INSULIN UNIVERSAL 1 LANCETS ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X THIN26G 43 SYRINGE/U-100/0.5ML/29G X 1/2" 67 UNIVERSAL 1 LANCETS ULTRA 1/2" 66 ULTRACARE INSULIN THIN 30G 43 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X UNIVERSAL 1 SYRINGE/U-100/0.5ML/30G X 5/16" 67 LANCETS/33G/MICRO-THIN 5/16" 66 ULTRACARE INSULIN 43 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X UP & UP GLUCOSE 8 SYRINGE/U-100/0.5ML/31G X 5/16" 67 urea 14 5/16" 66 ULTRACARE INSULIN ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X V-GO 20 43 SYRINGE/U-100/1ML/28G X 1/2" 67 V-GO 30 43 1/2" 66 ULTRACARE INSULIN V-GO 40 43 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X valganciclovir hcl 12 SYRINGE/U-100/1ML/29G X 5/16" 67 1/2" 66 ULTRACARE INSULIN valproate sodium 5 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X valproic acid 5 SYRINGE/U-100/1ML/30G X 5/16" 67 VALUE HEALTH INSULIN 5/16" 66 UNICOMPLEX-M 116 SYRINGE/U-100/0.5ML/29G X ULTRA-COMFORT INSULIN UNILET COMFORTOUCH 1/2" 67 SYRINGE/U-100/1ML/31G X LANCET 42 VALUE HEALTH INSULIN 5/16" 66 UNILET EXCELITE 43 SYRINGE/U-100/1ML/29G X ULTRA-THIN II AUTO 1/2" 67 UNILET EXCELITE II 43 LANCET 42 VALUE PLUS GLUCOSE 8 ULTRA-THIN II INSULIN UNILET G.P. LANCET 43 VALUE PLUS LANCETS SYRINGE SHORT/U- UNILET G.P. SUPERLITE STANDARD 21G 43 100/0.3ML/30GX5/16" 66 LANCET 43 VALUE PLUS LANCETS ULTRA-THIN II INSULIN UNILET GP 28 ULTRA SUPERTHIN 30G 43 SYRINGE SHORT/U- THIN 43 VALUE PLUS LANCETS THIN 100/0.3ML/31GX5/16" 66 UNILET LANCET 43 26G 43 ULTRA-THIN II INSULIN UNILET LANCETS MICRO- VALUE PLUS LANCING SYRINGE SHORT/U- THIN33G 43 DEVICE 43 100/0.5ML/30GX5/16" 66 UNILET LANCETS SUPER- VALUMARK LANCET SUPER ULTRA-THIN II INSULIN THIN30G 43 THIN 30G 43 SYRINGE SHORT/U- UNILET LANCETS ULTRA- VALUMARK LANCET ULTRA 100/0.5ML/31GX5/16" 67 THIN 28G 43 THIN 28G 43 ULTRA-THIN II INSULIN UNILET SUPERLITE VALVED HOLDING SYRINGE SHORT/U- LANCET 43 CHAMBER 73 100/1ML/30GX5/16" 67 UNISTIK 3 GENTLE 43 vancomycin hcl 2 ULTRA-THIN II INSULIN UNISTIK PRO SAFETY VANICREAM 20 SYRINGE SHORT/U- LANCET 21G 43 100/1ML/31GX5/16" 67 VANISHPOINT INSULIN UNISTIK PRO SAFETY SYRINGE/0.5ML/30G X 1/2" 67 ULTRA-THIN II INSULIN 43 SYRINGE/U- LANCET 25G VANISHPOINT INSULIN UNISTIK PRO SAFETY SYRINGE/0.5ML/30G X 100/0.5ML/29GX1/2" 67 LANCET 28G 43 ULTRA-THIN II INSULIN 5/16" 67 UNISTIK SAFETY LANCETS VANISHPOINT INSULIN SYRINGE/U-100/1ML/29GX1/2" 28G 43 67 SYRINGE/1ML/29G X 1/2" 67 UNISTIK SAFETY LANCETS VANISHPOINT INSULIN ULTRA-THIN II LANCETS 30G 43 28G 42 SYRINGE/1ML/30G X 5/16" 67 VAQTA 126

Index 31 VCF VAGINAL VITEYES CLASSIC WATCHHALER 73 CONTRACEPTIVE FILM 126 MULTIVITAMIN 117 water for irrigation, sterile 75 VCF VAGINAL VITEYES CLASSIC+OMEGA- CONTRACEPTIVE FOAM 126 3 117 WEST-VITE W/FOLIC ACID 77 VCF VAGINAL VITEYES CLASSIC/OMEGA- wheat dextrin 25 CONTRACEPTIVEGEL 126 3 117 white petrolatum 120 VITEYES OPTIC NERVE VELVACHOL 20 WHITE PETROLATUM 120 VENEXA 116 SUPPORT 117 VITRAMYN 117 white petrolatum-mineral oil 119 VENEXA FE 116 VITRANOL 117 WHOLE FOOD venlafaxine hcl 7 MULTIVITAMIN 117 VITRANOL FE 117 VENTRIXYL FE 116 WIBI 20 VITREXATE 117 VERSACLOZ 11 WINDMILL TRAINER 73 VIDA MIA AUTOLET VITREXATE FE 117 witch hazel (hamamelis LANCINGDEVICE 43 VITREXYL 117 virginiana) 22 VIDA MIA UNILET LANCETS VITREXYL/IRON 117 witch hazel-glycerin 22 SUPER THIN 30G 43 VITRUM 50+ ADULT-MULTI WOMENS 50+ MULTI VITAMIN& VIDA MIA UNILET LANCETS IRON FREE 117 MINERAL FORMULA 117 ULTRA THIN 28G 43 VITRUM 50+ SENIOR WOMENS BIOMULTIPLE 117 vigabatrin 5 MULTI 117 WOMENS MULTI VIIBRYD 6 VIVAGUARD LANCETS 43 GUMMIES 117 VIIBRYD STARTER PACK 6 VIVAGUARD LANCING WOMENS MULTI VITAMIN & DEVICE 43 MINERAL FORMULA 117 VIMPAT 5 WOMENS MULTIVITAMIN + VISTA ADVANCED AREDS2 VIVITROL 8 VORTEX HOLDING COLLAGEN GUMMIES 117 FORMULA 116 WRIST CUFF BLOOD VISTA ADVANCED DRY EYE CHAMBER/MASK/CHILDS 73 PRESSUREUNIT 29 FORMULA 116 XERMELO 24 VISTA GEL 119 VORTEX HOLDING CHAMBER/MASK/CHILDS/FR XEROSTOMIA RELIEF VITABEX 116 OG 73 SPRAY 76 VITABEX PLUS 116 VORTEX HOLDING XYREM 121 VITALET PRO LANCETS 43 CHAMBER/MASK/TODDLER YELETS TEENAGE VITALET PRO PLUS 73 FORMULA 117 LANCETS 43 VORTEX HOLDING YELLOW PETROLATUM 120 VITALINE BIOTIN FORTE 77 CHAMBER/MASK/TODDLER/L YOUR LIFE MULTI ADULT ADY BUG 73 VITALINE TOTAL FORMULA GUMMIES 117 VORTEX VALVED HOLDING YOUR LIFE TEEN 2 116 CHAMBER 73 VITALINE TOTAL FORMULA MULTIVITAMIN GUMMIES 117 VP INSULIN SYRINGE/U- ZEVRX INSULIN 3 116 100/0.3ML/29G X 1/2" 67 vitamin a 127 SYRINGE/0.5ML/30G X 1/2" 67 VRAYLAR 10 ZEVRX INSULIN VITAMIN D3 COMPLETE 116 WAL-BORN VITAMIN C 117 SYRINGE/0.5ML/30G X vitamin e 127 WALGREENS ADVANCED 5/16" 67 VITAMIN E WITH TRAVELLANCETS 28G 43 ZEVRX INSULIN PANTHENOL 20 WALGREENS COMFORT SYRINGE/1ML/30G X 1/2" 67 vitamins a & d (topical) 20 ASSUREDLANCETS MICRO ZEVRX INSULIN SYRINGE/1ML/30G X 5/16" 67 VITASANA 116 THIN/33G 43 WALGREENS COMFORT ZEVRX TWIST TOP LANCETS VITATRUM 117 ASSUREDLANCETS SUPER 30G 44 VITEYES CLASSIC 117 THIN/28G 43 ZIKS ARTHRITIS PAIN VITEYES CLASSIC WALGREENS GLUCOSE 8 RELIEF 20 ZIMS CRACK CREME ADVANCED 117 WALGREENS LANCETS 44 VITEYES CLASSIC MACULAR DAYTIME 20 SUPPORT 117 WALGREENS THIN zinc 75 LANCETS 44 VITEYES CLASSIC ZINC 118 MULTIIVITAMIN 117 WALGREENS ULTRA THIN LANCETS 44 zinc gluconate 75

Index 32 zinc oxide (topical) 22 zinc sulfate 75 ZINC SULFATE 75 ZINC W/A&C 75 ziprasidone hcl 10 ziprasidone mesylate 10 zonisamide 5 ZOSTAVAX 126 ZYPREXA RELPREVV 11 ZYVANA 118

Index 33